LATEST UPDATED NUR 242 MED SURG EXAM 4
- MEDICAL-SURGICAL NURSING | COMPLETE
EXAM WITH CORRECT ANSWERS AND
RATIONALES. A+ GUARANTEED SUCCESS
1. A nurse is caring for a client with a new
diagnosis of pulmonary embolism (PE). Which
finding requires immediate intervention?
A) Chest pain that worsens with deep
inspiration
B) Oxygen saturation of 88% on room air
C) Respiratory rate of 24 breaths per minute
D) Heart rate of 110 beats per minute
Correct answer: B
Rationale: An oxygen saturation of 88%
indicates hypoxemia requiring supplemental
oxygen. Chest pain, tachypnea, and
tachycardia are expected findings in PE but do
not require immediate intervention before
addressing hypoxemia.
2. A nurse is assessing a client with
community-acquired pneumonia. Which finding
is most consistent with this diagnosis?
,A) Dry, nonproductive cough and wheezing
B) Fever, productive cough with green sputum,
and crackles
C) Night sweats, hemoptysis, and weight loss
D) Sudden onset of severe dyspnea and
pleuritic chest pain
Correct answer: B
Rationale: Pneumonia typically presents with
fever, productive cough with purulent (green
or yellow) sputum, and crackles on
auscultation. Dry cough and wheezing suggest
asthma or bronchitis. Night sweats,
hemoptysis, and weight loss suggest
tuberculosis. Sudden dyspnea and pleuritic
pain suggest pulmonary embolism.
3. A nurse is caring for a client with a chest
tube after a thoracotomy. The nurse notes
continuous bubbling in the water seal
chamber. What is the priority action?
A) Document the finding as normal
B) Clamp the chest tube near the insertion site
C) Assess the system for an air leak
D) Increase the suction pressure
,Correct answer: C
Rationale: Continuous bubbling in the water
seal chamber indicates an air leak. The nurse
should assess the system for the source of the
leak (loose connections, cracked drainage
system). Clamping is not recommended.
Increasing suction will not resolve an air leak.
4. A nurse is providing discharge teaching to a
client with a new diagnosis of asthma. Which
statement by the client indicates
understanding of rescue versus controller
medications?
A) I will use my albuterol inhaler every day to
prevent attacks
B) I will use my fluticasone inhaler when I feel
short of breath
C) I will use my albuterol inhaler before
exercise if I have exercise-induced symptoms
D) I will stop my fluticasone when my
symptoms improve
Correct answer: C
Rationale: Albuterol is a rescue medication
used for acute symptoms or before exercise to
prevent bronchospasm. It is not a daily
, controller. Fluticasone is a controller
medication used daily for prevention, not for
acute symptoms. Controller medications
should not be stopped when symptoms
improve without provider guidance.
5. A nurse is assessing a client with chronic
obstructive pulmonary disease (COPD). Which
finding is most characteristic of emphysema?
A) Chronic cough with copious sputum
production
B) Barrel chest and pursed-lip breathing
C) Right-sided heart failure (cor pulmonale)
D) Clubbing of the fingers
Correct answer: B
Rationale: Emphysema is characterized by
barrel chest (hyperinflation), pursed-lip
breathing (to prolong expiration), and weight
loss. Chronic cough with copious sputum is
more typical of chronic bronchitis. Cor
pulmonale and clubbing occur in both but are
not the most characteristic findings.
- MEDICAL-SURGICAL NURSING | COMPLETE
EXAM WITH CORRECT ANSWERS AND
RATIONALES. A+ GUARANTEED SUCCESS
1. A nurse is caring for a client with a new
diagnosis of pulmonary embolism (PE). Which
finding requires immediate intervention?
A) Chest pain that worsens with deep
inspiration
B) Oxygen saturation of 88% on room air
C) Respiratory rate of 24 breaths per minute
D) Heart rate of 110 beats per minute
Correct answer: B
Rationale: An oxygen saturation of 88%
indicates hypoxemia requiring supplemental
oxygen. Chest pain, tachypnea, and
tachycardia are expected findings in PE but do
not require immediate intervention before
addressing hypoxemia.
2. A nurse is assessing a client with
community-acquired pneumonia. Which finding
is most consistent with this diagnosis?
,A) Dry, nonproductive cough and wheezing
B) Fever, productive cough with green sputum,
and crackles
C) Night sweats, hemoptysis, and weight loss
D) Sudden onset of severe dyspnea and
pleuritic chest pain
Correct answer: B
Rationale: Pneumonia typically presents with
fever, productive cough with purulent (green
or yellow) sputum, and crackles on
auscultation. Dry cough and wheezing suggest
asthma or bronchitis. Night sweats,
hemoptysis, and weight loss suggest
tuberculosis. Sudden dyspnea and pleuritic
pain suggest pulmonary embolism.
3. A nurse is caring for a client with a chest
tube after a thoracotomy. The nurse notes
continuous bubbling in the water seal
chamber. What is the priority action?
A) Document the finding as normal
B) Clamp the chest tube near the insertion site
C) Assess the system for an air leak
D) Increase the suction pressure
,Correct answer: C
Rationale: Continuous bubbling in the water
seal chamber indicates an air leak. The nurse
should assess the system for the source of the
leak (loose connections, cracked drainage
system). Clamping is not recommended.
Increasing suction will not resolve an air leak.
4. A nurse is providing discharge teaching to a
client with a new diagnosis of asthma. Which
statement by the client indicates
understanding of rescue versus controller
medications?
A) I will use my albuterol inhaler every day to
prevent attacks
B) I will use my fluticasone inhaler when I feel
short of breath
C) I will use my albuterol inhaler before
exercise if I have exercise-induced symptoms
D) I will stop my fluticasone when my
symptoms improve
Correct answer: C
Rationale: Albuterol is a rescue medication
used for acute symptoms or before exercise to
prevent bronchospasm. It is not a daily
, controller. Fluticasone is a controller
medication used daily for prevention, not for
acute symptoms. Controller medications
should not be stopped when symptoms
improve without provider guidance.
5. A nurse is assessing a client with chronic
obstructive pulmonary disease (COPD). Which
finding is most characteristic of emphysema?
A) Chronic cough with copious sputum
production
B) Barrel chest and pursed-lip breathing
C) Right-sided heart failure (cor pulmonale)
D) Clubbing of the fingers
Correct answer: B
Rationale: Emphysema is characterized by
barrel chest (hyperinflation), pursed-lip
breathing (to prolong expiration), and weight
loss. Chronic cough with copious sputum is
more typical of chronic bronchitis. Cor
pulmonale and clubbing occur in both but are
not the most characteristic findings.
