TEST BANK FOR MEDICAL-SURGICAL NURSING: CLINICAL
JUDGMENT AND COLLABORATIVE CARE QUESTIONS AND
CORRECT ANSWERS 2026
1. A nurse is caring for a client admitted with acute exacerbation of heart failure.
Which assessment finding should the nurse prioritize reporting to the healthcare
provider immediately?
A. +2 pitting edema in bilateral lower extremities
B. Oxygen saturation of 92% on 2L nasal cannula
C. Crackles heard in bilateral lung bases
D. Oxygen saturation dropping to 86% with ambulation
Correct Answer: D
Explanation: A drop in oxygen saturation to 86% with ambulation indicates
significant gas exchange impairment and exercise intolerance, requiring
immediate intervention and possible oxygen therapy adjustment. The other
findings are expected in heart failure but less urgent.
2. A client with type 2 diabetes mellitus has a hemoglobin A1c of 9.2%. Which
statement by the nurse best demonstrates understanding of evidence-based
practice when teaching this client?
A. "Your blood sugar is too high, so you need to start insulin immediately."
B. "This result indicates poor glucose control over the past 3 months, and we
should review your medication, diet, and exercise plan."
C. "You need to check your blood glucose every 2 hours to get it under control."
D. "This is normal for someone with diabetes, so no changes are needed."
Correct Answer: B
Explanation: Hemoglobin A1c reflects average blood glucose over 2-3 months.
An A1c of 9.2% indicates poor control (target is typically <7%), requiring
comprehensive review of the care plan. Evidence-based practice combines
research, clinical expertise, and patient preferences.
3. A client with suspected sepsis arrives at the emergency department. Which
nursing action should be performed first according to sepsis bundle protocols?
A. Obtain blood cultures
B. Administer broad-spectrum antibiotics
C. Measure lactate level
D. Administer 30 mL/kg crystalloid fluid bolus
Correct Answer: A
Explanation: Blood cultures should be obtained BEFORE administering
antibiotics to ensure accurate identification of the causative organism. While all
, actions are part of sepsis management, cultures must precede antibiotic
administration for optimal diagnostic accuracy.
4. A postoperative client 24 hours after abdominal surgery has a temperature of
38.9°C (102°F), heart rate of 118 bpm, and wound drainage that is yellow and
foul-smelling. Which nursing diagnosis takes priority?
A. Risk for fluid volume deficit
B. Impaired tissue integrity
C. Hyperthermia related to infection
D. Ineffective tissue perfusion
Correct Answer: C
Explanation: The client shows signs of surgical site infection with systemic
involvement (fever, tachycardia). Hyperthermia related to infection is the
priority as it indicates active infection requiring immediate intervention to
prevent sepsis.
5. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88% on room air. The nurse notes the client is using accessory
muscles to breathe and has a respiratory rate of 28 breaths/min. Which
intervention should the nurse implement first?
A. Apply a non-rebreather mask at 15 L/min
B. Administer oxygen via nasal cannula at 2-3 L/min
C. Encourage pursed-lip breathing and position the client upright
D. Prepare for endotracheal intubation
Correct Answer: C
Explanation: Clients with COPD often have chronic hypoxemia and rely on
hypoxic drive. Initial interventions should include non-invasive measures like
positioning and pursed-lip breathing. High-flow oxygen can suppress
respiratory drive in COPD clients.
6. A client with acute kidney injury (AKI) has a serum potassium level of 6.8
mEq/L. Which medication should the nurse anticipate administering first?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Regular insulin with dextrose
C. Furosemide (Lasix)
D. Calcium gluconate
Correct Answer: D
Explanation: Calcium gluconate stabilizes cardiac membranes and is the first
intervention for severe hyperkalemia to prevent life-threatening dysrhythmias.
, Insulin with dextrose and Kayexalate shift or remove potassium but take longer
to act.
7. A nurse is caring for a client with a nasogastric tube on low intermittent suction.
Which assessment finding indicates the need for immediate intervention?
A. Gastric pH of 3.0
B. Output of 400 mL in the past 8 hours
C. Client reports dry mouth and thirst
D. Tube placement verified by X-ray 12 hours ago
Correct Answer: C
Explanation: Dry mouth and thirst indicate fluid volume deficit, a common
complication of NG tube suction. The client requires fluid replacement and
electrolyte monitoring. NG tube placement should be verified every 4-8 hours
during continuous use.
8. A client with deep vein thrombosis (DVT) is receiving heparin infusion. Which
laboratory value requires the nurse to hold the heparin and notify the healthcare
provider?
A. PTT of 65 seconds (control: 30-40 seconds)
B. INR of 2.5
C. Platelet count of 85,000/mm³
D. Hemoglobin of 11.2 g/dL
Correct Answer: C
Explanation: A platelet count of 85,000/mm³ suggests possible heparin-
induced thrombocytopenia (HIT), a serious complication requiring immediate
heparin discontinuation. Therapeutic PTT is 1.5-2.5 times control (45-100
seconds).
9. A client with myocardial infarction is being treated with thrombolytic therapy.
Which finding indicates successful reperfusion?
A. Development of ventricular tachycardia
B. Relief of chest pain and reperfusion dysrhythmias
C. Decreased ST-segment elevation without pain relief
D. Increased cardiac enzymes in the first 2 hours
Correct Answer: B
Explanation: Successful reperfusion is indicated by relief of chest pain,
reperfusion dysrhythmias (like accelerated idioventricular rhythm), and rapid
ST-segment resolution. Ventricular tachycardia alone is not predictive of
success.
