Venous thromboembolism is one of the most preventable things that goes wrong on a med-surg unit, which is why the exam keeps returning to it. These questions cover recognising DVT and pulmonary embolism, prophylaxis, and the monitoring that anticoagulation demands — heparin and warfarin parameters, INR targets, and the bleeding signs that change the plan.
Question 1
57 of 125. Four hours after abdominal surgery, a patient on therapeutic anticoagulation requests an ice pack for incisional pain. The incision has minimal serosanguinous drainage without ecchymosis. Which action is clinically appropriate?
- A) A) Apply gel cold pack continuously with thin cloth barrier
- B) B) Use ice pack intermittently for 10 minutes hourly after assessing coagulation labs✓
- C) C) Provide chilled pillow for support without direct skin contact
- D) D) Administer crushed-ice compress for 20 minutes four times daily
Show rationale
Intermittent cold therapy reduces inflammation without impairing healing. Option B limits exposure time and verifies coagulation status, crucial for anticoagulated patients. Option A's continuous application risks tissue damage. Option C provides inadequate targeted therapy. Option D's prolonged direct pressure may disrupt the incision. Per AMSN protocols, cold therapy duration should be minimized with bleeding risks.
Question 2
96 of 125. A warfarin-treated patient with atrial fibrillation presents with INR 5.8 and scattered petechiae. No active bleeding. Current plan includes weekly INR checks. Which action updates the care plan?
- A) A) Hold warfarin and administer vitamin K IM✓
- B) B) Reduce warfarin dose and recheck INR tomorrow
- C) C) Continue warfarin and monitor for bruising
- D) D) Discharge with INR education and follow-up
Show rationale
A is correct for critical INR elevation (>5.0) with bleeding risk (petechiae), per ACC guidelines. IM vitamin K reverses anticoagulation safely without active hemorrhage. B is insufficient: dose reduction won’t rapidly lower INR. C ignores high bleeding risk. D is unsafe for unstable INR. CMSRN protocols mandate urgent intervention for supratherapeutic INR with dermatological signs.
Question 3
24 of 125. An 85-year-old on warfarin with recent gait instability falls in the bathroom, hitting her head without loss of consciousness. Vital signs are stable. Which nursing action demonstrates appropriate adverse event response?
- A) A) Apply ice to the injury and document the fall per facility protocol
- B) B) Notify the provider and initiate a neurological assessment every 30 minutes
- C) C) Complete an incident report and obtain a STAT head CT per fall policy✓
- D) D) Administer PRN acetaminophen and reassess pain in one hour
Show rationale
Anticoagulated patients with head trauma require urgent CT to rule out hemorrhage, and falls with injury are reportable events. Option C combines mandatory reporting (incident report) and risk-specific intervention (CT). Option A/B miss either imaging (critical for warfarin) or reporting. Option D ignores neurological risks. Cues (warfarin, head impact) make this high-risk, requiring protocol-driven escalation.
Question 4
29 of 125. When delegating post-lumbar puncture care to an LPN, which patient condition requires the RN to retain direct responsibility? The patient has:
- A) A) Migraine history and current headache rated 4/10
- B) B) Therapeutic INR of 2.3 on warfarin for atrial fibrillation✓
- C) C) Allergy to chlorhexidine with localized skin redness
- D) D) Mild back discomfort when repositioning in bed
Show rationale
Anticoagulated patients (B) have high bleeding risk at puncture sites, requiring RN-level monitoring for complications like spinal hematoma. Headache (A) and back pain (D) are common post-procedure issues manageable by LPNs with RN oversight. Localized allergy (C) may be addressed with LPN skin assessments. Cues (warfarin, atrial fibrillation) indicate critical anticoagulation status where RNs must perform neurological assessments per procedural guidelines, unlike distractors representing lower-risk scenarios.
Question 5
65 of 125. A 78-year-old patient with osteoporosis and taking apixaban falls in their hospital room. Assessment reveals left hip pain and mild confusion. Vital signs are BP 138/82, HR 88. Which action takes priority in post-fall management?
- A) A) Administer PRN acetaminophen for hip pain
- B) B) Notify the physician about the anticoagulant use
- C) C) Perform neurovascular checks on the affected limb
- D) D) Obtain STAT portable hip and pelvis X-rays✓
Show rationale
In patients with osteoporosis on anticoagulants, fracture and bleeding risks are critical discriminating cues. X-rays are prioritized to rule out fracture before mobilizing (per AMSN guidelines). While pain management (A) is needed, it shouldn't delay fracture identification. Anticoagulant notification (B) is essential but secondary to assessing for injury. Neurovascular checks (C) are important but less urgent than confirming/excluding fracture in this high-risk scenario. X-rays directly address the immediate life/function-threatening complication.
