RELIAS Medical-Surgical Nursing Competency Exam 2026 Updated
Questions and Answers | Complete Medical-Surgical Nursing Study Guide
with Verified Solutions, Detailed Rationales, Cardiovascular Disorders,
Respiratory Conditions, Neurological Disorders, Gastrointestinal
Diseases, Endocrine Disorders, Renal Nursing, Pharmacology, Patient
Safety, Clinical Judgment and Relias Assessment Preparation
Question 1: A patient with a history of heart failure is admitted with acute
pulmonary edema. Which assessment finding requires the most immediate
intervention by the nurse?
A. Oxygen saturation of 92% on room air
B. Bilateral crackles heard in the lower lung fields
C. Pink, frothy sputum production
D. Heart rate of 110 beats per minute
CORRECT ANSWER: C. Pink, frothy sputum production
Rationale: Pink, frothy sputum is a classic sign of severe pulmonary edema and
indicates fluid accumulation in the alveoli, which severely impairs gas exchange. This is
a medical emergency requiring immediate intervention such as high-flow oxygen,
diuretics, and positioning to improve ventilation. While the other options are
concerning, pink frothy sputum indicates the most critical level of respiratory
compromise.
Question 2: A nurse is caring for a patient who has just undergone a total hip
arthroplasty. Which position should the nurse avoid to prevent dislocation of the
prosthesis?
A. Keeping the legs abducted with an abduction pillow
B. Flexing the hip more than 90 degrees
C. Keeping the toes pointed upward
D. Using a raised toilet seat
CORRECT ANSWER: B. Flexing the hip more than 90 degrees
Rationale: After a total hip arthroplasty, flexing the hip beyond 90 degrees increases the
risk of posterior dislocation of the prosthetic joint. Patients are instructed to avoid
bending forward at the waist, sitting on low chairs, or crossing their legs. Abduction
pillows, keeping toes neutral, and using raised toilet seats are appropriate measures to
maintain proper alignment and prevent dislocation.
Question 3: A patient with chronic kidney disease (CKD) stage 4 is experiencing
muscle weakness and irregular heart rhythms. The nurse suspects hyperkalemia.
Which electrocardiogram (ECG) change is most characteristic of this condition?
A. Prolonged QT interval
B. Tall, peaked T waves
,C. ST-segment depression
D. Presence of U waves
CORRECT ANSWER: B. Tall, peaked T waves
Rationale: Hyperkalemia affects cardiac conduction, and the earliest and most
characteristic ECG change is the appearance of tall, peaked T waves. As potassium
levels rise further, the PR interval may prolong, the QRS complex may widen, and
eventually, a sine wave pattern may appear, leading to cardiac arrest. Prolonged QT
intervals are associated with hypocalcemia, while U waves are associated with
hypokalemia.
Question 4: A patient is receiving intravenous heparin for deep vein thrombosis
(DVT). The nurse notes that the patient’s activated partial thromboplastin time
(aPTT) is 90 seconds. The control value is 30 seconds. What is the nurse’s priority
action?
A. Continue the infusion as prescribed
B. Increase the infusion rate
C. Hold the infusion and notify the healthcare provider
D. Administer vitamin K immediately
CORRECT ANSWER: C. Hold the infusion and notify the healthcare provider
Rationale: The therapeutic range for aPTT when on heparin therapy is typically 1.5 to 2.5
times the control value. With a control of 30 seconds, the therapeutic range is 45–75
seconds. An aPTT of 90 seconds is above the therapeutic range, indicating an increased
risk of bleeding. The nurse should hold the infusion and notify the provider for further
orders, which may include reducing the dose. Vitamin K is the antidote for warfarin, not
heparin; protamine sulfate is the antidote for heparin.
Question 5: A patient with type 1 diabetes mellitus is found unconscious. Blood
glucose monitoring reveals a level of 40 mg/dL. The patient has no IV access. What
is the most appropriate immediate action?
A. Administer oral orange juice
B. Administer intramuscular glucagon
C. Wait for IV access to administer dextrose
D. Administer subcutaneous regular insulin
CORRECT ANSWER: B. Administer intramuscular glucagon
Rationale: In a patient with severe hypoglycemia who is unconscious and cannot
swallow safely, oral administration is contraindicated due to the risk of aspiration.
Glucagon stimulates the liver to release stored glucose and can be administered
intramuscularly or subcutaneously when IV access is not available. Waiting for IV
access delays critical treatment, and administering insulin would worsen the
hypoglycemia.
,Question 6: A nurse is assessing a patient with suspected appendicitis. Which
physical assessment finding is most indicative of this condition?
