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CMSRN EXAM QUESTIONS WITH
100% CORRECT ANSWERS |
VERIFIED | UPDATED
Question 1: The nurse receives all of the following stat
orders for Mr. Palmer. Which one should the nurse question?1) Oxygen per nasal cannula at 4 L per minute.2) Enoxaparin (Lovenox) 40 mg subcutaneously.3) Troponin level.4) Computed tomography (CT) angiogram.
CORRECT ANSWER: 2) Enoxaparin (Lovenox) 40 mg
subcutaneously.
Rationale: The nurse should questions the order for
Lovenox because the patient is receiving a heparin drip.
Question 2: The nurse should contact the physician
immediately if Mrs. Warren has which of these findings?1) The stoma appears pale and dry.2) The stoma appears red and shiny.
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3) There is 200 mL of dark green output from the stoma.4) There is 50 mL of serosanguinous drainage from the stoma.
CORRECT ANSWER: 1) The stoma appears pale and
dry.
Rationale: If there is an adequate blood supply to the
stoma, the color is pink or red, and the stoma is moist as a result of mucous production. A pale dry color suggests ischemia of the stoma or bowel and must be reported immediately to the physician. With an ileostomy initially after surgery, the output is a loose, dark green liquid that may contain some blood. The ileostomy usually begins to drain within 24 of surgery at more than one liter per day.
Question 3: When changing Mrs. Warren's ileostomy bag,
the nurse notices that the peristomal skin is irritated.Which of these actions by the nurse would be appropriate before reapplying the appliance?1) Wash the area with antiseptic soap and water.2) Clean the site with Dakin's solution.
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3) Use a solid skin barrier.4) Obtain an order for a topical antibiotic.
CORRECT ANSWER: 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly
irritate the surrounding tissue. Therefore, a solid skin barrier, with a pectin base or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties, should be applied.
Question 4: Which of these comments, if made by Mrs.
Warren before her surgery, would indicate that she had concerns about her body image?1) "I will have to stop my aerobics classes." 2) "I'm so afraid I may not survive the surgery." 3) "I need to go shopping for some loose, baggy clothes." 4) "I'm concerned that this may be only the first of many surgeries."
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CORRECT ANSWER: 3) "I need to go shopping for
some loose, baggy clothes."
Rationale: Body image refers to a person's perception of
self and determines how the person interacts with others.One does not need to purchase special clothing after ileostomy surgery, although some minor adjustments may be needed for comfort, e.g., stretch underwear or pantyhose for support.
Question 5: Because Mr. Palmer is receiving heparin, it is
essential for the nurse to 1) monitor his prothrombin time.2) observe him for signs of pulmonary embolism.3) limit his intake of foods high in vitamin K.4) check the femoral puncture site at frequent intervals.
CORRECT ANSWER: 4) check the femoral puncture
site at frequent intervals.
Rationale: Since bleeding is a common side effect of
heparin, it is vital to check the operative site, the femoral puncture area, for signs of bleeding.