JUDGMENT AND COLLABORATIVE CARE QUESTIONS AND
CORRECT ANSWERS 2026
1. A nurse is caring for a client admitted with acute exacerbation of heart failure.
Which assessment finding should the nurse prioritize reporting to the healthcare
provider immediately?
A. +2 pitting edema in bilateral lower extremities
B. Oxygen saturation of 92% on 2L nasal cannula
C. Crackles heard in bilateral lung bases
D. Oxygen saturation dropping to 86% with ambulation
Correct Answer: D
Explanation: A drop in oxygen saturation to 86% with ambulation indicates
significant gas exchange impairment and exercise intolerance, requiring
immediate intervention and possible oxygen therapy adjustment. The other
findings are expected in heart failure but less urgent.
2. A client with type 2 diabetes mellitus has a hemoglobin A1c of 9.2%. Which
statement by the nurse best demonstrates understanding of evidence-based
practice when teaching this client?
A. "Your blood sugar is too high, so you need to start insulin immediately."
B. "This result indicates poor glucose control over the past 3 months, and we
should review your medication, diet, and exercise plan."
C. "You need to check your blood glucose every 2 hours to get it under control."
D. "This is normal for someone with diabetes, so no changes are needed."
Correct Answer: B
Explanation: Hemoglobin A1c reflects average blood glucose over 2-3 months.
An A1c of 9.2% indicates poor control (target is typically <7%), requiring
comprehensive review of the care plan. Evidence-based practice combines
research, clinical expertise, and patient preferences.
3. A client with suspected sepsis arrives at the emergency department. Which
nursing action should be performed first according to sepsis bundle protocols?
A. Obtain blood cultures
B. Administer broad-spectrum antibiotics
C. Measure lactate level
D. Administer 30 mL/kg crystalloid fluid bolus
Correct Answer: A
Explanation: Blood cultures should be obtained BEFORE administering
antibiotics to ensure accurate identification of the causative organism. While all
, actions are part of sepsis management, cultures must precede antibiotic
administration for optimal diagnostic accuracy.
4. A postoperative client 24 hours after abdominal surgery has a temperature of
38.9°C (102°F), heart rate of 118 bpm, and wound drainage that is yellow and
foul-smelling. Which nursing diagnosis takes priority?
A. Risk for fluid volume deficit
B. Impaired tissue integrity
C. Hyperthermia related to infection
D. Ineffective tissue perfusion
Correct Answer: C
Explanation: The client shows signs of surgical site infection with systemic
involvement (fever, tachycardia). Hyperthermia related to infection is the
priority as it indicates active infection requiring immediate intervention to
prevent sepsis.
5. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88% on room air. The nurse notes the client is using accessory
muscles to breathe and has a respiratory rate of 28 breaths/min. Which
intervention should the nurse implement first?
A. Apply a non-rebreather mask at 15 L/min
B. Administer oxygen via nasal cannula at 2-3 L/min
C. Encourage pursed-lip breathing and position the client upright
D. Prepare for endotracheal intubation
Correct Answer: C
Explanation: Clients with COPD often have chronic hypoxemia and rely on
hypoxic drive. Initial interventions should include non-invasive measures like
positioning and pursed-lip breathing. High-flow oxygen can suppress
respiratory drive in COPD clients.
6. A client with acute kidney injury (AKI) has a serum potassium level of 6.8
mEq/L. Which medication should the nurse anticipate administering first?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Regular insulin with dextrose
C. Furosemide (Lasix)
D. Calcium gluconate
Correct Answer: D
Explanation: Calcium gluconate stabilizes cardiac membranes and is the first
intervention for severe hyperkalemia to prevent life-threatening dysrhythmias.
, Insulin with dextrose and Kayexalate shift or remove potassium but take longer
to act.
7. A nurse is caring for a client with a nasogastric tube on low intermittent suction.
Which assessment finding indicates the need for immediate intervention?
A. Gastric pH of 3.0
B. Output of 400 mL in the past 8 hours
C. Client reports dry mouth and thirst
D. Tube placement verified by X-ray 12 hours ago
Correct Answer: C
Explanation: Dry mouth and thirst indicate fluid volume deficit, a common
complication of NG tube suction. The client requires fluid replacement and
electrolyte monitoring. NG tube placement should be verified every 4-8 hours
during continuous use.
8. A client with deep vein thrombosis (DVT) is receiving heparin infusion. Which
laboratory value requires the nurse to hold the heparin and notify the healthcare
provider?
A. PTT of 65 seconds (control: 30-40 seconds)
B. INR of 2.5
C. Platelet count of 85,000/mm³
D. Hemoglobin of 11.2 g/dL
Correct Answer: C
Explanation: A platelet count of 85,000/mm³ suggests possible heparin-
induced thrombocytopenia (HIT), a serious complication requiring immediate
heparin discontinuation. Therapeutic PTT is 1.5-2.5 times control (45-100
seconds).
9. A client with myocardial infarction is being treated with thrombolytic therapy.
Which finding indicates successful reperfusion?
A. Development of ventricular tachycardia
B. Relief of chest pain and reperfusion dysrhythmias
C. Decreased ST-segment elevation without pain relief
D. Increased cardiac enzymes in the first 2 hours
Correct Answer: B
Explanation: Successful reperfusion is indicated by relief of chest pain,
reperfusion dysrhythmias (like accelerated idioventricular rhythm), and rapid
ST-segment resolution. Ventricular tachycardia alone is not predictive of
success.
