ANCC MED-SURG CERTIFICATION||
2025 LATEST UPDATE!!!
d - ANSWERA nurse is reviewing the medical record of a client who is receiving heparin
therapy for treatment of DVT. Which of the following interventions should the nurse
anticipate taking if the client's aPTT is 96 seconds?
a. Increase the heparin infusion flow rate by 2 mL/hr
b. continue to monitor the heparin infusion as prescribed
c. request a prothrombin time
d. stop the heparin infusion
a - ANSWERA nurse is providing teaching for a client who is 2 days post-op following a
heart transplant. Which of the following statements should the nurse include in the
teaching?
a. "you may no longer be able to feel chest pain.
"b. "your level of activity tolerance will not change."
c. "after 6 months, you will no longer need to restrict your sodium intake."
d. "you will be able to stop taking immunosuppressants after 12 months."
a - ANSWERA nurse is assess a client in the emergency room who has a
bradydysrhythmia. Which of the following findings should the nurse expect?
A. confusion
B. friction rub
C. hypertension
D. dry skin
d - ANSWERA nurse in the emergency department is caring for a client who had an
anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy.
The nurse should recognize that which of the following interventions is contraindicated?
A. administering IV morphine sulfate
B. administering oxygen at 2 :/min via nasal cannula
C. helping the client to the bedside commode
D. assisting with thrombolytic therapy
D - ANSWERA nurse is caring for a client who has endocarditis. Which of the following
findings should the nurse recognize as a potential complication?
A. ventricular depolarization
B. Guillain-Barre syndrome
C. myelodysplastic syndrome
D. Valvular disease
C - ANSWERA nurse is caring for a client who presents to the ER with a BP of 254/138
mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the
following actions should the nurse take first?
,A. obtain blood samples for laboratory testing
B. Tell the client to report vision changes
C. Place the head of the bed at 45 degrees
D. initiate an IV
a - ANSWERa nurse is caring for a client who has HF and is experiencing AF. The
nurse should plan to monitor for and report which of the following findings to the
provider immediately?
a. slurred speech
b. irregular pulse
c. dependent edema
d. persistent fatigue
b - ANSWERA nurse is assessing a client who has left-sided HF. Which of the following
manifestations should the nurse expect to find?
a. inc abdominal girth
b. weak peripheral pulses
c. jugular vein distention
d. dependent edema
b - ANSWERa nurse is caring for a client who is being treated for HF and has
prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of
the following as an adverse effect of these medications?
a. SOB
b. lightheadedness
c. dry cough
d. metallic taste
c - ANSWERa nurse is monitoring a client following coronary artery bypass graft
surgery. Which of the following findings can indicate cardiac tamponade?
a. sternal instability
b. inc WBC count
c. BP 140/82 mmHg on inspiration and 154/90 mmHg on expiration
d. sinus rhythm with occasional premature atrial contraction and HR 88/min
d - ANSWERA nurse is preparing a client for coronary angiography. The nurse should
report which of the following findings to the provider prior to the procedure?
a. hemoglobin 14.4 g/dL
b. history of peripheral arterial disease
c. urine output 200 mL/4 hr
d. previous allergic reaction to shellfish
a - ANSWERA nurse is caring for a client following insertion of a permanent pacemaker.
Which of the following client statements indicates a potential complication of the
insertion procedure?
a. "I can't get rid of these hiccups."
,b. "I feel dizzy when i stand."
c. "My incision site stings."
d. "I have a headache."
b - ANSWERA nurse is providing discharge teaching for a client who has a prescription
for the transdermal nitroglycerin patch. Which of the following instructions should the
nurse include in the teaching?
a. apply the new patch to the same site as the previous patch
b. place the patch on an area of skin away from skin folds and joints
c. keep the patch on 24 hr per day
d. replace the patch at the onset of angina
c - ANSWERA nurse is caring for a client in the first hour following an aortic aneurysm
repair. Which of the following findings can indicate shock and should be reported to the
provider?
a. serosanguinous drainage on dressing
b. severe pain with coughing
c. urine output of 20 mL/hr
d. increase in temp from 36.C (98.2F)- 37.5C (99.5F)
d - ANSWERA nurse caring for a client following an abdominal aortic aneurysm
resection. Which of the following is the priority assessment for this client?
a. neck vein distention
b. bowel sounds
c. peripheral edema
d. urine output
b - ANSWERA nurse is watching a client's ECG monitor and notes that the client's
rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The
client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse
should anticipate assisting with which of the following interventions?
