ADVANCED MED-SURG CJE
COMPREHENSIVE
STUDY GUIDE
SECTION 1: RESPIRATORY ASSESSMENT & INTERVENTIONS
QUESTION 1
A client had total hip arthroplasty 2 days ago. Assessment: alert and oriented x4, clear
speech, even shallow respirations with slight tachypnea, low-pitched rhonchi in bases
bilaterally, productive cough with green sputum, T 100.9°F, SpO2 88% RA. History: obesity,
severe osteoarthritis, HTN, former smoker. What condition is the client experiencing and
what actions should the nurse take?
ANSWER
Condition: Pneumonia
Actions:
• Administer oxygen 2 L via NC
• Administer acetaminophen for fever
Monitor:
• Oxygen saturation
• Temperature
RATIONALE / EXPLANATION
Green sputum, rhonchi, fever, and low SpO2 indicate pneumonia - a common post-op
complication. Priority is oxygenation (SpO2 88% is too low) and fever management. Continue
monitoring respiratory status.
QUESTION 2
A client with COPD arrives in the ED with audible inspiratory and expiratory wheezes, use of
accessory muscles, reports shortness of breath, and oxygen saturation of 86%. What is the
nurse's priority action?
ANSWER
Apply supplemental oxygen
Page 1 of 32
,RATIONALE / EXPLANATION
SpO2 86% indicates hypoxemia requiring immediate oxygen therapy. In COPD, start with low-
flow oxygen (1-2 L/min) to avoid suppressing hypoxic drive. Assess response and titrate
accordingly.
QUESTION 3
The nurse cares for a client with a tracheostomy and notes a cuff pressure of 12 cm H2O.
What is the priority action?
ANSWER
Inflate the cuff to 20 cm H2O
RATIONALE / EXPLANATION
Normal tracheostomy cuff pressure is 20-25 cm H2O. Pressure of 12 cm H2O is too low, risking
aspiration and air leak. Inflate to appropriate pressure to maintain seal and prevent
complications.
QUESTION 4
A client is in the ED after sustaining partial and full-thickness burns to the chest and neck
after a house fire. Transport note: soot around nares, inspiratory wheezes, T 99.8°F, HR
126, RR 14, BP 170/96, SpO2 90% on 6L via non-rebreather mask. What is the nurse's
priority action?
ANSWER
Perform a respiratory assessment
RATIONALE / EXPLANATION
Burns to chest/neck with soot around nares and wheezes indicate possible inhalation injury - a
life-threatening emergency. Assess airway immediately; prepare for potential intubation if airway
edema develops.
QUESTION 5
The nurse cares for a client with a left side pneumothorax that requires a chest tube
insertion. Where should the chest tube be inserted?
ANSWER
Left midaxillary line at the 4th-5th intercostal space
Page 2 of 32
,RATIONALE / EXPLANATION
Chest tubes for pneumothorax are placed in the "triangle of safety" - bordered by the lateral edge
of pectoralis major, lateral edge of latissimus dorsi, and a line at the level of the nipple (4th-5th
intercostal space).
Page 3 of 32
, SECTION 2: CARDIOVASCULAR & CIRCULATION
QUESTION 6
A client prescribed furosemide 40 mg PO daily for left-sided heart failure. Nursing note:
Crackles in bilateral lung bases, can ambulate to bathroom without SOB, T 98.2°F, HR 86,
RR 18, BP 140/68. What data indicates treatment is effective?
ANSWER
Client reports they can ambulate to the bathroom and back without shortness
of breath.
RATIONALE / EXPLANATION
Improved exercise tolerance (ambulating without SOB) indicates the diuretic is reducing
pulmonary congestion. Crackles may still be present but functional improvement is a positive
outcome.
QUESTION 7
The ED nurse suspects stroke for a client with numbness and drooping of the right side of
face and difficulty understanding speech. Which cardiac rhythm is most likely associated with
the stroke?
ANSWER
Atrial fibrillation
RATIONALE / EXPLANATION
A-fib causes irregular atrial contractions that allow blood to pool and form clots. These clots can
travel to the brain causing embolic stroke. A-fib is the most common cause of cardioembolic
stroke.
QUESTION 8
A client with history of angina arrives at a facility without a cardiac cath lab. Has taken 3
nitroglycerin tablets without relief. Reports chest pain x 1 hour, nausea, vomiting. Cool,
clammy, pale skin. History: HTN, ischemic stroke 8 months ago, Crohn's disease. ECG
shows ST elevation in V5, V6, and Lead II. What data contraindicates fibrinolytic therapy?
