TIA Medical-Surgical Nursing 2 — Questions and Answers
Question 1: A patient with a fractured hip is in Buck's traction. Which nursing action is most important?
- Remove weights when repositioning
- Maintain continuous traction as ordered (Correct answer)
- Elevate the affected leg 90 degrees
- Place a pillow under the knee of the affected leg
Correct answer: Maintain continuous traction as ordered
Buck's traction must remain continuous to maintain alignment and reduce muscle spasm — weights must never be removed without an order.
Question 2: A patient post-CABG has a mediastinal chest tube draining 200 mL of bright red blood in 1 hour. The nurse should:
- Document and monitor for another hour
- Milk the chest tube vigorously
- Notify the surgeon immediately (Correct answer)
- Increase the suction on the drainage system
Correct answer: Notify the surgeon immediately
Drainage of 200 mL/hr of bright red blood post-CABG indicates hemorrhage and requires immediate surgical notification.
Question 3: Which lab value is most important to monitor in a patient receiving heparin therapy?
- PT/INR
- aPTT (Correct answer)
- Platelet count only
- Fibrinogen level
Correct answer: aPTT
The aPTT (activated partial thromboplastin time) is used to monitor the therapeutic effect of heparin.
Question 4: A patient with cirrhosis develops asterixis (flapping tremor). This finding indicates:
- Hypoglycemia
- Hepatic encephalopathy (Correct answer)
- Vitamin K deficiency
- Portal hypertension only
Correct answer: Hepatic encephalopathy
Asterixis is a hallmark sign of hepatic encephalopathy caused by ammonia accumulation affecting the brain.
Question 5: A nurse is caring for a patient with a suspected pulmonary embolism. Which action is the priority?
- Obtain a 12-lead ECG
- Administer anticoagulant therapy
- Prepare the patient for CT pulmonary angiography
- Administer high-flow oxygen (Correct answer)
Correct answer: Administer high-flow oxygen
Oxygenation is the priority intervention for PE because the clot obstructs pulmonary blood flow, causing hypoxemia.
Question 6: Which dietary instruction is most important for a patient with gout?
- Increase dairy product consumption
- Avoid high-purine foods like red meat and organ meats (Correct answer)
- Limit fluid intake to 1 L per day
- Increase vitamin C supplements only
Correct answer: Avoid high-purine foods like red meat and organ meats
Purine-rich foods increase uric acid production, which precipitates gout attacks, so they must be limited.
TIA Medical-Surgical Nursing 2
A patient with a fractured hip is in Buck's traction.
Which nursing action is most important?