Medical-Surgical Nursing Exam 1 Questions & Answers (2025/2026 update) –
Latest Questions & Answers| Questions & Answers| Grade A+| 100% Correct
(Verified Solutions)-
Question 1
The nurse is caring for a client who has a son with a streptococcus throat infection. Which nurse
recommendation would be best to advise the client to do in order to prevent acquiring the
infection?
A) Take prophylactic antibiotics for 10 days.
B) Avoid all contact with the son for two weeks.
C) Frequently wash her hands and surfaces of the home.
D) Wear a mask at all times when inside the house.
E) Gargle with salt water three times daily.
Correct Answer: C) Frequently wash her hands and surfaces of the home.
Rationale: Streptococcus pyogenes is primarily transmitted through respiratory droplets
and direct contact with contaminated surfaces or secretions. Handwashing is the single
most effective intervention in breaking the chain of infection. Cleaning surfaces prevents
the spread of pathogens that can live on inanimate objects (fomites).
Question 2
The nurse is caring for a client infected with Rocky Mountain spotted fever. The nurse should
ask if the client has experienced which of the following?
A) Being bitten by a tick.
B) Consumption of raw shellfish.
C) Travel to a tropical rainforest.
D) Contact with stagnant water.
E) Recent exposure to someone with a skin rash.
Correct Answer: A) Was bitten by a tick
Rationale: Rocky Mountain spotted fever is a bacterial disease caused by Rickettsia
rickettsii, which is transmitted to humans through the bite of an infected tick (specifically
the American dog tick, Rocky Mountain wood tick, or brown dog tick). A history of tick
exposure is a critical diagnostic clue.
Question 3
The nurse is caring for a client with a protozoa infection. Which is the most likely mode of
transmission?
A) Inhalation of airborne droplets.
B) Ingestion of contaminated food or water.
C) Direct skin-to-skin contact.
D) Exposure to contaminated blood.
E) Genetic predisposition.
, 2
Correct Answer: B) Ingestion of contaminated food or water
Rationale: Most protozoal infections, such as Giardiasis or Cryptosporidiosis, are
transmitted via the fecal-oral route. This typically occurs when a person ingests cysts found
in contaminated water or food sources. While some protozoa are transmitted via vectors
(like Malaria), food and water are the most common general modes for this class.
Question 4
The nurse is caring for a client who is recovering from an allergic reaction. Which leukocyte
level would the nurse expect to be the most elevated?
A) Neutrophils
B) Monocytes
C) Lymphocytes
D) Basophils
E) Eosinophils
Correct Answer: E) Eosinophils
Rationale: Eosinophils are a type of white blood cell specifically involved in responding to
parasitic infections and allergic reactions. During a hypersensitivity reaction, the body
increases eosinophil production to help neutralize histamine and other inflammatory
mediators.
Question 5
The nurse is caring for a client who has an infected wound on the great toe that is red with a
purulent exudate. The nurse expects that this client has which type of infection?
A) Systemic
B) Secondary
C) Localized
D) Opportunistic
E) Latent
Correct Answer: C) Localized
Rationale: A localized infection is restricted to one specific area of the body. Symptoms like
redness (erythema), heat, swelling, and purulent exudate (pus) at the site of the toe indicate
that the infectious process is contained in that specific tissue rather than spreading
throughout the bloodstream.
Question 6
The client experienced a fall. Nursing assessment reveals that the client is experiencing
tachycardia, hypotension, confusion, tachypnea, and flat jugular veins. What should be the
nurse's first response?
A) Obtain a 12-lead ECG.
B) Administer oxygen.
, 3
C) Elevate the head of the bed.
D) Check the client’s blood glucose.
E) Start a large-bore IV line.
Correct Answer: B) Administer oxygen.
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the nurse
must ensure adequate oxygenation first. In shock states (indicated by tachycardia and
hypotension), the tissues are deprived of oxygen. Administering supplemental oxygen is the
most immediate action to improve tissue perfusion and cellular function.
Question 7
The family wants to know why the nurse is putting a urinary catheter in a client experiencing
shock. What is the nurse's best response?
A) "It prevents the client from becoming incontinent while confused."
B) "It helps us collect sterile samples for infection testing."
C) "It will help monitor how much urine the kidneys are able to produce."
D) "It is standard procedure for all clients admitted to the unit."
E) "It reduces the risk of skin breakdown during recovery."
Correct Answer: C) "It will help monitor how much urine the kidneys are able to produce."
Rationale: Urine output is a primary indicator of visceral organ perfusion. In shock, the
body shunts blood away from the kidneys to the heart and brain. A urinary catheter allows
for hourly measurement; an output of less than 30 mL/hr indicates inadequate renal
perfusion and worsening shock.