ANSWER
Stroke history
Page 4 of 32
COMPREHENSIVE
STUDY GUIDE
SECTION 1: RESPIRATORY ASSESSMENT & INTERVENTIONS
QUESTION 1
A client had total hip arthroplasty 2 days ago. Assessment: alert and oriented x4, clear
speech, even shallow respirations with slight tachypnea, low-pitched rhonchi in bases
bilaterally, productive cough with green sputum, T 100.9°F, SpO2 88% RA. History: obesity,
severe osteoarthritis, HTN, former smoker. What condition is the client experiencing and
what actions should the nurse take?
ANSWER
Condition: Pneumonia
Actions:
• Administer oxygen 2 L via NC
• Administer acetaminophen for fever
Monitor:
• Oxygen saturation
• Temperature
RATIONALE / EXPLANATION
Green sputum, rhonchi, fever, and low SpO2 indicate pneumonia - a common post-op
complication. Priority is oxygenation (SpO2 88% is too low) and fever management. Continue
monitoring respiratory status.
QUESTION 2
A client with COPD arrives in the ED with audible inspiratory and expiratory wheezes, use of
accessory muscles, reports shortness of breath, and oxygen saturation of 86%. What is the
nurse's priority action?
ANSWER
Apply supplemental oxygen
Page 1 of 32
,RATIONALE / EXPLANATION
SpO2 86% indicates hypoxemia requiring immediate oxygen therapy. In COPD, start with low-
flow oxygen (1-2 L/min) to avoid suppressing hypoxic drive. Assess response and titrate
accordingly.
QUESTION 3
The nurse cares for a client with a tracheostomy and notes a cuff pressure of 12 cm H2O.
What is the priority action?
ANSWER
Inflate the cuff to 20 cm H2O
RATIONALE / EXPLANATION
Normal tracheostomy cuff pressure is 20-25 cm H2O. Pressure of 12 cm H2O is too low, risking
aspiration and air leak. Inflate to appropriate pressure to maintain seal and prevent
complications.
QUESTION 4
A client is in the ED after sustaining partial and full-thickness burns to the chest and neck
after a house fire. Transport note: soot around nares, inspiratory wheezes, T 99.8°F, HR
126, RR 14, BP 170/96, SpO2 90% on 6L via non-rebreather mask. What is the nurse's
priority action?
ANSWER
Perform a respiratory assessment
RATIONALE / EXPLANATION
Burns to chest/neck with soot around nares and wheezes indicate possible inhalation injury - a
life-threatening emergency. Assess airway immediately; prepare for potential intubation if airway
edema develops.
QUESTION 5
The nurse cares for a client with a left side pneumothorax that requires a chest tube
insertion. Where should the chest tube be inserted?
ANSWER
Left midaxillary line at the 4th-5th intercostal space
Page 2 of 32
,RATIONALE / EXPLANATION
Chest tubes for pneumothorax are placed in the "triangle of safety" - bordered by the lateral edge
of pectoralis major, lateral edge of latissimus dorsi, and a line at the level of the nipple (4th-5th
intercostal space).
Page 3 of 32
, SECTION 2: CARDIOVASCULAR & CIRCULATION
QUESTION 6
A client prescribed furosemide 40 mg PO daily for left-sided heart failure. Nursing note:
Crackles in bilateral lung bases, can ambulate to bathroom without SOB, T 98.2°F, HR 86,
RR 18, BP 140/68. What data indicates treatment is effective?
ANSWER
Client reports they can ambulate to the bathroom and back without shortness
of breath.
RATIONALE / EXPLANATION
Improved exercise tolerance (ambulating without SOB) indicates the diuretic is reducing
pulmonary congestion. Crackles may still be present but functional improvement is a positive
outcome.
QUESTION 7
The ED nurse suspects stroke for a client with numbness and drooping of the right side of
face and difficulty understanding speech. Which cardiac rhythm is most likely associated with
the stroke?
ANSWER
Atrial fibrillation
RATIONALE / EXPLANATION
A-fib causes irregular atrial contractions that allow blood to pool and form clots. These clots can
travel to the brain causing embolic stroke. A-fib is the most common cause of cardioembolic
stroke.
QUESTION 8
A client with history of angina arrives at a facility without a cardiac cath lab. Has taken 3
nitroglycerin tablets without relief. Reports chest pain x 1 hour, nausea, vomiting. Cool,
clammy, pale skin. History: HTN, ischemic stroke 8 months ago, Crohn's disease. ECG
shows ST elevation in V5, V6, and Lead II. What data contraindicates fibrinolytic therapy?
ANSWER
Stroke history
Page 4 of 32
