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o C. Prepare for emergency
tracheostomy.
o D. Apply humidified oxygen
Medical-Surgical Nursing
therapy.
1. A patient with cirrhosis develops ascites
4. A patient with acute myeloid leukemia
and a serum albumin level of 2.3 g/dL.
develops a fever, mucositis, and
Which intervention would most
neutropenia. What is the nurse’s
effectively reduce the fluid
highest priority?
accumulation in the abdomen?
o A. Administer prescribed
o A. Encourage a low-sodium diet.
antibiotics immediately.
o B. Administer intravenous
o B. Isolate the patient to prevent
furosemide.
infection spread.
o C. Administer intravenous
o C. Provide mouth care with a
albumin and perform
soft toothbrush.
paracentesis.
o D. Monitor for signs of
o D. Restrict fluid intake to 1 liter
thrombocytopenia.
per day.
5. A patient with a history of atrial
2. A patient with acute pancreatitis
fibrillation develops sudden unilateral
presents with severe epigastric pain
leg pain, pallor, and a pulseless
radiating to the back and hypocalcemia.
extremity. What is the priority action?
Which finding requires immediate
intervention? o A. Administer anticoagulants.
o A. Positive Chvostek’s sign. o B. Perform Doppler ultrasound
of the leg.
o B. Cullen’s sign around the
umbilicus. o C. Notify the vascular surgeon
immediately.
o C. Lipase level of 1,200 U/L.
o D. Elevate the affected limb.
o D. Respiratory rate of 24
breaths per minute.
3. After a thyroidectomy, a patient 6. A patient receiving IV fluids at 125
develops stridor, restlessness, and mL/hr suddenly develops crackles in the
difficulty breathing. What is the nurse's lungs and jugular vein distention. What
most immediate action? is the nurse’s initial action?
o A. Administer IV calcium o A. Reduce the IV flow rate.
gluconate.
o B. Notify the physician
o B. Assess for hypocalcemia immediately.
using Trousseau’s sign.
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o C. Administer a loop diuretic as o C. Apply an antiseptic dressing
prescribed. over the site.
o D. Elevate the head of the bed. o D. Flush the catheter with
heparinized saline.
7. During a blood transfusion, a patient
complains of chills and develops a fever 10. While performing wound care, the
of 38.5°C. What is the first nursing nurse observes that the wound bed is
action? pale with minimal granulation tissue.
What does this indicate about the
o A. Stop the transfusion
wound-healing process?
immediately.
o A. The wound is infected.
o B. Administer paracetamol as
prescribed. o B. There is insufficient perfusion
to the wound bed.
o C. Notify the blood bank.
o C. The patient is experiencing
o D. Document the findings in the
poor nutritional intake.
patient’s chart.
o D. The wound is in the
8. A nurse is inserting an indwelling
maturation phase of healing.
urinary catheter in a female patient but
accidentally contaminates the catheter.
What is the best next step?
11. A patient with diabetes mellitus
o A. Continue with the procedure presents with nausea, confusion, and
using sterile gloves. Kussmaul breathing. The arterial blood
gas reveals pH 7.28, HCO₃⁻ 14 mEq/L,
o B. Obtain a new sterile catheter
and PaCO₂ 30 mmHg. Which
kit and restart the procedure.
intervention is most critical?
o C. Clean the catheter with
o A. Administer intravenous
sterile normal saline and
insulin.
proceed.
o B. Start bicarbonate therapy
o D. Inform the physician and
immediately.
document the incident.
o C. Provide oral glucose.
9. A patient with a central venous catheter
(CVC) develops redness, swelling, and o D. Administer oxygen at 2
purulent discharge at the insertion site. L/min.
What is the nurse's most appropriate
12. A patient receiving heparin therapy for
response?
deep vein thrombosis develops a
o A. Remove the catheter platelet count of 80,000/mm³. What is
immediately. the most appropriate action?
o B. Notify the physician and send o A. Continue the heparin
a catheter tip for culture. infusion and monitor the
platelet count.
