OLIVAREZ COLLEGE TAGAYTAY

College Of Nursing

Evaluation Exam

Medical – Surgical Nursing (Neuro. – Cardio)

1 .A 78-year-old client is admitted to the emergency department with

numbness and weakness of the left arm and slurred speech. Which
nursing intervention is priority?
a. Prepare to administer recombinant tissue plasminogen activator
(rt –PA).
b. Discuss the precipitating factors that caused the symptoms.
c.Schedule for a STAT computed tomography (CT) scan of the head.
d. Notify the speech pathologist for an emergency consult.

2. The nurse is assessing the client experiencing motor loss as a

result of a left sided cerebrovascular accident (CVA). Which clinical
manifestations would the nurse document?
a. Hemiparesis of the client’s left arm & apraxia
b. Paralysis of the right side of the body & ataxia
c. Homonymous hemianopsia & diplopia
d. Impulsive behavior & hostility toward family

3. A client diagnosed with atrial fibrillation has experienced a

transient ischemic attack(TIA). Which medication would the nurse
anticipate being ordered for the client on discharge?
a. An oral anticoagulant medication
b. A beta – blocker medication
c. An anti-hyperuricemic medication
d. A thrombolytic medication

4. The client is diagnosed with expressive aphasia. Which psychosocial

client problem would the nurse include in the plan of care?
a. Potencial for injury
b. Powerlessness
c. Disturbed thought processes
d. sexual dysfunction

5. Which assessment data would indicate to the nurse that the client
would be at risk for a hemorrhagic stroke?
a. a blood glucose level of 280mg/dL
b. a right sided carotid bruit
c. a blood pressure of 220/120 mmHg
d. presence of bronchogenic carcinoma

6. The 85 year old client diagnosed with a stroke is complaining of a

severe headache. Which intervention should the nurse implement first?
a. Administer a nonnarcotic analgesic
b. Prepare for a STAT magnetic resonace imaging (MRI)
c. Start an intravenous line with D5W at 100 ml/hr
d. Complete a neurological assessment
7. A client diagnosed with a subarachnoid hemorrhage has undergone a
craniotomy for repair of a ruptured aneurysm. Which intervention will
the intensive care nurse implement?
a. administer a stool softener
b. encourage the client to cough hourly
c. monitor neurological status every shift
d. maintain the dopamine drip to keep BP at 160/90 mmHg

8. The client diagnosed with a closed head injury is admitted to the

rehabilitation department. Which medication order would the nurse
question?

a. A subcutaneous anticoagulant
b. An intravenous osmotic diuretic
c. An oral anticonvulsant
d. An oral proton pump inhibitor

9. The client that just had a 3 minute seizure has no apparent injuries
& is oriented to name, place, & time but is very lethargic & just wants
to sleep. Which intervention should the nurse implement?
a. perform a complete neurological assessment
b. Awaken the client every 30 minutes
c. Turn the client to the side & allow him to sleep
d. Interview the client to find out what caused the seizure

11. Which cardiac enzyme would the nurse expect to elevate first in a
client diagnosed with myocardial infarction?
a. Creatinie phosphokinase (CPK-MB)
b. Lactate dehydrogenase (LDH)
c. troponin
d. White blood cells (WBC)

12. Along with persistent, crushing chest pain, which signs/symptoms

would make the nurse suspect that the client is experiencing a
myocardial infarction?
a. Mid-epigastric pain and pyrosis
b. Diaphoresis and cool clammy skin.
c. Intermittent claudication and pallor.
d. Jagular vein distention and dependent edema.

13. The nurse is administering a calcium channel blocker to the client

diagnosed with a myocardial infarction. Which assessment data would
cause the nurse to question administering this medication?
a. The client’s apical pulse is 64
b. The client’s calcium level is elevated.
c. The client’s telemetry shows occasional PVC’s.
d. The client’s blood pressure is 90/62.

14. The client has just returned from a cardiac catheterization. Which
assessment data would warrant immediate intervention from the nurse?
a. The client’s BP is 110/70and pulse is 90.
b. The client groin dressing is dry and intact.
c. The client refuses to keep the leg straight.
15. The male client is diagnosed with coronary artery disease (CAD) and
is prescribed sublingual nitroglycerin. Which statement indicates the
client needs more teaching?
a.” I should keep the tablets in the dark colored bottle they
came in.”
b. ”If the tablets do not burn under my tongue, they are not
effective.”
c. “I should keep the bottle with me In my pocket at all times.”
d. “If my chest pain is not gone with one tablet, I will go to
the ER.’

16. The nurse is preparing to administer a beta blocker to the client

diagnosed with coronary artery disease. Which assessment data would
cause the nurse to question administering the medication?
a. The client has a BP of 110/70.
b. The client has an apical pulse of 56.
c. The client is complaining of a headache.
d. The client’s potassium level is 4.5 mEq/L.

17. Which intervention should the nurse implement when administering a

loop diuretic to a client diagnosed with coronary artery disease?
a. Assess the client’s radial pulse of 56.
b Assess the client’s serum potassium level.
c. Assess the client’s glucometer reading.
d. Assess the client’s pulse oximeter reading.

18. The client shows ventricular fibrillation on the telemetry at the

nurse station. Which action should the telemetry nurse implement first?
a. Administer epinephrine IVP.
b. Prepare to defibrillate the client.
c. Call a STAT code.
d. Start Cardiopulmonary resuscitation.

19. The client is experiencing multifocal premature ventricular

contractions. Which anti-dysrhythmic medication would the nurse expect
the health –care provider to order for this client?
a. Lidocaine.
b. Atropine
c. Dogoxin
d. Adenosine

20. Which intervention should the nurse implement when defibrillating a

client who is in ventricular fibrillation?
a. Defibrillate the client at 50, 100, and 200 joules.
b. Do not remove the oxygen source during defibrillator.
c. Place petroleum jelly on the defibrillator pads.
d. Shout ‘all clear’ prior to defibrillating the client.

21. The client exhibiting ventricular tachycardia. Which intervention

should the nurse implement first?
a. Administer Lidocaine, an antidysrhythmic, IVP.
b. Prepare to defibrillate the client at 200 joules.
c. Assess the client’s apical pulse and blood pressure.
d. Start basic cardiopulmonary resuscitation.
22. The client is in complete heart block. Which interventions should
the nurse implement first?
a. Prepare to insert a pacemaker
b. Administer atropine, an antidysrhythmic .
c. Obtain a STAT electrocardiogram (ECG).
d. Notify the health-care provider.

23. The client’s telemetry reading shows a p-wave before each QRS
complex and the rate is 78. Which action should the nurse implement?
a. Document this as normal sinus rhythm.
b. Request a 12 lead electrocardiogram.
c. Prepare to administer the cardiotonic digoxin po.
d. Assess the client’s cardiac enzymes.

24. a client with a perforated gastric ulcer is scheduled for emergency

surgery. The client cannot sign the operative consent form because
of sedation from narcotic analgesics that have been administered.
The nurse should take which of the following most appropriate
actionin the care of this client.

a. obtain a telephone consent from a family members and have the

consent witnessed by two person

b. obtain a court orderfor the surgery

c. send the client to surgery without the consentform being signed

d. have the hospitalchaplai sign the informed consent immediately