Detailed Answer Key For Medical Surgical Exam, A+ Solutions
Course
Medical Surgical
1. A nurse is caring for a client with heart failure. Which assessment finding indicates fluid
volume excess?
A. Dry mucous membranes
B. Weight loss of 2 lb in 24 hours
C. Bilateral crackles in the lungs
D. Decreased jugular venous pressure
Correct Answer: C. Bilateral crackles in the lungs
Rationale: Fluid overload in heart failure causes pulmonary congestion, leading to crackles upon
auscultation. Dry mucous membranes and weight loss suggest dehydration, while decreased
jugular venous pressure is not consistent with fluid excess.
2. A patient with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which
finding requires immediate intervention?
A. Muscle weakness
B. Hyperactive bowel sounds
C. Peaked T waves on ECG
D. Increased urine output
Correct Answer: C. Peaked T waves on ECG
Rationale: Hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T waves are
an early sign of cardiac toxicity and require immediate treatment to prevent cardiac arrest.
3. A nurse is teaching a patient who recently experienced a myocardial infarction. Which
statement indicates understanding?
A. "I can stop taking medications when I feel better."
B. "Smoking cessation will reduce my risk of another heart attack."
C. "Exercise should be avoided permanently."
D. "Chest pain is expected after a heart attack."
Correct Answer: B. "Smoking cessation will reduce my risk of another heart attack."
,Rationale: Smoking is a major modifiable risk factor for coronary artery disease. Quitting
significantly decreases the risk of recurrent myocardial infarction.
4. Which assessment finding is most concerning in a patient receiving opioid analgesics?
A. Respiratory rate of 8 breaths/minute
B. Mild constipation
C. Drowsiness after administration
D. Dry mouth
Correct Answer: A. Respiratory rate of 8 breaths/minute
Rationale: Respiratory depression is the most serious adverse effect of opioids and requires
immediate intervention. Constipation, drowsiness, and dry mouth are common but less urgent
side effects.
5. A patient with diabetes mellitus is experiencing hypoglycemia. Which symptom would
the nurse expect?
A. Warm, dry skin
B. Polyuria
C. Diaphoresis and shakiness
D. Fruity breath odor
Correct Answer: C. Diaphoresis and shakiness
Rationale: Hypoglycemia activates the sympathetic nervous system, producing sweating,
tremors, hunger, and tachycardia. Fruity breath odor is associated with diabetic ketoacidosis.
6. Which intervention should the nurse implement first for a patient experiencing an acute
asthma attack?
A. Encourage fluid intake
B. Administer prescribed bronchodilator
C. Obtain a chest X-ray
D. Teach breathing exercises
Correct Answer: B. Administer prescribed bronchodilator
Rationale: During an acute asthma attack, restoring airway patency is the priority. Rapid-acting
bronchodilators relieve bronchospasm and improve airflow.
,7. A postoperative patient suddenly develops shortness of breath, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Pneumonia
B. Atelectasis
C. Pulmonary embolism
D. Pleural effusion
Correct Answer: C. Pulmonary embolism
Rationale: Sudden dyspnea, chest pain, and tachycardia in a postoperative patient are classic
signs of pulmonary embolism, a potentially fatal complication requiring immediate action.
8. A nurse is assessing a patient with a possible stroke. Which finding is most indicative of a
stroke?
A. Bilateral leg swelling
B. Sudden unilateral weakness
C. Chronic headache history
D. Intermittent abdominal pain
Correct Answer: B. Sudden unilateral weakness
Rationale: Sudden weakness or numbness on one side of the body is a hallmark sign of stroke
and warrants immediate evaluation.
9. A patient with cirrhosis develops ascites. What is the primary cause of ascites in this
condition?
A. Increased hemoglobin production
B. Excessive insulin secretion
C. Portal hypertension and decreased albumin
D. Increased red blood cell destruction
Correct Answer: C. Portal hypertension and decreased albumin
Rationale: Cirrhosis causes portal hypertension and reduced albumin production, leading to
fluid leakage into the abdominal cavity and development of ascites.
, 10. Which laboratory value is most important for the nurse to monitor in a patient
receiving warfarin therapy?
A. Hemoglobin A1C
B. INR
C. Serum sodium
D. White blood cell count
Correct Answer: B. INR
Rationale: The International Normalized Ratio (INR) evaluates the effectiveness and safety of
warfarin therapy. Therapeutic monitoring helps prevent both bleeding and clotting complications.
11. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD).
Which oxygen delivery method is most appropriate?
A. Nonrebreather mask at 15 L/min
B. Venturi mask delivering controlled oxygen
C. Oxygen tent
D. Simple mask at 10 L/min
Correct Answer: B. Venturi mask delivering controlled oxygen
Rationale: COPD patients are at risk for carbon dioxide retention. A Venturi mask delivers a
precise oxygen concentration, reducing the risk of suppressing the patient's respiratory drive.
12. A patient with deep vein thrombosis (DVT) suddenly develops shortness of breath.
What is the nurse's priority action?
A. Elevate the affected leg
B. Encourage ambulation
C. Assess oxygen saturation and notify the provider
D. Apply a heating pad
Correct Answer: C. Assess oxygen saturation and notify the provider
Rationale: Sudden dyspnea in a patient with DVT may indicate a pulmonary embolism, a life-
threatening emergency requiring immediate assessment and intervention.