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o B. Discontinue heparin and o C. Increase the suction
notify the physician. pressure.
o C. Administer vitamin K to o D. Administer supplemental
reverse the effects of heparin. oxygen.
o D. Initiate warfarin therapy to 16. A patient with a history of COPD
replace heparin. presents with dyspnea, oxygen
saturation of 88%, and pH 7.31. The
13. A postoperative patient develops a low-
nurse notes the patient has been on 4
grade fever, decreased breath sounds,
L/min of oxygen via nasal cannula. What
and inspiratory crackles. Which
is the most appropriate intervention?
complication should the nurse suspect?
o A. Increase oxygen flow rate to
o A. Atelectasis.
6 L/min.
o B. Pulmonary embolism.
o B. Reduce oxygen to 2 L/min
o C. Pneumonia. and encourage pursed-lip
breathing.
o D. Pleural effusion.
o C. Prepare for intubation and
14. A patient in the intensive care unit (ICU) mechanical ventilation.
develops agitation, a heart rate of 150
bpm, and diaphoresis while on o D. Administer a bronchodilator
mechanical ventilation. Which condition via nebulization.
is the nurse most concerned about?
17. A patient with infective endocarditis
o A. Acute respiratory distress develops sudden onset of left-sided
syndrome (ARDS). hemiplegia and slurred speech. What
should the nurse suspect?
o B. Ventilator-associated
pneumonia. o A. Septic emboli to the brain.
o C. Airway obstruction. o B. Transient ischemic attack
(TIA).
o D. Delirium tremens.
o C. Hemorrhagic stroke.
15. A nurse observes that a patient’s chest
tube drainage has abruptly stopped. o D. Progressive valvular
The patient appears dyspneic and has dysfunction.
diminished breath sounds on the
18. A nurse is caring for a patient with acute
affected side. What should the nurse do
ischemic stroke who is receiving tissue
first?
plasminogen activator (tPA). Which
o A. Assess the chest tube system finding requires immediate
for kinks or clots. discontinuation of the infusion?
o B. Notify the physician o A. Sudden onset of severe
immediately. headache.
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o B. Blood pressure of 160/90 o D. Bilateral brisk pupillary
mmHg. reflexes.
o C. Blood glucose of 60 mg/dL. 22. A patient with a colostomy reports
leakage of stool around the stoma.
o D. Decreased level of
What is the nurse's most appropriate
consciousness.
response?
19. A patient with a history of peptic ulcer
o A. Suggest the patient wear a
disease is admitted with severe
smaller pouching system.
abdominal pain and a rigid, board-like
abdomen. Which complication is most o B. Check the stoma size and
likely? recommend a refitting.
o A. Peritonitis. o C. Increase the frequency of
pouch changes.
o B. Gastrointestinal bleeding.
o D. Clean the stoma area with
o C. Bowel obstruction.
antiseptic and reapply the
o D. Gastric carcinoma. pouch.
20. A patient with newly diagnosed type 1 23. A nurse is teaching a patient with
diabetes is admitted with diabetic asthma how to use a peak flow meter.
ketoacidosis (DKA). Which laboratory What instruction should the nurse
finding would confirm the diagnosis? emphasize?
o A. Serum glucose of 250 mg/dL. o A. Take a deep breath and blow
out as hard as possible into the
o B. Serum bicarbonate of 18 device.
mEq/L.
o B. Perform the measurement
o C. Arterial blood pH of 7.32. before using a bronchodilator.
o D. Presence of ketones in the o C. Average three readings for
urine. the final result.
21. A nurse is conducting a focused o D. Use the meter only when
neurological assessment on a patient asthma symptoms are present.
who had a traumatic brain injury. Which
finding suggests increasing intracranial 24. A patient receiving IV antibiotics
pressure (ICP)? develops sudden itching, facial flushing,
and difficulty breathing. What is the
o A. Decreasing blood pressure priority action?
and tachycardia.
o A. Stop the infusion
o B. Unilateral pupil dilation and immediately.
decerebrate posturing.
o B. Administer IV hydrocortisone
o C. Restlessness and Glasgow as prescribed.
Coma Scale (GCS) of 14.
