Medical Surgical LPN RN
Assessment 1ShiftKey
1. A patient with chronic kidney disease is on a low-protein diet. What is the
rationale for this diet?
A. To reduce fluid retention
B. To decrease uremic toxins
C. To prevent hypokalemia
D. To avoid hyperglycemia
Answer: B. To decrease uremic toxins
Rationale: In chronic kidney disease, the kidneys can't filter protein waste products
effectively. A low-protein diet helps reduce the buildup of uremic toxins.
2. A client is admitted with pneumonia and has an oxygen saturation of 86% on room
air. What is the nurse’s priority action?
A. Administer antipyretics
B. Obtain sputum culture
C. Apply oxygen via nasal cannula
D. Elevate the head of the bed
Answer: C. Apply oxygen via nasal cannula
Rationale: The immediate concern is hypoxia. Oxygen should be administered to
improve oxygenation.
,3. A post-op abdominal surgery patient complains of gas pain and abdominal
distention. What is the nurse’s best action?
A. Offer a carbonated beverage
B. Encourage ambulation
C. Withhold oral intake
D. Place the patient in a supine position
Answer: B. Encourage ambulation
Rationale: Ambulation promotes peristalsis and can relieve gas pain and distention.
4. Which lab value should the nurse monitor when a patient is on warfarin therapy?
A. Platelets
B. PT/INR
C. aPTT
D. Hemoglobin
Answer: B. PT/INR
Rationale: PT/INR levels are used to monitor the effectiveness and safety of warfarin
therapy.
5. A diabetic client is diaphoretic, anxious, and has a blood glucose of 48 mg/dL.
What is the nurse’s priority intervention?
A. Administer IV insulin
B. Provide a high-protein snack
C. Give 15g of fast-acting carbohydrate
D. Notify the healthcare provider
Answer: C. Give 15g of fast-acting carbohydrate
Rationale: The patient is experiencing hypoglycemia. The priority is to raise the blood
glucose quickly with a fast-acting carbohydrate (e.g., juice or glucose tabs).
,6. Which of the following is a priority nursing diagnosis for a patient with a deep vein
thrombosis (DVT)?
A. Acute pain
B. Risk for bleeding
C. Ineffective tissue perfusion
D. Risk for infection
Answer: C. Ineffective tissue perfusion
Rationale: A DVT can impair venous return and lead to tissue hypoxia, making tissue
perfusion the priority concern.
7. A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. The patient
becomes drowsy and lethargic. What is the best action?
A. Decrease the oxygen flow rate
B. Call a rapid response
C. Place the patient in Trendelenburg position
D. Increase fluid intake
Answer: A. Decrease the oxygen flow rate
Rationale: COPD patients rely on hypoxic drive; too much oxygen can reduce their
respiratory effort.
8. A patient reports sudden severe chest pain and shortness of breath after surgery.
What should the nurse suspect?
A. Pneumothorax
B. Pulmonary embolism
C. Myocardial infarction
D. Pleuritis
Answer: B. Pulmonary embolism
, Rationale: Sudden chest pain and dyspnea after surgery are classic signs of a
pulmonary embolism.9. A patient with heart failure is receiving furosemide. Which
electrolyte imbalance should the nurse monitor for?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that can cause loss of potassium, leading to
hypokalemia.
10. A client with a new ileostomy is concerned about the consistency of the stool.
What should the nurse explain?
A. "Your stool will be formed and brown."
B. "Your stool will be liquid and continuous."
C. "You’ll pass stool once a day in the morning."
D. "Your stool will be semisolid after healing."
Answer: B. "Your stool will be liquid and continuous."
Rationale: Ileostomies drain liquid stool because they bypass the colon, where water
reabsorption occurs.
11. A nurse is caring for a patient with cirrhosis who has ascites. What is the most
appropriate nursing action?
