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220 VERIFIED QUESTIONS AND 100% CORRECT
RATIONALE FROM MEDICAL-SURGICAL NURSING TEST
BANK WITH CLINICAL JUDGMENT PRACTICE– HONAN 3RD
EDITION UPDATED FOR 2026-2027, ALREADY GRADED A+
GUARANTEED PASS
Q1.
A patient with chronic obstructive pulmonary disease (COPD) is admitted to the
medical-surgical unit for worsening shortness of breath. On assessment, the nurse
notes an SpO₂ of 88% while receiving 2 L/min oxygen via nasal cannula, a
productive cough, and clubbing of the fingernails. After administration of IV
morphine for dyspnea, the patient’s respiratory rate decreases to 10 breaths per
minute. Which finding requires immediate nursing action?
A) SpO₂ 88%
B) Productive cough with thick sputum
C) Respiratory rate of 10/min after morphine
D) Clubbing of fingernails
Answer: C
Rationale: A respiratory rate of 10/min following morphine administration is a
sign of opioid-induced respiratory depression, which can quickly lead to
hypoventilation, CO₂ retention, and respiratory arrest. While low oxygen
saturation and chronic cough are expected findings in COPD, and clubbing
develops over time, acute hypoventilation is life-threatening and requires
immediate intervention.
Q2.
A patient who is 12 hours post-thyroidectomy reports tingling around the lips and
fingertips. The nurse also observes muscle twitching in the patient’s face when
lightly tapping over the cheek. Which nursing intervention is the priority?
A) Reassure the patient this is expected after surgery
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B) Notify the provider and assess serum calcium levels
C) Apply warm compresses to the neck incision site
D) Encourage the patient to perform deep breathing exercises
Answer: B
Rationale: Tingling and muscle twitching after thyroid surgery indicate
hypocalcemia, often due to accidental removal or injury of the parathyroid glands.
This complication can progress to tetany, laryngospasm, and airway compromise.
The nurse should immediately notify the provider and check calcium levels. The
other interventions do not address the underlying emergency.
Q3.
The charge nurse is prioritizing four patients during morning rounds. Which patient
should be seen first?
A) A COPD patient whose oxygen saturation is 90% on room air
B) A post-operative patient who is reporting severe pain rated 8/10
C) A patient who developed confusion and fever within the last hour
D) A hypertensive patient with blood pressure 160/92 but no symptoms
Answer: C
Rationale: A new change in mental status with fever suggests possible sepsis or
acute infection with neurologic compromise, which is a high-priority situation.
Hypoxemia in COPD, post-op pain, and elevated blood pressure require
intervention but are not immediately life-threatening. The unstable, acutely
deteriorating patient always takes priority.
Q4.
A patient with heart failure is receiving IV furosemide. The nurse enters the room
after the patient complains of generalized weakness and painful leg cramps. Which
laboratory value is most important to assess?
A) Serum sodium
B) Serum potassium
C) Serum creatinine
D) Serum calcium
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Answer: B
Rationale: Loop diuretics such as furosemide can cause significant potassium loss,
leading to hypokalemia. Symptoms include muscle cramps, weakness, and
arrhythmias, which can be life-threatening if not corrected. While sodium and
calcium are also affected by diuretics, potassium imbalance is the most urgent and
directly linked to the patient’s presentation.
Q5.
The nurse is teaching a patient with a new colostomy about proper pouch care.
Which patient statement indicates correct understanding of the teaching?
A) “I should empty the pouch when it is one-third to one-half full.”
B) “I will only need to change the pouch once every 2 weeks.”
C) “It is normal for the skin around the stoma to be red and sore.”
D) “I should avoid cleaning the stoma with water and just leave it dry.”
Answer: A
Rationale: The colostomy pouch should be emptied when it is one-third to one-
half full to prevent leakage, odor, and detachment from excessive weight. The
pouching system is usually changed every 3–7 days, not every 2 weeks. The
peristomal skin should remain clean and intact, not irritated. Gentle cleansing with
warm water is recommended for skin protection and comfort.
Q6.