a. delivery of precordial thump
b. vagal stimulation
c. administration of atropine IV
d. defibrillation
a - ANSWERA nurse is providing discharge teaching for a client who has HF. The nurse
should instruct the client to report which of the following findings immediately to the
provider?
a. weight gain of 2 lb in 24 hr
b. inc of 10 mmHg in systolic BP
c. dyspnea with exertion
d. dizziness when rising quickly
, c - ANSWERA nurse is admitting a client who has a leg ulcer and a history of DM. The
nurse should use which of the following focused assessments to help differentiate
between an arterial ulcer and a venous stasis ulcer?
a. explore the clients family history of peripheral vascular disease
b. note the presence or absence of pain at the ulcer site
c. inquire about the presence or absence of claudication
d. ask if the client has had a recent infection
c - ANSWERA nurse is reviewing the laboratory results of several clients who have
peripheral arterial disease. The nurse should plan to provide dietary teaching for the
client who has which laboratory values?
a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL
b. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL
c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
b - ANSWERa nurse is providing health teaching for a group of clients. Which of the
following clients is at risk for developing peripheral arterial disease?
a. a client who has hypothyroidism
b. a client who has DM
c. a client whose daily caloric intake consists of 25% fat
d. a client who consumes two bottles of beer a day
a, b, e - ANSWERa nurse is planning a presentation about hypertension for a
community women's group. which of the following lifestyle modifications should the
nurse include (select all that apply)
a. limited alcohol intake
b. regular exercise program
c. decreased Mg intake
d. reduced K intake
e. smoking cessation
b - ANSWERA nurse is caring for a client in the first 8 hr following coronary artery
bypass graft surgery. Which of the following client findings should the nurse report to
the provider?
a. mediastinal drainage 100 mL/hr
b. BP 160/80 mmHg
c. Temp 37.1 (98.8)
d. K 3.8 mEq/L
d - ANSWERA nurse is caring for a client who has a history of angina and is schedules
for a stress test at 1100. Which of the following statements by the client requires the
nurse to contact the provider for possible rescheduling?
a. "I'm still hungry after the bowl of cereal I ate at 7am."
b. "I didn't take my heart pills this morning because the doctor told me not to."
2025 LATEST UPDATE!!!
d - ANSWERA nurse is reviewing the medical record of a client who is receiving heparin
therapy for treatment of DVT. Which of the following interventions should the nurse
anticipate taking if the client's aPTT is 96 seconds?
a. Increase the heparin infusion flow rate by 2 mL/hr
b. continue to monitor the heparin infusion as prescribed
c. request a prothrombin time
d. stop the heparin infusion
a - ANSWERA nurse is providing teaching for a client who is 2 days post-op following a
heart transplant. Which of the following statements should the nurse include in the
teaching?
a. "you may no longer be able to feel chest pain.
"b. "your level of activity tolerance will not change."
c. "after 6 months, you will no longer need to restrict your sodium intake."
d. "you will be able to stop taking immunosuppressants after 12 months."
a - ANSWERA nurse is assess a client in the emergency room who has a
bradydysrhythmia. Which of the following findings should the nurse expect?
A. confusion
B. friction rub
C. hypertension
D. dry skin
d - ANSWERA nurse in the emergency department is caring for a client who had an
anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy.
The nurse should recognize that which of the following interventions is contraindicated?
A. administering IV morphine sulfate
B. administering oxygen at 2 :/min via nasal cannula
C. helping the client to the bedside commode
D. assisting with thrombolytic therapy
D - ANSWERA nurse is caring for a client who has endocarditis. Which of the following
findings should the nurse recognize as a potential complication?
A. ventricular depolarization
B. Guillain-Barre syndrome
C. myelodysplastic syndrome
D. Valvular disease
C - ANSWERA nurse is caring for a client who presents to the ER with a BP of 254/138
mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the
following actions should the nurse take first?