A. Increase oral fluids
B. Place the patient in supine position
C. Restrict sodium intake
D. Administer potassium supplements
Answer: C. Restrict sodium intake
Assessment 1ShiftKey
1. A patient with chronic kidney disease is on a low-protein diet. What is the
rationale for this diet?
A. To reduce fluid retention
B. To decrease uremic toxins
C. To prevent hypokalemia
D. To avoid hyperglycemia
Answer: B. To decrease uremic toxins
Rationale: In chronic kidney disease, the kidneys can't filter protein waste products
effectively. A low-protein diet helps reduce the buildup of uremic toxins.
2. A client is admitted with pneumonia and has an oxygen saturation of 86% on room
air. What is the nurse’s priority action?
A. Administer antipyretics
B. Obtain sputum culture
C. Apply oxygen via nasal cannula
D. Elevate the head of the bed
Answer: C. Apply oxygen via nasal cannula
Rationale: The immediate concern is hypoxia. Oxygen should be administered to
improve oxygenation.
,3. A post-op abdominal surgery patient complains of gas pain and abdominal
distention. What is the nurse’s best action?
A. Offer a carbonated beverage
B. Encourage ambulation
C. Withhold oral intake
D. Place the patient in a supine position
Answer: B. Encourage ambulation
Rationale: Ambulation promotes peristalsis and can relieve gas pain and distention.
4. Which lab value should the nurse monitor when a patient is on warfarin therapy?
A. Platelets
B. PT/INR
C. aPTT
D. Hemoglobin
Answer: B. PT/INR
Rationale: PT/INR levels are used to monitor the effectiveness and safety of warfarin
therapy.
5. A diabetic client is diaphoretic, anxious, and has a blood glucose of 48 mg/dL.
What is the nurse’s priority intervention?
A. Administer IV insulin
B. Provide a high-protein snack
C. Give 15g of fast-acting carbohydrate
D. Notify the healthcare provider
Answer: C. Give 15g of fast-acting carbohydrate
Rationale: The patient is experiencing hypoglycemia. The priority is to raise the blood
glucose quickly with a fast-acting carbohydrate (e.g., juice or glucose tabs).
,6. Which of the following is a priority nursing diagnosis for a patient with a deep vein
thrombosis (DVT)?
A. Acute pain
B. Risk for bleeding
C. Ineffective tissue perfusion
D. Risk for infection
Answer: C. Ineffective tissue perfusion
Rationale: A DVT can impair venous return and lead to tissue hypoxia, making tissue
perfusion the priority concern.
7. A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. The patient
becomes drowsy and lethargic. What is the best action?
A. Decrease the oxygen flow rate
B. Call a rapid response
C. Place the patient in Trendelenburg position
D. Increase fluid intake
Answer: A. Decrease the oxygen flow rate
Rationale: COPD patients rely on hypoxic drive; too much oxygen can reduce their
respiratory effort.
8. A patient reports sudden severe chest pain and shortness of breath after surgery.
What should the nurse suspect?
A. Pneumothorax
B. Pulmonary embolism
C. Myocardial infarction
D. Pleuritis
Answer: B. Pulmonary embolism
, Rationale: Sudden chest pain and dyspnea after surgery are classic signs of a
pulmonary embolism.9. A patient with heart failure is receiving furosemide. Which
electrolyte imbalance should the nurse monitor for?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that can cause loss of potassium, leading to
hypokalemia.
10. A client with a new ileostomy is concerned about the consistency of the stool.
What should the nurse explain?
A. "Your stool will be formed and brown."
B. "Your stool will be liquid and continuous."
C. "You’ll pass stool once a day in the morning."
D. "Your stool will be semisolid after healing."
Answer: B. "Your stool will be liquid and continuous."
Rationale: Ileostomies drain liquid stool because they bypass the colon, where water
reabsorption occurs.
11. A nurse is caring for a patient with cirrhosis who has ascites. What is the most
appropriate nursing action?
A. Increase oral fluids
B. Place the patient in supine position
C. Restrict sodium intake
D. Administer potassium supplements
Answer: C. Restrict sodium intake