13. Which finding is most characteristic of left-sided heart failure?
A. Hepatomegaly
B. Peripheral edema
Course
Medical Surgical
1. A nurse is caring for a client with heart failure. Which assessment finding indicates fluid
volume excess?
A. Dry mucous membranes
B. Weight loss of 2 lb in 24 hours
C. Bilateral crackles in the lungs
D. Decreased jugular venous pressure
Correct Answer: C. Bilateral crackles in the lungs
Rationale: Fluid overload in heart failure causes pulmonary congestion, leading to crackles upon
auscultation. Dry mucous membranes and weight loss suggest dehydration, while decreased
jugular venous pressure is not consistent with fluid excess.
2. A patient with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which
finding requires immediate intervention?
A. Muscle weakness
B. Hyperactive bowel sounds
C. Peaked T waves on ECG
D. Increased urine output
Correct Answer: C. Peaked T waves on ECG
Rationale: Hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T waves are
an early sign of cardiac toxicity and require immediate treatment to prevent cardiac arrest.
3. A nurse is teaching a patient who recently experienced a myocardial infarction. Which
statement indicates understanding?
A. "I can stop taking medications when I feel better."
B. "Smoking cessation will reduce my risk of another heart attack."
C. "Exercise should be avoided permanently."
D. "Chest pain is expected after a heart attack."
Correct Answer: B. "Smoking cessation will reduce my risk of another heart attack."
,Rationale: Smoking is a major modifiable risk factor for coronary artery disease. Quitting
significantly decreases the risk of recurrent myocardial infarction.
4. Which assessment finding is most concerning in a patient receiving opioid analgesics?
A. Respiratory rate of 8 breaths/minute
B. Mild constipation
C. Drowsiness after administration
D. Dry mouth
Correct Answer: A. Respiratory rate of 8 breaths/minute
Rationale: Respiratory depression is the most serious adverse effect of opioids and requires
immediate intervention. Constipation, drowsiness, and dry mouth are common but less urgent
side effects.
5. A patient with diabetes mellitus is experiencing hypoglycemia. Which symptom would
the nurse expect?
A. Warm, dry skin
B. Polyuria
C. Diaphoresis and shakiness
D. Fruity breath odor
Correct Answer: C. Diaphoresis and shakiness
Rationale: Hypoglycemia activates the sympathetic nervous system, producing sweating,
tremors, hunger, and tachycardia. Fruity breath odor is associated with diabetic ketoacidosis.
6. Which intervention should the nurse implement first for a patient experiencing an acute
asthma attack?
A. Encourage fluid intake
B. Administer prescribed bronchodilator
C. Obtain a chest X-ray
D. Teach breathing exercises
Correct Answer: B. Administer prescribed bronchodilator
Rationale: During an acute asthma attack, restoring airway patency is the priority. Rapid-acting
bronchodilators relieve bronchospasm and improve airflow.
,7. A postoperative patient suddenly develops shortness of breath, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Pneumonia
B. Atelectasis
C. Pulmonary embolism
D. Pleural effusion
Correct Answer: C. Pulmonary embolism
Rationale: Sudden dyspnea, chest pain, and tachycardia in a postoperative patient are classic
signs of pulmonary embolism, a potentially fatal complication requiring immediate action.
8. A nurse is assessing a patient with a possible stroke. Which finding is most indicative of a
stroke?
A. Bilateral leg swelling
B. Sudden unilateral weakness
C. Chronic headache history
D. Intermittent abdominal pain
Correct Answer: B. Sudden unilateral weakness
Rationale: Sudden weakness or numbness on one side of the body is a hallmark sign of stroke
and warrants immediate evaluation.
9. A patient with cirrhosis develops ascites. What is the primary cause of ascites in this
condition?
A. Increased hemoglobin production
B. Excessive insulin secretion
C. Portal hypertension and decreased albumin
D. Increased red blood cell destruction
Correct Answer: C. Portal hypertension and decreased albumin
Rationale: Cirrhosis causes portal hypertension and reduced albumin production, leading to
fluid leakage into the abdominal cavity and development of ascites.
, 10. Which laboratory value is most important for the nurse to monitor in a patient
receiving warfarin therapy?
A. Hemoglobin A1C
B. INR
C. Serum sodium
D. White blood cell count
Correct Answer: B. INR
Rationale: The International Normalized Ratio (INR) evaluates the effectiveness and safety of
warfarin therapy. Therapeutic monitoring helps prevent both bleeding and clotting complications.
11. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD).
Which oxygen delivery method is most appropriate?
A. Nonrebreather mask at 15 L/min
B. Venturi mask delivering controlled oxygen
C. Oxygen tent
D. Simple mask at 10 L/min
Correct Answer: B. Venturi mask delivering controlled oxygen
Rationale: COPD patients are at risk for carbon dioxide retention. A Venturi mask delivers a
precise oxygen concentration, reducing the risk of suppressing the patient's respiratory drive.
12. A patient with deep vein thrombosis (DVT) suddenly develops shortness of breath.
What is the nurse's priority action?
A. Elevate the affected leg
B. Encourage ambulation
C. Assess oxygen saturation and notify the provider
D. Apply a heating pad
Correct Answer: C. Assess oxygen saturation and notify the provider
Rationale: Sudden dyspnea in a patient with DVT may indicate a pulmonary embolism, a life-
threatening emergency requiring immediate assessment and intervention.
13. Which finding is most characteristic of left-sided heart failure?
A. Hepatomegaly
B. Peripheral edema