Question 6
67 of 125. A patient with low health literacy is discharged with warfarin. Which teaching method best ensures comprehension?
- A) A) Provide detailed written medication instructions
- B) B) Use teach-back technique with simple language✓
- C) C) Schedule follow-up with a pharmacist
- D) D) Demonstrate blood draw for INR monitoring
Show rationale
Teach-back actively confirms understanding, essential for low health literacy. Written instructions (A) alone are ineffective if unreadable. Pharmacist consults (C) are valuable but don't replace nurse-led validation. INR demonstration (D) addresses monitoring but not overall comprehension. Health Literacy Universal Precautions from AHRQ mandate techniques like teach-back for critical safety information.
Question 7
77 of 125. When accessing a port for a dehydrated patient with newly diagnosed small bowel obstruction, the nurse cannot aspirate blood after three Huber needle placement attempts. The patient reports tenderness over the port. Which step addresses potential catheter tip malposition while preventing injury?
- A) A) Flush vigorously with saline to clear possible fibrin occlusion
- B) B) Reposition the patient and attempt aspiration with deep inspiration
- C) C) Administer alteplase per protocol and reassess patency in 30 minutes
- D) D) Obtain a STAT chest X-ray for catheter tip verification✓
Show rationale
Inability to aspirate plus tenderness suggests catheter migration or tip malposition, especially in dehydration which alters vascular volume. Vigorous flushing (A) risks vessel damage if malpositioned. Repositioning (B) is ineffective without tip confirmation. Alteplase (C) assumes occlusion, not malposition. Chest X-ray confirms tip location per INS standards before further action, preventing complications like extravasation or thrombosis.
Question 8
89 of 125. During an emergency splenectomy on a patient with thrombocytopenia, the closing sponge count reveals one missing laparotomy sponge. The surgeon has already closed the fascia and is suturing subcutaneous tissue. What action should the circulating nurse prioritize?
- A) A) Complete an incident report and notify risk management after the procedure
- B) B) Request an immediate intraoperative X-ray to locate the missing sponge✓
- C) C) Perform another manual search of the surgical field and kick buckets
- D) D) Document the discrepancy and alert the post-anesthesia care unit staff
Show rationale
AORN guidelines mandate immediate imaging when counts remain unresolved during cavity closure. Thrombocytopenia increases bleeding risk if re-exploration is needed later, making intraoperative X-ray critical. Option A delays resolution, risking retained foreign object. Option C is ineffective after fascia closure since sponges can't be in the field. Option D neglects intraoperative resolution requirements. The key cues are fascia closure completion and thrombocytopenia, necessitating rapid, non-invasive verification before skin closure.
Question 9
95 of 125. A 72-year-old patient with a BMI of 38 undergoes elective total hip replacement. On postoperative day 3, they report mild calf tenderness but no swelling. Their platelet count is 95,000/mm³, and they received enoxaparin 6 hours ago. Which assessment finding warrants immediate notification of the provider?
- A) A) Oxygen saturation drops from 98% to 96% on room air
- B) B) Unilateral calf circumference increases by 3 cm compared to pre-op
- C) C) Sudden onset of dyspnea when ambulating to the bathroom✓
- D) D) Mild erythema over the posterior calf with pain rated 2/10
Show rationale
Sudden dyspnea suggests possible pulmonary embolism (PE), a life-threatening complication requiring urgent intervention. The patient has DVT risk factors (age, obesity, orthopedic surgery) and calf tenderness. Option A is less urgent as 96% SpO₂ may reflect atelectasis. Option B indicates possible DVT but isn't immediately life-threatening. Option D describes localized inflammation, not embolism. PE requires rapid anticoagulation per ACCP guidelines, while other findings need monitoring or non-urgent evaluation.
Question 10
100 of 125. During a 6-hour prone spinal fusion for a diabetic patient with BMI 38, the circulating nurse notices the patient's abdomen is hanging freely. Which intervention is most urgent?
- A) A) Repositioning the chest rolls to elevate the thorax higher
- B) B) Placing a pillow under the shins to reduce lumbar pressure
- C) C) Adjusting the frame to allow abdominal decompression✓
- D) D) Adding extra padding under the iliac crests and knees
Show rationale
Free-hanging abdomen in prone position compromises ventilation (restricting diaphragmatic excursion) and increases venous pressure, raising bleeding risk—especially critical in long surgeries for obese diabetics with fragile vasculature. Abdominal decompression directly addresses these threats. Option A may worsen abdominal compression if rolls are misplaced. Option B focuses on peripheral pressure points but ignores the immediate cardiopulmonary threat. Option D addresses skin integrity but not visceral compression. ASPAN standards prioritize mitigating ventilation compromise during prone positioning.