A patient with diabetes mellitus is admitted for an infected foot ulcer. The nurse
notes purulent drainage, foul odor, and erythema around the wound. The patient’s
blood glucose is 320 mg/dL despite insulin coverage. What is the nurse’s priority
intervention?
A) Reinforce diet teaching for diabetes
B) Notify the provider and prepare for IV antibiotics
C) Apply warm compresses to the wound
D) Encourage ambulation to improve circulation
Answer: B
Rationale: Poorly controlled diabetes combined with an infected wound requires
immediate IV antibiotic therapy to prevent systemic infection and sepsis. While
diet teaching and ambulation are important in long-term management, the priority
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is to control infection promptly. Warm compresses do not address the underlying
infection.
Q7.
The nurse is caring for a patient with acute pancreatitis. Which intervention has the
highest priority in the plan of care?
A) Maintaining the patient NPO and initiating IV fluids
B) Encouraging early ambulation to prevent pneumonia
C) Administering stool softeners as prescribed
D) Teaching the patient to avoid fatty foods
Answer: A
Rationale: Acute pancreatitis requires bowel rest to reduce pancreatic enzyme
stimulation. Keeping the patient NPO with aggressive IV fluid resuscitation
prevents hypovolemia and pancreatic autodigestion. Diet teaching is important for
discharge but not an immediate priority.
Q8.
A patient is admitted with suspected pulmonary embolism. The nurse notes sudden
shortness of breath, chest pain, and tachycardia. What is the nurse’s priority action?
A) Administer supplemental oxygen immediately
B) Notify the rapid response team after calling the provider
C) Place the patient in Trendelenburg position
D) Encourage the patient to cough and deep breathe
Answer: A
Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen therapy
is the first priority to correct hypoxemia. After stabilizing oxygenation, the nurse
should notify the provider or rapid response team. Trendelenburg is not indicated,
and coughing may worsen dyspnea.
Q9.
A nurse is teaching a patient with heart failure about daily self-monitoring. Which
statement indicates effective understanding?
220 VERIFIED QUESTIONS AND 100% CORRECT
RATIONALE FROM MEDICAL-SURGICAL NURSING TEST
BANK WITH CLINICAL JUDGMENT PRACTICE– HONAN 3RD
EDITION UPDATED FOR 2026-2027, ALREADY GRADED A+
GUARANTEED PASS
Q1.
A patient with chronic obstructive pulmonary disease (COPD) is admitted to the
medical-surgical unit for worsening shortness of breath. On assessment, the nurse
notes an SpO₂ of 88% while receiving 2 L/min oxygen via nasal cannula, a
productive cough, and clubbing of the fingernails. After administration of IV
morphine for dyspnea, the patient’s respiratory rate decreases to 10 breaths per
minute. Which finding requires immediate nursing action?
A) SpO₂ 88%
B) Productive cough with thick sputum
C) Respiratory rate of 10/min after morphine
D) Clubbing of fingernails
Answer: C
Rationale: A respiratory rate of 10/min following morphine administration is a
sign of opioid-induced respiratory depression, which can quickly lead to
hypoventilation, CO₂ retention, and respiratory arrest. While low oxygen
saturation and chronic cough are expected findings in COPD, and clubbing
develops over time, acute hypoventilation is life-threatening and requires
immediate intervention.
Q2.
A patient who is 12 hours post-thyroidectomy reports tingling around the lips and
fingertips. The nurse also observes muscle twitching in the patient’s face when
lightly tapping over the cheek. Which nursing intervention is the priority?
A) Reassure the patient this is expected after surgery
,2 | Page
B) Notify the provider and assess serum calcium levels
C) Apply warm compresses to the neck incision site
D) Encourage the patient to perform deep breathing exercises
Answer: B
Rationale: Tingling and muscle twitching after thyroid surgery indicate
hypocalcemia, often due to accidental removal or injury of the parathyroid glands.
This complication can progress to tetany, laryngospasm, and airway compromise.
The nurse should immediately notify the provider and check calcium levels. The
other interventions do not address the underlying emergency.
