TIA Medical-Surgical Nursing 2

Question 1

A patient with a fractured hip is in Buck's traction. Which nursing action is most important?

Accepted Answer

Maintain continuous traction as ordered

Answer

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:

Accepted Answer

Notify the surgeon immediately

Answer

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?

Accepted Answer

aPTT

Answer

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:

Accepted Answer

Hepatic encephalopathy

Answer

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?

Accepted Answer

Administer high-flow oxygen

Answer

Oxygenation is the priority intervention for PE because the clot obstructs pulmonary blood flow, causing hypoxemia.

TIA - Assessment Technologies Institute Practice Test