EPIC ADULT MED SURG NURSE 100
ASSESSMENT QUESTIONS WITH
CORRECT ANSWERS.
Course
Epic
1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD)
receiving oxygen therapy. Which finding requires immediate intervention?
A. Oxygen saturation of 91%
B. Respiratory rate of 22 breaths/min
C. Patient becoming increasingly drowsy
D. Mild productive cough
Answer: C. Patient becoming increasingly drowsy
Rationale: Increasing drowsiness may indicate carbon dioxide retention and respiratory failure in
COPD patients receiving oxygen therapy. Immediate assessment and intervention are required.
2. A patient with heart failure reports sudden shortness of breath and pink frothy sputum.
What is the nurse’s priority action?
A. Encourage oral fluids
B. Place the patient in high Fowler’s position
C. Administer pain medication
D. Prepare the patient for discharge
Answer: B. Place the patient in high Fowler’s position
Rationale: Pink frothy sputum suggests pulmonary edema. High Fowler’s position helps improve
lung expansion and reduce respiratory distress while additional interventions are initiated.
3. A nurse is assessing a postoperative patient. Which finding suggests possible deep vein
thrombosis (DVT)?
A. Bilateral leg swelling
B. Calf pain and unilateral swelling
C. Cool extremities bilaterally
D. Bounding pedal pulses
Answer: B. Calf pain and unilateral swelling
Rationale: Unilateral calf pain, warmth, and swelling are classic signs of DVT and require
immediate evaluation to prevent pulmonary embolism.
, 4. A patient with diabetes mellitus becomes shaky, diaphoretic, and confused. What should
the nurse do first?
A. Administer insulin
B. Check blood glucose level
C. Encourage exercise
D. Restrict fluids
Answer: B. Check blood glucose level
Rationale: The symptoms suggest hypoglycemia. Blood glucose should be checked immediately
to confirm the condition before treatment.
5. A nurse is caring for a patient with a nasogastric tube connected to suction. Which
assessment finding should be reported immediately?
A. Green gastric drainage
B. Dry mouth
C. Abdominal distention and absent bowel sounds
D. Mild nausea
Answer: C. Abdominal distention and absent bowel sounds
Rationale: Distention and absent bowel sounds may indicate bowel obstruction or paralytic ileus,
requiring prompt intervention.
6. A patient with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which
assessment finding is most concerning?
A. Muscle cramps
B. Peaked T waves on ECG
C. Fatigue
D. Dry skin
Answer: B. Peaked T waves on ECG
Rationale: Hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T waves are a
critical sign requiring urgent treatment.
7. A nurse is caring for a patient after thyroidectomy. Which finding indicates possible
airway compromise?
A. Hoarse voice and neck swelling
B. Mild incisional pain
C. Blood pressure 130/80 mmHg
D. Heart rate 88 beats/min
, Answer: A. Hoarse voice and neck swelling
Rationale: Hoarseness and neck swelling may indicate edema or hemorrhage compromising the
airway after thyroid surgery.
8. A patient with pneumonia suddenly develops confusion and restlessness. What is the
nurse’s priority action?
A. Reassure the patient
B. Check oxygen saturation
C. Administer sedatives
D. Restrict fluids
Answer: B. Check oxygen saturation
Rationale: Confusion and restlessness may be early signs of hypoxia. Oxygenation should be
assessed immediately.
9. A nurse is assessing a patient receiving blood transfusion therapy. Which finding suggests
a transfusion reaction?
A. Mild fatigue
B. Fever and chills
C. Increased appetite
D. Dry cough
Answer: B. Fever and chills
Rationale: Fever and chills are common signs of a transfusion reaction and require immediate
discontinuation of the transfusion.
10. A patient with a history of gastrointestinal bleeding reports black, tarry stools. What is the
nurse’s best response?
A. Document as normal finding
B. Encourage high-fiber foods
C. Notify the healthcare provider immediately
D. Administer antidiarrheal medication
Answer: C. Notify the healthcare provider immediately
Rationale: Black, tarry stools (melena) may indicate upper gastrointestinal bleeding and require
prompt medical evaluation.
11. A nurse is caring for a patient with chest pain suspected of having a myocardial
infarction. Which laboratory value is most specific for cardiac muscle injury?