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o C. Maintain airway and call for o C. Administer aspirin 325 mg
emergency assistance. orally.
o D. Prepare to administer o D. Start nitroglycerin infusion.
epinephrine.
28. A postoperative patient reports severe
25. A nurse is administering enteral feeding pain despite receiving prescribed
to a patient with a nasogastric tube. opioids. The nurse notes redness,
Before starting the feeding, what is the warmth, and swelling at the surgical
most critical action? site. What is the nurse's best action?
o A. Flush the tube with sterile o A. Reassess the pain after 30
water. minutes.
o B. Verify tube placement with o B. Notify the physician about
pH testing. possible wound infection.
o C. Check for residual gastric o C. Administer an additional
volume. dose of opioid.
o D. Ensure the patient is o D. Apply a warm compress to
positioned at a 45-degree angle. the area.
26. A patient receiving chemotherapy 29. A patient with Parkinson’s disease is
develops oral mucositis. Which prescribed levodopa-carbidopa. Which
intervention should the nurse prioritize statement by the patient indicates a
to promote comfort? need for further teaching?
o A. Encourage the use of an o A. “I will take the medication on
alcohol-based mouthwash. an empty stomach.”
o B. Administer viscous lidocaine o B. “I may experience dizziness
before meals. when standing up.”
o C. Offer acidic juices to cleanse o C. “This medication will cure my
the oral cavity. disease.”
o D. Use a hard-bristled o D. “I should avoid high-protein
toothbrush to maintain oral meals when taking this drug.”
hygiene.
30. A patient develops a sudden onset of
27. A patient in the emergency department high fever, tachycardia, and confusion
presents with severe chest pain, 12 hours after surgery. What should the
diaphoresis, and ST elevation in the nurse suspect?
anterior leads. Which is the nurse's first
o A. Systemic inflammatory
priority?
response syndrome (SIRS).
o A. Obtain a 12-lead ECG.
o B. Malignant hyperthermia.
o B. Administer oxygen at 2
o C. Postoperative infection.
L/min.
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o D. Pulmonary embolism. 34. A patient admitted for severe burns
develops dark brown urine. What is the
31. A patient with advanced liver failure
nurse’s priority?
presents with asterixis, confusion, and
lethargy. Which intervention is most o A. Administer IV fluids to
appropriate? maintain urine output.
o A. Administer lactulose as o B. Monitor for signs of infection.
prescribed.
o C. Obtain a urine sample for
o B. Restrict dietary protein culture and sensitivity.
intake.
o D. Notify the physician to
o C. Provide IV vitamin K initiate dialysis.
supplementation.
35. A patient with a history of myocardial
o D. Start paracentesis for ascites. infarction is prescribed beta-blockers.
Which finding indicates the need for
32. During a blood transfusion, the patient
immediate intervention?
develops back pain, hypotension, and
hemoglobinuria. What complication o A. Heart rate of 50 bpm.
should the nurse suspect?
o B. Blood pressure of 130/80
o A. Febrile non-hemolytic mmHg.
reaction.
o C. Occasional premature
o B. Acute hemolytic reaction. ventricular contractions.
o C. Anaphylactic shock. o D. Fatigue and weakness after
activity.
o D. Transfusion-associated
circulatory overload. 36. nurse is caring for a patient with
nephrotic syndrome who develops
33. A nurse is caring for a patient with
generalized edema. Which laboratory
Guillain-Barré syndrome experiencing
value would most likely correlate with
ascending paralysis. What is the priority
this finding?
assessment?
o A. Decreased serum albumin.
o A. Motor strength in the upper
extremities. o B. Increased blood urea
nitrogen (BUN).
o B. Reflexes in the lower
extremities. o C. Elevated serum sodium.
o C. Respiratory rate and effort. o D. Decreased serum creatinine.
o D. Sensation in the distal 37. A patient with a history of atrial
extremities. fibrillation presents with sudden-onset
left lower leg pain, pallor, and
pulselessness. What should the nurse
suspect?