A. Rebound tenderness in the left lower quadrant
B. Positive McBurney’s point tenderness
C. Hyperactive bowel sounds in all quadrants
D. Pain relieved by eating
CORRECT ANSWER: B. Positive McBurney’s point tenderness
Rationale: McBurney’s point is located one-third of the distance from the anterior
superior iliac spine to the umbilicus. Tenderness at this specific location is a classic
sign of appendicitis. Rebound tenderness in the left lower quadrant suggests
diverticulitis or other left-sided pathology. Bowel sounds are often hypoactive or absent
in appendicitis due to inflammation, and pain from appendicitis is not relieved by
eating.
Question 7: A patient is diagnosed with syndrome of inappropriate antidiuretic
hormone (SIADH). Which laboratory finding would the nurse expect to see?
A. Serum sodium 150 mEq/L
B. Serum osmolality 310 mOsm/kg
C. Urine specific gravity 1.005
D. Serum sodium 125 mEq/L
CORRECT ANSWER: D. Serum sodium 125 mEq/L
Rationale: SIADH results in excessive water retention due to inappropriate secretion of
ADH, leading to dilutional hyponatremia. Therefore, serum sodium levels are low
(hyponatremia), and serum osmolality is decreased. Urine specific gravity is typically
high because the urine is concentrated despite low serum osmolality. A serum sodium
of 150 mEq/L indicates hypernatremia, which is seen in diabetes insipidus, not SIADH.
Question 8: A patient with chronic obstructive pulmonary disease (COPD) is being
discharged. Which instruction regarding oxygen therapy is most important for the
nurse to include?
A. Increase the oxygen flow rate if shortness of breath occurs
B. Use petroleum jelly to lubricate the nares
C. Avoid smoking or open flames near the oxygen source
D. Remove the nasal cannula during meals only
CORRECT ANSWER: C. Avoid smoking or open flames near the oxygen source
Rationale: Oxygen supports combustion, creating a significant fire hazard. Patients
must be strictly instructed to avoid smoking, candles, or any open flames while using
oxygen. Increasing oxygen flow rates without a prescription can suppress the hypoxic
drive in some COPD patients, leading to CO2 retention. Petroleum-based products are
flammable and should not be used with oxygen; water-soluble lubricants are preferred.
, Question 9: A patient is admitted with a diagnosis of diabetic ketoacidosis (DKA).
Which initial intervention is the highest priority?
A. Administer subcutaneous insulin
B. Initiate fluid resuscitation with normal saline
C. Monitor urinary ketones every hour
D. Administer potassium supplements
CORRECT ANSWER: B. Initiate fluid resuscitation with normal saline
Rationale: The primary pathophysiology in DKA involves severe dehydration due to
osmotic diuresis. Fluid resuscitation is the first priority to restore intravascular volume,
improve tissue perfusion, and help lower blood glucose levels. Insulin therapy is
initiated after fluid replacement has begun. Potassium levels must be monitored
closely, but replacement is only given if levels are low or normal, as insulin therapy will
shift potassium into cells.
Question 10: A nurse is caring for a patient with a chest tube connected to a water-
seal drainage system. The nurse observes continuous bubbling in the water-seal
chamber. What does this indicate?
A. The system is functioning normally
B. There is an air leak in the system
C. The lung has fully re-expanded
D. The suction pressure is too high
CORRECT ANSWER: B. There is an air leak in the system
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak
somewhere in the system or from the patient’s pleural space. Intermittent bubbling that
corresponds with respiration is normal. If the bubbling is continuous, the nurse should
check the connections and the insertion site to locate the leak. Tidaling (fluctuation of
water level with respiration) indicates the system is patent, but continuous bubbling is
abnormal.
Question 11: A patient with liver cirrhosis is exhibiting signs of hepatic
encephalopathy. Which medication is the nurse likely to anticipate being
prescribed?
A. Furosemide
B. Lactulose
C. Omeprazole
D. Metoprolol
CORRECT ANSWER: B. Lactulose
Rationale: Lactulose is a non-absorbable disaccharide that acidifies the colon,
converting ammonia (NH3) to ammonium (NH4+), which is then excreted in the feces.
This helps reduce serum ammonia levels, which are elevated in hepatic
Questions and Answers | Complete Medical-Surgical Nursing Study Guide
with Verified Solutions, Detailed Rationales, Cardiovascular Disorders,
Respiratory Conditions, Neurological Disorders, Gastrointestinal
Diseases, Endocrine Disorders, Renal Nursing, Pharmacology, Patient
Safety, Clinical Judgment and Relias Assessment Preparation
Question 1: A patient with a history of heart failure is admitted with acute
pulmonary edema. Which assessment finding requires the most immediate
intervention by the nurse?