,A. obtain blood samples for laboratory testing
B. Tell the client to report vision changes
C. Place the head of the bed at 45 degrees
D. initiate an IV
a - ANSWERa nurse is caring for a client who has HF and is experiencing AF. The
nurse should plan to monitor for and report which of the following findings to the
provider immediately?
a. slurred speech
b. irregular pulse
c. dependent edema
d. persistent fatigue
b - ANSWERA nurse is assessing a client who has left-sided HF. Which of the following
manifestations should the nurse expect to find?
a. inc abdominal girth
b. weak peripheral pulses
c. jugular vein distention
d. dependent edema
b - ANSWERa nurse is caring for a client who is being treated for HF and has
prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of
the following as an adverse effect of these medications?
a. SOB
b. lightheadedness
c. dry cough
d. metallic taste
c - ANSWERa nurse is monitoring a client following coronary artery bypass graft
surgery. Which of the following findings can indicate cardiac tamponade?
a. sternal instability
b. inc WBC count
c. BP 140/82 mmHg on inspiration and 154/90 mmHg on expiration
d. sinus rhythm with occasional premature atrial contraction and HR 88/min
d - ANSWERA nurse is preparing a client for coronary angiography. The nurse should
report which of the following findings to the provider prior to the procedure?
a. hemoglobin 14.4 g/dL
b. history of peripheral arterial disease
c. urine output 200 mL/4 hr
d. previous allergic reaction to shellfish
a - ANSWERA nurse is caring for a client following insertion of a permanent pacemaker.
Which of the following client statements indicates a potential complication of the
insertion procedure?
a. "I can't get rid of these hiccups."
,b. "I feel dizzy when i stand."
c. "My incision site stings."
d. "I have a headache."
b - ANSWERA nurse is providing discharge teaching for a client who has a prescription
for the transdermal nitroglycerin patch. Which of the following instructions should the
nurse include in the teaching?
a. apply the new patch to the same site as the previous patch
b. place the patch on an area of skin away from skin folds and joints
c. keep the patch on 24 hr per day
d. replace the patch at the onset of angina
c - ANSWERA nurse is caring for a client in the first hour following an aortic aneurysm
repair. Which of the following findings can indicate shock and should be reported to the
provider?
a. serosanguinous drainage on dressing
b. severe pain with coughing
c. urine output of 20 mL/hr
d. increase in temp from 36.C (98.2F)- 37.5C (99.5F)
d - ANSWERA nurse caring for a client following an abdominal aortic aneurysm
resection. Which of the following is the priority assessment for this client?
a. neck vein distention
b. bowel sounds
c. peripheral edema
d. urine output
b - ANSWERA nurse is watching a client's ECG monitor and notes that the client's
rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The
client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse
should anticipate assisting with which of the following interventions?
a. delivery of precordial thump
b. vagal stimulation
c. administration of atropine IV
d. defibrillation
a - ANSWERA nurse is providing discharge teaching for a client who has HF. The nurse
should instruct the client to report which of the following findings immediately to the
provider?
a. weight gain of 2 lb in 24 hr
b. inc of 10 mmHg in systolic BP
c. dyspnea with exertion
d. dizziness when rising quickly
, c - ANSWERA nurse is admitting a client who has a leg ulcer and a history of DM. The
nurse should use which of the following focused assessments to help differentiate
between an arterial ulcer and a venous stasis ulcer?
a. explore the clients family history of peripheral vascular disease
b. note the presence or absence of pain at the ulcer site
c. inquire about the presence or absence of claudication
d. ask if the client has had a recent infection
c - ANSWERA nurse is reviewing the laboratory results of several clients who have
peripheral arterial disease. The nurse should plan to provide dietary teaching for the
client who has which laboratory values?
a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL
b. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL
c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
b - ANSWERa nurse is providing health teaching for a group of clients. Which of the
following clients is at risk for developing peripheral arterial disease?
a. a client who has hypothyroidism
b. a client who has DM
c. a client whose daily caloric intake consists of 25% fat
d. a client who consumes two bottles of beer a day
a, b, e - ANSWERa nurse is planning a presentation about hypertension for a
community women's group. which of the following lifestyle modifications should the
nurse include (select all that apply)
a. limited alcohol intake
b. regular exercise program
c. decreased Mg intake
d. reduced K intake
e. smoking cessation
b - ANSWERA nurse is caring for a client in the first 8 hr following coronary artery
bypass graft surgery. Which of the following client findings should the nurse report to
the provider?
a. mediastinal drainage 100 mL/hr
b. BP 160/80 mmHg
c. Temp 37.1 (98.8)
d. K 3.8 mEq/L
d - ANSWERA nurse is caring for a client who has a history of angina and is schedules
for a stress test at 1100. Which of the following statements by the client requires the
nurse to contact the provider for possible rescheduling?
a. "I'm still hungry after the bowl of cereal I ate at 7am."
b. "I didn't take my heart pills this morning because the doctor told me not to."