ASSESSMENT QUESTIONS WITH
CORRECT ANSWERS.
Course
Epic
1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD)
receiving oxygen therapy. Which finding requires immediate intervention?
A. Oxygen saturation of 91%
B. Respiratory rate of 22 breaths/min
C. Patient becoming increasingly drowsy
D. Mild productive cough
Answer: C. Patient becoming increasingly drowsy
Rationale: Increasing drowsiness may indicate carbon dioxide retention and respiratory failure in
COPD patients receiving oxygen therapy. Immediate assessment and intervention are required.
2. A patient with heart failure reports sudden shortness of breath and pink frothy sputum.
What is the nurse’s priority action?
A. Encourage oral fluids
B. Place the patient in high Fowler’s position
C. Administer pain medication
D. Prepare the patient for discharge
Answer: B. Place the patient in high Fowler’s position
Rationale: Pink frothy sputum suggests pulmonary edema. High Fowler’s position helps improve
lung expansion and reduce respiratory distress while additional interventions are initiated.
3. A nurse is assessing a postoperative patient. Which finding suggests possible deep vein
thrombosis (DVT)?
A. Bilateral leg swelling
B. Calf pain and unilateral swelling
C. Cool extremities bilaterally
D. Bounding pedal pulses
Answer: B. Calf pain and unilateral swelling
Rationale: Unilateral calf pain, warmth, and swelling are classic signs of DVT and require
immediate evaluation to prevent pulmonary embolism.
, 4. A patient with diabetes mellitus becomes shaky, diaphoretic, and confused. What should
the nurse do first?
A. Administer insulin
B. Check blood glucose level
C. Encourage exercise
D. Restrict fluids
Answer: B. Check blood glucose level
Rationale: The symptoms suggest hypoglycemia. Blood glucose should be checked immediately
to confirm the condition before treatment.
5. A nurse is caring for a patient with a nasogastric tube connected to suction. Which
assessment finding should be reported immediately?
A. Green gastric drainage
B. Dry mouth
C. Abdominal distention and absent bowel sounds
D. Mild nausea
Answer: C. Abdominal distention and absent bowel sounds
Rationale: Distention and absent bowel sounds may indicate bowel obstruction or paralytic ileus,
requiring prompt intervention.
6. A patient with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which
assessment finding is most concerning?
A. Muscle cramps
B. Peaked T waves on ECG
C. Fatigue
D. Dry skin
Answer: B. Peaked T waves on ECG
Rationale: Hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T waves are a
critical sign requiring urgent treatment.
7. A nurse is caring for a patient after thyroidectomy. Which finding indicates possible
airway compromise?
A. Hoarse voice and neck swelling
B. Mild incisional pain
C. Blood pressure 130/80 mmHg
D. Heart rate 88 beats/min
, Answer: A. Hoarse voice and neck swelling
Rationale: Hoarseness and neck swelling may indicate edema or hemorrhage compromising the
airway after thyroid surgery.
8. A patient with pneumonia suddenly develops confusion and restlessness. What is the
nurse’s priority action?
A. Reassure the patient
B. Check oxygen saturation
C. Administer sedatives
D. Restrict fluids
Answer: B. Check oxygen saturation
Rationale: Confusion and restlessness may be early signs of hypoxia. Oxygenation should be
assessed immediately.
9. A nurse is assessing a patient receiving blood transfusion therapy. Which finding suggests
a transfusion reaction?
A. Mild fatigue
B. Fever and chills
C. Increased appetite
D. Dry cough
Answer: B. Fever and chills
Rationale: Fever and chills are common signs of a transfusion reaction and require immediate
discontinuation of the transfusion.
10. A patient with a history of gastrointestinal bleeding reports black, tarry stools. What is the
nurse’s best response?
A. Document as normal finding
B. Encourage high-fiber foods
C. Notify the healthcare provider immediately
D. Administer antidiarrheal medication
Answer: C. Notify the healthcare provider immediately
Rationale: Black, tarry stools (melena) may indicate upper gastrointestinal bleeding and require
prompt medical evaluation.
11. A nurse is caring for a patient with chest pain suspected of having a myocardial
infarction. Which laboratory value is most specific for cardiac muscle injury?
