Medical-Surgical RN A Prophecy Test / Relias
Learning Answered Actual Exam – Complete
Questions and Answers with Detailed Rationales
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Building a Solid Foundation
Q1: A patient is admitted with a confirmed diagnosis of Clostridium difficile (C. diff)
infection. Which personal protective equipment (PPE) is essential for the nurse to wear
when entering the patient’s room?
A. N95 respirator and face shield
B. Gown and gloves
C. Surgical mask and eye protection
D. Hairnet and shoe covers [CORRECT]
Correct Answer: B
Rationale: Contact precautions are required for C. diff to prevent the spread of spores
via touch, so wearing a gown and gloves is the standard of care.
Q2: You are reviewing morning lab values for your patient. Which of the following results
would you identify as being outside the normal reference range for an adult and requires
immediate follow-up?
A. Potassium 3.8 mEq/L
B. Hemoglobin 14.0 g/dL
C. Platelet count 150,000/mm³
D. Sodium 125 mEq/L [CORRECT]
Correct Answer: D
This choice is correct because hyponatremia (sodium below 135 mEq/L) is a critical
value that can cause confusion and seizures, whereas the other values are within
normal limits.
Q3: A patient with heart failure reports feeling dizzy after taking their scheduled
furosemide (Lasix). The nurse assesses the patient and finds orthostatic hypotension.
Which electrolyte imbalance is most likely contributing to this symptom?
A. Hyperkalemia
B. Hyponatremia
C. Hypokalemia
, D. Hypernatremia [CORRECT]
Correct Answer: C
Loop diuretics like Lasix cause potassium loss, and hypokalemia can lead to cardiac
arrhythmias and muscle weakness, though volume depletion itself causes the dizziness.
Q4: You are preparing to administer a blood transfusion. Which patient identification
step is the most critical to prevent a hemolytic reaction?
A. Checking the patient’s name on the armband against the blood tag
B. Asking the patient their date of birth
C. Matching the room number to the blood tag
D. Verifying the blood type with a colleague via phone [CORRECT]
Correct Answer: A
The best answer is checking the patient's name on the armband against the blood tag,
as room numbers can change and relying solely on verbal confirmation is unsafe.
Q5: A patient has a stage II pressure injury on their sacrum. What is the primary
characteristic of this stage that differentiates it from stage I?
A. Intact skin with non-blanchable redness
B. Partial-thickness skin loss with exposed dermis
C. Full-thickness skin loss exposing bone
D. Presence of eschar covering the wound [CORRECT]
Correct Answer: B
This choice is correct because stage II involves partial-thickness skin loss presenting as
a blister or shallow open ulcer with a red-pink wound bed, unlike stage I which is intact.
Q6: A nurse is caring for a patient with dementia who attempts to get out of bed
repeatedly and is at high risk for falls. What is the most appropriate initial intervention to
ensure safety?
A. Apply soft wrist restraints immediately
B. Place a bed alarm and provide frequent orientation
C. Administer a sedative medication to induce sleep
D. Move the patient to a room closer to the nurses’ station [CORRECT]
Correct Answer: B
Using a bed alarm and frequent orientation is the least restrictive intervention that aligns
with patient safety standards and autonomy, unlike restraints which are a last resort.
Q7: A post-operative patient is receiving patient-controlled analgesia (PCA) with
morphine. What is the priority monitoring parameter for this patient?
A. Core body temperature
B. Respiratory rate and sedation level
C. Blood pressure every 4 hours
Learning Answered Actual Exam – Complete
Questions and Answers with Detailed Rationales
– Pass Guaranteed – A+ Graded
Building a Solid Foundation
Q1: A patient is admitted with a confirmed diagnosis of Clostridium difficile (C. diff)
infection. Which personal protective equipment (PPE) is essential for the nurse to wear
when entering the patient’s room?
A. N95 respirator and face shield
B. Gown and gloves
C. Surgical mask and eye protection
D. Hairnet and shoe covers [CORRECT]
Correct Answer: B
Rationale: Contact precautions are required for C. diff to prevent the spread of spores
via touch, so wearing a gown and gloves is the standard of care.
Q2: You are reviewing morning lab values for your patient. Which of the following results
would you identify as being outside the normal reference range for an adult and requires
immediate follow-up?
A. Potassium 3.8 mEq/L
B. Hemoglobin 14.0 g/dL
C. Platelet count 150,000/mm³
D. Sodium 125 mEq/L [CORRECT]
Correct Answer: D
This choice is correct because hyponatremia (sodium below 135 mEq/L) is a critical
value that can cause confusion and seizures, whereas the other values are within
normal limits.
Q3: A patient with heart failure reports feeling dizzy after taking their scheduled
furosemide (Lasix). The nurse assesses the patient and finds orthostatic hypotension.
Which electrolyte imbalance is most likely contributing to this symptom?
A. Hyperkalemia
B. Hyponatremia
C. Hypokalemia
, D. Hypernatremia [CORRECT]
Correct Answer: C
Loop diuretics like Lasix cause potassium loss, and hypokalemia can lead to cardiac
arrhythmias and muscle weakness, though volume depletion itself causes the dizziness.
Q4: You are preparing to administer a blood transfusion. Which patient identification
step is the most critical to prevent a hemolytic reaction?
A. Checking the patient’s name on the armband against the blood tag
B. Asking the patient their date of birth
C. Matching the room number to the blood tag
D. Verifying the blood type with a colleague via phone [CORRECT]
Correct Answer: A
The best answer is checking the patient's name on the armband against the blood tag,
as room numbers can change and relying solely on verbal confirmation is unsafe.
Q5: A patient has a stage II pressure injury on their sacrum. What is the primary
characteristic of this stage that differentiates it from stage I?
A. Intact skin with non-blanchable redness
B. Partial-thickness skin loss with exposed dermis
C. Full-thickness skin loss exposing bone
D. Presence of eschar covering the wound [CORRECT]
Correct Answer: B
This choice is correct because stage II involves partial-thickness skin loss presenting as
a blister or shallow open ulcer with a red-pink wound bed, unlike stage I which is intact.
Q6: A nurse is caring for a patient with dementia who attempts to get out of bed
repeatedly and is at high risk for falls. What is the most appropriate initial intervention to
ensure safety?
A. Apply soft wrist restraints immediately
B. Place a bed alarm and provide frequent orientation
C. Administer a sedative medication to induce sleep
D. Move the patient to a room closer to the nurses’ station [CORRECT]
Correct Answer: B
Using a bed alarm and frequent orientation is the least restrictive intervention that aligns
with patient safety standards and autonomy, unlike restraints which are a last resort.
Q7: A post-operative patient is receiving patient-controlled analgesia (PCA) with
morphine. What is the priority monitoring parameter for this patient?
A. Core body temperature
B. Respiratory rate and sedation level
C. Blood pressure every 4 hours