Q3.
The charge nurse is prioritizing four patients during morning rounds. Which patient
should be seen first?
A) A COPD patient whose oxygen saturation is 90% on room air
B) A post-operative patient who is reporting severe pain rated 8/10
C) A patient who developed confusion and fever within the last hour
D) A hypertensive patient with blood pressure 160/92 but no symptoms
Answer: C
Rationale: A new change in mental status with fever suggests possible sepsis or
acute infection with neurologic compromise, which is a high-priority situation.
Hypoxemia in COPD, post-op pain, and elevated blood pressure require
intervention but are not immediately life-threatening. The unstable, acutely
deteriorating patient always takes priority.
Q4.
A patient with heart failure is receiving IV furosemide. The nurse enters the room
after the patient complains of generalized weakness and painful leg cramps. Which
laboratory value is most important to assess?
A) Serum sodium
B) Serum potassium
C) Serum creatinine
D) Serum calcium
,3 | Page
Answer: B
Rationale: Loop diuretics such as furosemide can cause significant potassium loss,
leading to hypokalemia. Symptoms include muscle cramps, weakness, and
arrhythmias, which can be life-threatening if not corrected. While sodium and
calcium are also affected by diuretics, potassium imbalance is the most urgent and
directly linked to the patient’s presentation.
Q5.
The nurse is teaching a patient with a new colostomy about proper pouch care.
Which patient statement indicates correct understanding of the teaching?
A) “I should empty the pouch when it is one-third to one-half full.”
B) “I will only need to change the pouch once every 2 weeks.”
C) “It is normal for the skin around the stoma to be red and sore.”
D) “I should avoid cleaning the stoma with water and just leave it dry.”
Answer: A
Rationale: The colostomy pouch should be emptied when it is one-third to one-
half full to prevent leakage, odor, and detachment from excessive weight. The
pouching system is usually changed every 3–7 days, not every 2 weeks. The
peristomal skin should remain clean and intact, not irritated. Gentle cleansing with
warm water is recommended for skin protection and comfort.
Q6.
A patient with diabetes mellitus is admitted for an infected foot ulcer. The nurse
notes purulent drainage, foul odor, and erythema around the wound. The patient’s
blood glucose is 320 mg/dL despite insulin coverage. What is the nurse’s priority
intervention?
A) Reinforce diet teaching for diabetes
B) Notify the provider and prepare for IV antibiotics
C) Apply warm compresses to the wound
D) Encourage ambulation to improve circulation
Answer: B
Rationale: Poorly controlled diabetes combined with an infected wound requires
immediate IV antibiotic therapy to prevent systemic infection and sepsis. While
diet teaching and ambulation are important in long-term management, the priority
, 4 | Page
is to control infection promptly. Warm compresses do not address the underlying
infection.
Q7.
The nurse is caring for a patient with acute pancreatitis. Which intervention has the
highest priority in the plan of care?
A) Maintaining the patient NPO and initiating IV fluids
B) Encouraging early ambulation to prevent pneumonia
C) Administering stool softeners as prescribed
D) Teaching the patient to avoid fatty foods
Answer: A
Rationale: Acute pancreatitis requires bowel rest to reduce pancreatic enzyme
stimulation. Keeping the patient NPO with aggressive IV fluid resuscitation
prevents hypovolemia and pancreatic autodigestion. Diet teaching is important for
discharge but not an immediate priority.
Q8.
A patient is admitted with suspected pulmonary embolism. The nurse notes sudden
shortness of breath, chest pain, and tachycardia. What is the nurse’s priority action?
A) Administer supplemental oxygen immediately
B) Notify the rapid response team after calling the provider
C) Place the patient in Trendelenburg position
D) Encourage the patient to cough and deep breathe
Answer: A
Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen therapy
is the first priority to correct hypoxemia. After stabilizing oxygenation, the nurse
should notify the provider or rapid response team. Trendelenburg is not indicated,
and coughing may worsen dyspnea.
Q9.
A nurse is teaching a patient with heart failure about daily self-monitoring. Which
statement indicates effective understanding?
