ANCC Med-Surg Certification (EXAM PREP PRACTICE
SOLUTION) (MEDSURG-BC™)
|COMPREHENSIVE FREQUENTLY MOST TESTED
QUESTIONS AND VERIFIED ANSWERS|GET IT A+
Signs of fat embolism
1. Mental status changes
2. Petechiae-late sign
3. Dyspnea - ✔✔ANSW✔✔..Bergman's triad
Sign of meningitis- supine flex neck will cause involuntary flexion of hips and knees -
✔✔ANSW✔✔..Brudzinski sign
Sign of meningitis- lift flexed knee and slowly extend will cause back pain if positive -
✔✔ANSW✔✔..Kernig's sign
Nerve hyperexcitability (tetany) seen with hypocalemia
Abnormal reaction to stimulation of facial nerve
Inflate bp cuff to greater than systolic and hand and wrist with involuntarly curl inward -
✔✔ANSW✔✔..Chvostek's sign
Trousseau' sign
is positive when a patient is holding a clenched fist over his chest to describe dull,
pressing chest pain consistent with the discomfort of angina pectoris. -
✔✔ANSW✔✔..Levine sign
B: Choice B would show a lateral wall MI.
Choice A would show an anterior MI.
Choice C would show an inferior wall MI.
Choice D would show a posterior wall MI. - ✔✔ANSW✔✔..A patient is diagnosed with a
lateral wall ST segment elevation myocardial infarction (STEMI). What do you expect
the EKG to show?
a. ST elevation in leads V1 -V6
b. ST elevation in leads I, aVL, V5, V6
c. ST elevation in leads II, III, aVF
d. ST elevation in leads V7, V8, V9
,commonly caused by E.coli in elderly males and/or those who are not sexually active
and have normal immune function. In sexually active males with a history of unprotected
sex, the causative organisms are likely gonorrhea and/or chlamydia. Cases of
epididymitis caused by Staph aureus are rare. Epididymitis caused by cytomegalovirus
(CMV) is incredibly rare unless the patient is immunocompromised. -
✔✔ANSW✔✔..Epididymitis
Nimodipine or Nimotop is a calcium channel blocker which causes vasodilation of the
blood vessels. is hypervolemia, hypertension, and hemodilution. These three factors will
maintain the patency of the vessels, making it difficult for them to vasoconstrict.
Vasospasm left unchecked can cause stroke, neurological compromise, and death. -
✔✔ANSW✔✔..Triple H therapy for
Subarachnoid Hemorrhage- induced
Vasospasm
Adverse effects caused by dx procedure or treatment - ✔✔ANSW✔✔..Iatrogenic
1,2. And 3 or 4 is positive - ✔✔ANSW✔✔..Confussion assessment method(cam)
Onset: Acute changes in mental status. · Attention: Inattentive, stable, or fluctuating. ·
Thinking: Disorganized, rambling, switching topics, illogical. ·
Level of consciousness: Altered (ranging from alert to coma). ·
Orientation: Time, place, person. ·
Memory: Impaired. ·
Perceptual disturbances: Hallucinations, illusions. Psychomotor abnormalities:
Agitations or retardation. ·
Sleep-wake cycle: Awake at night, sleepy in the daytime. - ✔✔ANSW✔✔..The
Confusion Assessment Method
d - ✔✔ANSW✔✔..A 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/hrb. continue to monitor the heparin infusion as prescribedc.
request a prothrombin timed. stop the heparin infusion
a - ✔✔ANSW✔✔..A 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 - ✔✔ANSW✔✔..A nurse is assess a client in the emergency room who has a
bradydysrhythmia. Which of the following findings should the nurse expect?A.
confusionB. friction rubC. hypertensionD. dry skin
d - ✔✔ANSW✔✔..A 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 sulfateB. administering oxygen at 2 :/min
via nasal cannulaC. helping the client to the bedside commodeD. assisting with
thrombolytic therapy
D - ✔✔ANSW✔✔..A nurse is caring for a client who has endocarditis. Which of the
following findings should the nurse recognize as a potential complication?A. ventricular
depolarizationB. Guillain-Barre syndromC. myelodysplastic syndromeD. Valvular
disease
C - ✔✔ANSW✔✔..A 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 testingB. Tell the client to report vision changesC. Place the head of the bed
at 45 degreesD. initiate an IV
a - ✔✔ANSW✔✔..a 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 speechb. irregular pulsec. dependent edemad.
persistent fatigue
b - ✔✔ANSW✔✔..A nurse is assessing a client who has left-sided HF. Which of the
following manifestations should the nurse expect to find?a. inc abdominal girthb. weak
peripheral pulsesc. jugular vein distentiond. dependent edema
b - ✔✔ANSW✔✔..a 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. SOBb. lightheadednessc. dry
coughd. metallic taste
c - ✔✔ANSW✔✔..a nurse is monitoring a client following coronary artery bypass graft
surgery. Which of the following findings can indicate cardiac tamponade?a. sternal
instabilityb. inc WBC countc. BP 140/82 mmHg on inspiration and 154/90 mmHg on
expirationd. sinus rhythm with occasional premature atrial contraction and HR 88/min
, d - ✔✔ANSW✔✔..A nurse is preparing a client for coroncary angiography. The nurse
should report which of the following findings to the provider prior to the procedure?a.
hemoglobin 14.4 g/dLb. history of peripheral arterial diseasec. urine output 200 mL/4
hrd. previous allergic reaction to shellfish
a - ✔✔ANSW✔✔..A 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 - ✔✔ANSW✔✔..A 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 patchb. place the patch on an area of skin away from skin folds and jointsc.
keep the patch on 24 hr per dayd. replace the patch at the onset of angina
c - ✔✔ANSW✔✔..A 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 dressingb. severe pain with
coughingc. urine output of 20 mL/hrd. increase in temp from 36.C (98.2F)- 37.5C
(99.5F)
d - ✔✔ANSW✔✔..A 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
distentionb. bowel soundsc. peripheral edemad. urine output
b - ✔✔ANSW✔✔..A 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 thumpb. vagal stimulationc. administration of atropine IVd. defibrillation
a - ✔✔ANSW✔✔..A 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 hrb. inc of 10 mmHg in systolic BPc. dyspnea
with exertiond. dizziness when rising quickly
c - ✔✔ANSW✔✔..A 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 diseaseb. note the presence or absence of pain at the ulcer sitec.
inquire about the presence or absence of claudicationd. ask if the client has had a
recent infection
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