Relias Med-Surg Clinical Assessment
Medical-Surgical Telemetry | Prophecy RN A
Exam Questions with Answers & Rationales
Graded A+ | 100% Pass Guaranteed
Question 1
A nurse is preparing to administer a transfusion of packed red blood cells (PRBCs)
to a client who has heart failure. Which of the following manifestations should the
nurse monitor to prevent fluid volume overload? (Select all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension
ANSWER – A, C, D
Rationale: Dyspnea, jugular vein distention, and confusion are signs of fluid
overload. Hypotension is not typical; blood pressure may rise. Gastrointestinal
bloating is non-specific.
Question 2
A nurse is caring for a client with a spinal cord injury (SCI) at T6 and suspects
autonomic dysreflexia. Which action should the nurse take first?
A. Check for a fecal impaction.
B. Examine the skin for breakdown.
C. Check the bladder for distention.
D. Place the client in a sitting position.
,ANSWER – D
Rationale: Sitting lowers blood pressure and is the least invasive first step. Then
assess and remove the trigger (bladder, bowel, skin).
Question 3
A nurse is teaching a newly licensed nurse about risk factors for wound
dehiscence. Which factors should be included? (Select all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection
ANSWER – A, C, E
Rationale: Poor nutrition, obesity, and infection increase dehiscence risk. Altered
mental status and pain meds are not direct risk factors.
Question 4
A nurse is caring for a client with an endotracheal tube on mechanical ventilation.
Which intervention reduces the risk of ventilator-associated pneumonia (VAP)?
A. Position the head of the bed flat.
B. Turn the client every 4 hours.
C. Rinse the mouth with an antimicrobial solution every 2-4 hours.
D. Perform hand hygiene only before suctioning.
ANSWER – C
Rationale: Oral care with antimicrobial rinse every 2-4 hours reduces bacterial
colonization. Head of bed should be ≥30°, turning every 2 hours, and hand hygiene
before and after suctioning.
Question 5
, A nurse is instructing a new nurse about diuretics for heart failure. Which
medication puts clients at risk for both hyperkalemia and hyponatremia?
A. Furosemide
B. Hydrochlorothiazide
C. Spironolactone
D. Bumetanide
ANSWER – C
Rationale: Spironolactone (potassium-sparing) can cause hyperkalemia and also
hyponatremia. Loop and thiazide diuretics cause hypokalemia.
Question 6
A client with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L.
Which ECG finding is most concerning?
A. Prominent U wave
B. Wide QRS complex
C. ST segment elevation
D. Prolonged PR interval
ANSWER – B
Rationale: Hyperkalemia causes widened QRS, peaked T waves, and eventually
sine wave. U waves are hypokalemia.
Question 7
A nurse is administering IV furosemide to a client with acute pulmonary edema.
Which assessment finding indicates the medication is effective?
A. Decreased urine output
B. Decreased dyspnea and crackles
C. Increased jugular venous distention
D. Increased blood pressure
Medical-Surgical Telemetry | Prophecy RN A
Exam Questions with Answers & Rationales
Graded A+ | 100% Pass Guaranteed
Question 1
A nurse is preparing to administer a transfusion of packed red blood cells (PRBCs)
to a client who has heart failure. Which of the following manifestations should the
nurse monitor to prevent fluid volume overload? (Select all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension
ANSWER – A, C, D
Rationale: Dyspnea, jugular vein distention, and confusion are signs of fluid
overload. Hypotension is not typical; blood pressure may rise. Gastrointestinal
bloating is non-specific.
Question 2
A nurse is caring for a client with a spinal cord injury (SCI) at T6 and suspects
autonomic dysreflexia. Which action should the nurse take first?
A. Check for a fecal impaction.
B. Examine the skin for breakdown.
C. Check the bladder for distention.
D. Place the client in a sitting position.
,ANSWER – D
Rationale: Sitting lowers blood pressure and is the least invasive first step. Then
assess and remove the trigger (bladder, bowel, skin).
Question 3
A nurse is teaching a newly licensed nurse about risk factors for wound
dehiscence. Which factors should be included? (Select all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection
ANSWER – A, C, E
Rationale: Poor nutrition, obesity, and infection increase dehiscence risk. Altered
mental status and pain meds are not direct risk factors.
Question 4
A nurse is caring for a client with an endotracheal tube on mechanical ventilation.
Which intervention reduces the risk of ventilator-associated pneumonia (VAP)?
A. Position the head of the bed flat.
B. Turn the client every 4 hours.
C. Rinse the mouth with an antimicrobial solution every 2-4 hours.
D. Perform hand hygiene only before suctioning.
ANSWER – C
Rationale: Oral care with antimicrobial rinse every 2-4 hours reduces bacterial
colonization. Head of bed should be ≥30°, turning every 2 hours, and hand hygiene
before and after suctioning.
Question 5
, A nurse is instructing a new nurse about diuretics for heart failure. Which
medication puts clients at risk for both hyperkalemia and hyponatremia?
A. Furosemide
B. Hydrochlorothiazide
C. Spironolactone
D. Bumetanide
ANSWER – C
Rationale: Spironolactone (potassium-sparing) can cause hyperkalemia and also
hyponatremia. Loop and thiazide diuretics cause hypokalemia.
Question 6
A client with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L.
Which ECG finding is most concerning?
A. Prominent U wave
B. Wide QRS complex
C. ST segment elevation
D. Prolonged PR interval
ANSWER – B
Rationale: Hyperkalemia causes widened QRS, peaked T waves, and eventually
sine wave. U waves are hypokalemia.
Question 7
A nurse is administering IV furosemide to a client with acute pulmonary edema.
Which assessment finding indicates the medication is effective?
A. Decreased urine output
B. Decreased dyspnea and crackles
C. Increased jugular venous distention
D. Increased blood pressure