Question 8
A client experiencing shock has had a urinary output of 250 mL in the last 10 hours. What is the
nurse's most appropriate response?
A) Document the finding as normal.
B) Increase the rate of IV fluids.
C) Perform a bladder scan.
D) Notify the physician.
E) Encourage the client to drink more fluids.
Correct Answer: D) Notify the physician.
Rationale: While 250 mL over 10 hours averages to 25 mL/hr, this is below the standard
minimum of 30 mL/hr. In the context of shock, any decrease in renal output is a significant
sign of declining cardiac output or worsening fluid volume deficit and requires immediate
medical intervention.
Question 9
Which client is most likely to be experiencing hypovolemic shock?
, 4
A) A client with a massive myocardial infarction.
B) A client who had surgery 24 hours ago and who also has a nasogastric tube.
C) A client with a spinal cord injury at the T4 level.
D) A client with a severe allergic reaction to penicillin.
E) A client with an overwhelming systemic bacterial infection.
Correct Answer: B) A client who had surgery 24 hours ago and who also has a nasogastric
tube.
Rationale: Hypovolemic shock is caused by a loss of intravascular fluid. Postoperative
clients are at risk due to potential surgical blood loss, and a nasogastric tube can further
deplete fluids and electrolytes through continuous suctioning, leading to a volume deficit.
Question 10
The physician has ordered arterial blood gases (ABGs) for a client experiencing shock. The nurse
knows that which value indicates shock?
A) pH 7.45
B) PaO2 95 mmHg
C) pH 7.32
D) HCO3 24 mEq/L
E) PaCO2 38 mmHg
Correct Answer: C) pH 7.32
Rationale: Shock leads to poor tissue perfusion and a shift from aerobic to anaerobic
metabolism, resulting in the buildup of lactic acid. This cause metabolic acidosis, which is
reflected by a pH lower than the normal range of 7.35–7.45.
Question 11
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first
response?
A) Apply a cold compress.
B) Assess for pain.
C) Notify the surgeon.
D) Document the finding.
E) Elevate the leg on two pillows.
Correct Answer: B) Assess for pain.
Rationale: The first step of the nursing process is assessment. When a client reports a
subjective symptom (like a feeling of heat), the nurse must gather more data, including
checking for pain, redness, swelling, and pulses, to determine if the client is developing a
complication like a Deep Vein Thrombosis (DVT) or infection.
Latest Questions & Answers| Questions & Answers| Grade A+| 100% Correct
(Verified Solutions)-
Question 1
The nurse is caring for a client who has a son with a streptococcus throat infection. Which nurse
recommendation would be best to advise the client to do in order to prevent acquiring the
infection?
A) Take prophylactic antibiotics for 10 days.
B) Avoid all contact with the son for two weeks.
C) Frequently wash her hands and surfaces of the home.
D) Wear a mask at all times when inside the house.
E) Gargle with salt water three times daily.
Correct Answer: C) Frequently wash her hands and surfaces of the home.
Rationale: Streptococcus pyogenes is primarily transmitted through respiratory droplets
and direct contact with contaminated surfaces or secretions. Handwashing is the single
most effective intervention in breaking the chain of infection. Cleaning surfaces prevents
the spread of pathogens that can live on inanimate objects (fomites).
Question 2
The nurse is caring for a client infected with Rocky Mountain spotted fever. The nurse should
ask if the client has experienced which of the following?
A) Being bitten by a tick.
B) Consumption of raw shellfish.
C) Travel to a tropical rainforest.
D) Contact with stagnant water.
E) Recent exposure to someone with a skin rash.
Correct Answer: A) Was bitten by a tick
Rationale: Rocky Mountain spotted fever is a bacterial disease caused by Rickettsia
rickettsii, which is transmitted to humans through the bite of an infected tick (specifically
the American dog tick, Rocky Mountain wood tick, or brown dog tick). A history of tick
exposure is a critical diagnostic clue.
Question 3
The nurse is caring for a client with a protozoa infection. Which is the most likely mode of
transmission?
A) Inhalation of airborne droplets.
B) Ingestion of contaminated food or water.
C) Direct skin-to-skin contact.
D) Exposure to contaminated blood.
E) Genetic predisposition.
, 2
Correct Answer: B) Ingestion of contaminated food or water
Rationale: Most protozoal infections, such as Giardiasis or Cryptosporidiosis, are
transmitted via the fecal-oral route. This typically occurs when a person ingests cysts found
in contaminated water or food sources. While some protozoa are transmitted via vectors
(like Malaria), food and water are the most common general modes for this class.
Question 4
The nurse is caring for a client who is recovering from an allergic reaction. Which leukocyte
level would the nurse expect to be the most elevated?
