ANCC Medical-Surgical Nursing Certification 2 — Questions and Answers
Question 1: A patient is receiving a blood transfusion and develops fever, chills, and flank pain 15 minutes after starting. The nurse's priority action is:
- Slow the infusion rate and monitor for improvement
- Stop the transfusion, maintain IV access with NS, and notify the provider (Correct answer)
- Administer acetaminophen and diphenhydramine
- Increase the flow rate to complete the transfusion faster
Correct answer: Stop the transfusion, maintain IV access with NS, and notify the provider
These symptoms suggest an acute hemolytic transfusion reaction; stopping the transfusion immediately is the priority to prevent further harm.
Question 2: A patient with chronic kidney disease has a potassium level of 6.3 mEq/L and peaked T-waves on ECG. Which intervention is most urgent?
- Dietary potassium restriction counseling
- Administer calcium gluconate IV to stabilize cardiac membranes (Correct answer)
- Administer sodium polystyrene sulfonate (Kayexalate)
- Schedule dialysis within 24 hours
Correct answer: Administer calcium gluconate IV to stabilize cardiac membranes
Calcium gluconate is the fastest intervention to stabilize cardiac membrane potential and prevent life-threatening arrhythmia from hyperkalemia.
Question 3: Post-op day 1 after a right hemicolectomy, a patient's ostomy stoma appears pale and dusky. What is the correct interpretation?
- Normal appearance for the first 24 hours
- Stoma is adequately perfused
- Possible stoma ischemia requiring immediate provider notification (Correct answer)
- Stoma requires more frequent irrigation
Correct answer: Possible stoma ischemia requiring immediate provider notification
A healthy stoma should be beefy red; a pale or dusky stoma suggests ischemia or necrosis requiring urgent assessment.
Question 4: A patient has serum sodium of 118 mEq/L and is symptomatic with seizures. Which IV solution is indicated?
- D5W (5% dextrose in water)
- 0.9% Normal saline
- 3% Hypertonic saline (Correct answer)
- 0.45% Half-normal saline
Correct answer: 3% Hypertonic saline
Severe symptomatic hyponatremia with seizures requires hypertonic (3%) saline to rapidly correct sodium and resolve neurologic symptoms.
Question 5: A patient with a chest tube develops subcutaneous emphysema around the insertion site. What does this indicate?
- The chest tube is functioning correctly
- Air is leaking into the subcutaneous tissue, possibly indicating tube displacement (Correct answer)
- This is a normal finding post-thoracostomy
- The water seal chamber is malfunctioning
Correct answer: Air is leaking into the subcutaneous tissue, possibly indicating tube displacement
Subcutaneous emphysema (crepitus around the insertion site) suggests the chest tube has become dislodged or there is an air leak.
Question 6: Which preoperative nursing intervention most reduces the risk of surgical site infection (SSI)?
- Shaving the operative site the night before surgery
- Administering prophylactic antibiotics within 60 minutes before incision (Correct answer)
- Keeping the patient NPO for 12 hours before surgery
- Applying povidone-iodine scrub the morning of surgery
Correct answer: Administering prophylactic antibiotics within 60 minutes before incision
Evidence-based SSI prevention bundles include prophylactic antibiotics given within 60 minutes before surgical incision.
ANCC Medical-Surgical Nursing Certification 2
A patient is receiving a blood transfusion and develops fever, chills, and flank pain 15 minutes after starting.
The nurse's priority action is: