1|Page
MEDICAL SURGICAL PROCTORED EXAM 2025|
BRAND NEW ACTUAL EXAM WITH 100% VERIFIED
QUESTIONS AND CORRECT SOLUTIONS|
GUARANTEED VALUE PACK| ACE YOUR GRADES.
A nurse is caring for a client who sustained a basal skull fracture. When
performing morning hygiene care, the nurse notices a thin stream of clear
drainage coming from out of the client's right nostril. Which of the following
actions should the nurse take first? - (answers)*Test the drainage for glucose.
Rationale: The greatest risk to a client who has a basal skull fracture is injury from
cerebral spinal fluid (CSF) leak; therefore, the nurse should first test the drainage
for glucose.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should
recognize that the client is at risk for autonomic dysreflexia. Which of the
following interventions should the nurse take to prevent autonomic dysreflexia? -
(answers)*Prevent bladder distention.
Rationale: Autonomic dysreflexia can occur in clients who have a spinal cord
injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an
irritation, or stimulus to the nervous system below the level of injury. Triggers of
autonomic dysreflexia include bladder distention, insertion of rectal suppository,
enemas, or a sudden change in position
A nurse is caring for a client who is being evaluated for endometrial cancer. Which
of the following findings should the nurse expect the client to report? -
(answers)*Abnormal vaginal bleeding
,2|Page
Rationale: The nurse should expect the client to experience abnormal vaginal
bleeding, including postmenopausal bleeding and bleeding between normal
periods. Abnormal vaginal bleeding is the most common finding in endometrial
cancer in premenopausal women.
A nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the
following is the priority finding the nurse should report to the provider? -
(answers)*Abdomen is distended
Rationale: When using the airway, breathing, circulation approach to client care,
the nurse should recognize the presence of abdominal distention has the
potential to compromise the client's respiratory status as the distention increases
abdominal pressure on the diaphragm and impairs ventilation. This is the priority
finding for the nurse to report
A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority? -
(answers)*Altered level of consciousness
Rationale: When using the airway, breathing, circulation approach to client care,
the nurse determines that the priority finding is for the nurse to monitor the
client's altered level of consciousness. A fracture of one of the long bones of the
body places the client is at risk for fat embolism, which causes a decrease in
oxygenation and alters the client's level of consciousness.
,3|Page
A nurse is assisting in the plan of care for a client who had a removal of the
pituitary gland. Which of the following actions should the nurse include in the
plan? - (answers)*Change the nasal drip pad as needed.
Rationale: The nurse should change the nasal drip pad as needed because the
client will have nasal packing and bloody nasal drainage until the surgical site is
healed.
A nurse is reinforcing discharge teaching with a client about how to care for a
newly created ileal conduit. Which of the following instructions should the nurse
include in the teaching? - (answers)*Empty the ostomy pouch when it is 2/3 full.
Rationale: The ileal conduit cannot store urine the way the bladder did; urine will
flow continuously into a collecting device. Emptying the device when the pouch is
2/3 full will prevent leakage, skin irritation, and infection.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg
daily following a myocardial infarction. The nurse should instruct the client that
aspirin is prescribed for clients who have coronary artery disease for which of the
following effects? - (answers)*To prevent blood clotting
Rationale: Aspirin is used to prevent clot formation by reducing platelet
aggregation. Therefore, the nurse should instruct the client the aspirin is
prescribed for clients who have coronary artery disease to prevent myocardial
infarction caused by clots in the coronary arteries.
, 4|Page
A nurse is collecting data from a client who has open-angle glaucoma. Which of
the following findings should the nurse expect? - (answers)*Loss of peripheral
vision
Rationale: The nurse should expect to find the client experiencing a gradual loss
of peripheral vision with a narrowing of the visual field with open-angle glaucoma.
A nurse is collecting data from a client who has acute gastroenteritis. Which of
the following data collection findings should the nurse identify as the priority? -
(answers)*Potassium 2.5 mEq/L
Rationale: When using the airway, breathing, circulation approach to client care,
the nurse determines that the priority finding is a potassium level of 2.5 mEq/dL.
In the presence of fluid volume deficit, potassium depletion can occur.
Complications from hypokalemia include cardiac and respiratory manifestations.
A nurse is reinforcing discharge teaching with a client who had a total abdominal
hysterectomy and a vaginal repair. Which of the following statements by the
client indicates a need for further teaching? - (answers)* "I will take a tub bath
instead of a shower."
Rationale: To reduce the risk of infection, the client should avoid tub baths
following a total abdominal hysterectomy.
MEDICAL SURGICAL PROCTORED EXAM 2025|
BRAND NEW ACTUAL EXAM WITH 100% VERIFIED
QUESTIONS AND CORRECT SOLUTIONS|
GUARANTEED VALUE PACK| ACE YOUR GRADES.
A nurse is caring for a client who sustained a basal skull fracture. When
performing morning hygiene care, the nurse notices a thin stream of clear
drainage coming from out of the client's right nostril. Which of the following
actions should the nurse take first? - (answers)*Test the drainage for glucose.
Rationale: The greatest risk to a client who has a basal skull fracture is injury from
cerebral spinal fluid (CSF) leak; therefore, the nurse should first test the drainage
for glucose.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should
recognize that the client is at risk for autonomic dysreflexia. Which of the
following interventions should the nurse take to prevent autonomic dysreflexia? -
(answers)*Prevent bladder distention.
Rationale: Autonomic dysreflexia can occur in clients who have a spinal cord
injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an
irritation, or stimulus to the nervous system below the level of injury. Triggers of
autonomic dysreflexia include bladder distention, insertion of rectal suppository,
enemas, or a sudden change in position
A nurse is caring for a client who is being evaluated for endometrial cancer. Which
of the following findings should the nurse expect the client to report? -
(answers)*Abnormal vaginal bleeding
,2|Page
Rationale: The nurse should expect the client to experience abnormal vaginal
bleeding, including postmenopausal bleeding and bleeding between normal
periods. Abnormal vaginal bleeding is the most common finding in endometrial
cancer in premenopausal women.
A nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the
following is the priority finding the nurse should report to the provider? -
(answers)*Abdomen is distended
Rationale: When using the airway, breathing, circulation approach to client care,
the nurse should recognize the presence of abdominal distention has the
potential to compromise the client's respiratory status as the distention increases
abdominal pressure on the diaphragm and impairs ventilation. This is the priority
finding for the nurse to report
A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority? -
(answers)*Altered level of consciousness
Rationale: When using the airway, breathing, circulation approach to client care,
the nurse determines that the priority finding is for the nurse to monitor the
client's altered level of consciousness. A fracture of one of the long bones of the
body places the client is at risk for fat embolism, which causes a decrease in
oxygenation and alters the client's level of consciousness.
,3|Page
A nurse is assisting in the plan of care for a client who had a removal of the
pituitary gland. Which of the following actions should the nurse include in the
plan? - (answers)*Change the nasal drip pad as needed.
Rationale: The nurse should change the nasal drip pad as needed because the
client will have nasal packing and bloody nasal drainage until the surgical site is
healed.
A nurse is reinforcing discharge teaching with a client about how to care for a
newly created ileal conduit. Which of the following instructions should the nurse
include in the teaching? - (answers)*Empty the ostomy pouch when it is 2/3 full.
Rationale: The ileal conduit cannot store urine the way the bladder did; urine will
flow continuously into a collecting device. Emptying the device when the pouch is
2/3 full will prevent leakage, skin irritation, and infection.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg
daily following a myocardial infarction. The nurse should instruct the client that
aspirin is prescribed for clients who have coronary artery disease for which of the
following effects? - (answers)*To prevent blood clotting
Rationale: Aspirin is used to prevent clot formation by reducing platelet
aggregation. Therefore, the nurse should instruct the client the aspirin is
prescribed for clients who have coronary artery disease to prevent myocardial
infarction caused by clots in the coronary arteries.
, 4|Page
A nurse is collecting data from a client who has open-angle glaucoma. Which of
the following findings should the nurse expect? - (answers)*Loss of peripheral
vision
Rationale: The nurse should expect to find the client experiencing a gradual loss
of peripheral vision with a narrowing of the visual field with open-angle glaucoma.
A nurse is collecting data from a client who has acute gastroenteritis. Which of
the following data collection findings should the nurse identify as the priority? -
(answers)*Potassium 2.5 mEq/L
Rationale: When using the airway, breathing, circulation approach to client care,
the nurse determines that the priority finding is a potassium level of 2.5 mEq/dL.
In the presence of fluid volume deficit, potassium depletion can occur.
Complications from hypokalemia include cardiac and respiratory manifestations.
A nurse is reinforcing discharge teaching with a client who had a total abdominal
hysterectomy and a vaginal repair. Which of the following statements by the
client indicates a need for further teaching? - (answers)* "I will take a tub bath
instead of a shower."
Rationale: To reduce the risk of infection, the client should avoid tub baths
following a total abdominal hysterectomy.