A) Neutrophils
B) Monocytes
C) Lymphocytes
D) Basophils
E) Eosinophils
Correct Answer: E) Eosinophils
Rationale: Eosinophils are a type of white blood cell specifically involved in responding to
parasitic infections and allergic reactions. During a hypersensitivity reaction, the body
increases eosinophil production to help neutralize histamine and other inflammatory
mediators.
Question 5
The nurse is caring for a client who has an infected wound on the great toe that is red with a
purulent exudate. The nurse expects that this client has which type of infection?
A) Systemic
B) Secondary
C) Localized
D) Opportunistic
E) Latent
Correct Answer: C) Localized
Rationale: A localized infection is restricted to one specific area of the body. Symptoms like
redness (erythema), heat, swelling, and purulent exudate (pus) at the site of the toe indicate
that the infectious process is contained in that specific tissue rather than spreading
throughout the bloodstream.
Question 6
The client experienced a fall. Nursing assessment reveals that the client is experiencing
tachycardia, hypotension, confusion, tachypnea, and flat jugular veins. What should be the
nurse's first response?
A) Obtain a 12-lead ECG.
B) Administer oxygen.
, 3
C) Elevate the head of the bed.
D) Check the client’s blood glucose.
E) Start a large-bore IV line.
Correct Answer: B) Administer oxygen.
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the nurse
must ensure adequate oxygenation first. In shock states (indicated by tachycardia and
hypotension), the tissues are deprived of oxygen. Administering supplemental oxygen is the
most immediate action to improve tissue perfusion and cellular function.
Question 7
The family wants to know why the nurse is putting a urinary catheter in a client experiencing
shock. What is the nurse's best response?
A) "It prevents the client from becoming incontinent while confused."
B) "It helps us collect sterile samples for infection testing."
C) "It will help monitor how much urine the kidneys are able to produce."
D) "It is standard procedure for all clients admitted to the unit."
E) "It reduces the risk of skin breakdown during recovery."
Correct Answer: C) "It will help monitor how much urine the kidneys are able to produce."
Rationale: Urine output is a primary indicator of visceral organ perfusion. In shock, the
body shunts blood away from the kidneys to the heart and brain. A urinary catheter allows
for hourly measurement; an output of less than 30 mL/hr indicates inadequate renal
perfusion and worsening shock.
Question 8
A client experiencing shock has had a urinary output of 250 mL in the last 10 hours. What is the
nurse's most appropriate response?
A) Document the finding as normal.
B) Increase the rate of IV fluids.
C) Perform a bladder scan.
D) Notify the physician.
E) Encourage the client to drink more fluids.
Correct Answer: D) Notify the physician.
Rationale: While 250 mL over 10 hours averages to 25 mL/hr, this is below the standard
minimum of 30 mL/hr. In the context of shock, any decrease in renal output is a significant
sign of declining cardiac output or worsening fluid volume deficit and requires immediate
medical intervention.
Question 9
Which client is most likely to be experiencing hypovolemic shock?
, 4
A) A client with a massive myocardial infarction.
B) A client who had surgery 24 hours ago and who also has a nasogastric tube.
C) A client with a spinal cord injury at the T4 level.
D) A client with a severe allergic reaction to penicillin.
E) A client with an overwhelming systemic bacterial infection.
Correct Answer: B) A client who had surgery 24 hours ago and who also has a nasogastric
tube.
Rationale: Hypovolemic shock is caused by a loss of intravascular fluid. Postoperative
clients are at risk due to potential surgical blood loss, and a nasogastric tube can further
deplete fluids and electrolytes through continuous suctioning, leading to a volume deficit.
Question 10
The physician has ordered arterial blood gases (ABGs) for a client experiencing shock. The nurse
knows that which value indicates shock?
A) pH 7.45
B) PaO2 95 mmHg
C) pH 7.32
D) HCO3 24 mEq/L
E) PaCO2 38 mmHg
Correct Answer: C) pH 7.32
Rationale: Shock leads to poor tissue perfusion and a shift from aerobic to anaerobic
metabolism, resulting in the buildup of lactic acid. This cause metabolic acidosis, which is
reflected by a pH lower than the normal range of 7.35–7.45.
Question 11
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first
response?
A) Apply a cold compress.
B) Assess for pain.
C) Notify the surgeon.
D) Document the finding.
E) Elevate the leg on two pillows.
Correct Answer: B) Assess for pain.
Rationale: The first step of the nursing process is assessment. When a client reports a
subjective symptom (like a feeling of heat), the nurse must gather more data, including
checking for pain, redness, swelling, and pulses, to determine if the client is developing a
complication like a Deep Vein Thrombosis (DVT) or infection.