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o A. Arterial embolism. 41. A nurse finds a patient unconscious and
pulseless. The defibrillator shows a
o B. Deep vein thrombosis.
rhythm consistent with ventricular
o C. Acute compartment fibrillation. What is the nurse’s
syndrome. immediate action?
o D. Peripheral neuropathy. o A. Start chest compressions.
38. A nurse is preparing to administer a o B. Administer epinephrine.
second dose of chemotherapy to a
o C. Deliver a defibrillation shock.
patient. Which assessment finding
would warrant delaying the infusion? o D. Secure the patient’s airway.
o A. Platelet count of 42. A nurse is caring for a patient who is
75,000/mm³. NPO and receiving continuous enteral
feeding via a nasogastric tube. The
o B. Hemoglobin of 12 g/dL.
patient starts vomiting. What is the
o C. Neutrophil count of nurse’s priority action?
1,500/mm³.
o A. Stop the feeding
o D. Total bilirubin of 1 mg/dL. immediately.
39. A patient with septic shock is receiving o B. Check tube placement with
norepinephrine. Which assessment an X-ray.
finding indicates the drug is having its
o C. Elevate the head of the bed.
intended effect?
o D. Administer an antiemetic.
o A. Increased urine output.
43. A patient receiving IV fluids develops
o B. Warm, flushed skin.
crackles in the lungs and jugular vein
o C. Decreased heart rate. distension. What is the nurse’s next
step?
o D. Reduced respiratory rate.
o A. Decrease the IV fluid infusion
40. A nurse observes paradoxical chest rate.
movement in a patient with chest
trauma. What is the priority nursing o B. Administer diuretics as
intervention? prescribed.
o A. Administer supplemental o C. Elevate the head of the bed
oxygen. to 90 degrees.
o B. Prepare for chest tube o D. Notify the healthcare
insertion. provider immediately.
o C. Immobilize the chest wall. 44. A patient with a tracheostomy has thick
secretions and reports difficulty
o D. Call for immediate breathing. What is the most appropriate
intubation. intervention?
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o A. Perform tracheostomy o B. Prepare for endoscopic
suctioning. variceal ligation.
o B. Increase the flow rate of o C. Insert a nasogastric tube for
humidified oxygen. decompression.
o C. Encourage the patient to o D. Start IV fluids to maintain
cough forcefully. hemodynamic stability.
o D. Replace the tracheostomy 48. A patient with a chest tube for
tube. hemothorax drainage has 200 mL of
bright red output in 1 hour. What is the
45. A nurse is assessing a patient who is 4
nurse's priority action?
hours postoperative from abdominal
surgery. Which finding requires o A. Assess the patient for signs of
immediate intervention? hypovolemia.
o A. Urine output of 20 mL/hr. o B. Reposition the chest tube to
improve drainage.
o B. Temperature of 37.8°C
(100°F). o C. Notify the healthcare
provider immediately.
o C. Blood pressure of 110/70
mmHg. o D. Increase the suction level of
the drainage system.
o D. Pain level of 8/10 on a
numeric scale. 49. A nurse is caring for a patient receiving
total parenteral nutrition (TPN). Which
46. A patient with an external fixator for a
finding would require immediate
fractured femur reports severe pain
action?
unrelieved by analgesics. The nurse
notes swelling, pallor, and decreased o A. Blood glucose of 250 mg/dL.
capillary refill. What should the nurse
o B. Serum potassium of 3.5
suspect?
mEq/L.
o A. Compartment syndrome.
o C. Temperature of 38.5°C
o B. Osteomyelitis. (101.3°F).
o C. Venous thromboembolism. o D. Slightly cloudy TPN solution.
o D. Displacement of the fracture. 50. A patient with a diagnosis of acute
pancreatitis has a serum calcium level of
47. A patient with a history of liver cirrhosis
7.8 mg/dL. Which clinical manifestation
presents with hematemesis and is
should the nurse monitor for?
diagnosed with esophageal varices.
Which intervention should the nurse o A. Tetany and positive
prioritize? Chvostek’s sign.
o A. Administer a proton pump o B. Polyuria and polydipsia.
inhibitor.
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o C. Generalized edema and
ascites.
o D. Hyperreflexia and
tachycardia.