A. Oxygen saturation of 92% on room air
B. Bilateral crackles heard in the lower lung fields
C. Pink, frothy sputum production
D. Heart rate of 110 beats per minute
CORRECT ANSWER: C. Pink, frothy sputum production
Rationale: Pink, frothy sputum is a classic sign of severe pulmonary edema and
indicates fluid accumulation in the alveoli, which severely impairs gas exchange. This is
a medical emergency requiring immediate intervention such as high-flow oxygen,
diuretics, and positioning to improve ventilation. While the other options are
concerning, pink frothy sputum indicates the most critical level of respiratory
compromise.
Question 2: A nurse is caring for a patient who has just undergone a total hip
arthroplasty. Which position should the nurse avoid to prevent dislocation of the
prosthesis?
A. Keeping the legs abducted with an abduction pillow
B. Flexing the hip more than 90 degrees
C. Keeping the toes pointed upward
D. Using a raised toilet seat
CORRECT ANSWER: B. Flexing the hip more than 90 degrees
Rationale: After a total hip arthroplasty, flexing the hip beyond 90 degrees increases the
risk of posterior dislocation of the prosthetic joint. Patients are instructed to avoid
bending forward at the waist, sitting on low chairs, or crossing their legs. Abduction
pillows, keeping toes neutral, and using raised toilet seats are appropriate measures to
maintain proper alignment and prevent dislocation.
Question 3: A patient with chronic kidney disease (CKD) stage 4 is experiencing
muscle weakness and irregular heart rhythms. The nurse suspects hyperkalemia.
Which electrocardiogram (ECG) change is most characteristic of this condition?
A. Prolonged QT interval
B. Tall, peaked T waves
,C. ST-segment depression
D. Presence of U waves
CORRECT ANSWER: B. Tall, peaked T waves
Rationale: Hyperkalemia affects cardiac conduction, and the earliest and most
characteristic ECG change is the appearance of tall, peaked T waves. As potassium
levels rise further, the PR interval may prolong, the QRS complex may widen, and
eventually, a sine wave pattern may appear, leading to cardiac arrest. Prolonged QT
intervals are associated with hypocalcemia, while U waves are associated with
hypokalemia.
Question 4: A patient is receiving intravenous heparin for deep vein thrombosis
(DVT). The nurse notes that the patient’s activated partial thromboplastin time
(aPTT) is 90 seconds. The control value is 30 seconds. What is the nurse’s priority
action?
A. Continue the infusion as prescribed
B. Increase the infusion rate
C. Hold the infusion and notify the healthcare provider
D. Administer vitamin K immediately
CORRECT ANSWER: C. Hold the infusion and notify the healthcare provider
Rationale: The therapeutic range for aPTT when on heparin therapy is typically 1.5 to 2.5
times the control value. With a control of 30 seconds, the therapeutic range is 45–75
seconds. An aPTT of 90 seconds is above the therapeutic range, indicating an increased
risk of bleeding. The nurse should hold the infusion and notify the provider for further
orders, which may include reducing the dose. Vitamin K is the antidote for warfarin, not
heparin; protamine sulfate is the antidote for heparin.
Question 5: A patient with type 1 diabetes mellitus is found unconscious. Blood
glucose monitoring reveals a level of 40 mg/dL. The patient has no IV access. What
is the most appropriate immediate action?
A. Administer oral orange juice
B. Administer intramuscular glucagon
C. Wait for IV access to administer dextrose
D. Administer subcutaneous regular insulin
CORRECT ANSWER: B. Administer intramuscular glucagon
Rationale: In a patient with severe hypoglycemia who is unconscious and cannot
swallow safely, oral administration is contraindicated due to the risk of aspiration.
Glucagon stimulates the liver to release stored glucose and can be administered
intramuscularly or subcutaneously when IV access is not available. Waiting for IV
access delays critical treatment, and administering insulin would worsen the
hypoglycemia.
,Question 6: A nurse is assessing a patient with suspected appendicitis. Which
physical assessment finding is most indicative of this condition?
A. Rebound tenderness in the left lower quadrant
B. Positive McBurney’s point tenderness
C. Hyperactive bowel sounds in all quadrants
D. Pain relieved by eating
CORRECT ANSWER: B. Positive McBurney’s point tenderness
Rationale: McBurney’s point is located one-third of the distance from the anterior
superior iliac spine to the umbilicus. Tenderness at this specific location is a classic
sign of appendicitis. Rebound tenderness in the left lower quadrant suggests
diverticulitis or other left-sided pathology. Bowel sounds are often hypoactive or absent
in appendicitis due to inflammation, and pain from appendicitis is not relieved by
eating.
Question 7: A patient is diagnosed with syndrome of inappropriate antidiuretic
hormone (SIADH). Which laboratory finding would the nurse expect to see?
A. Serum sodium 150 mEq/L
B. Serum osmolality 310 mOsm/kg
C. Urine specific gravity 1.005
D. Serum sodium 125 mEq/L
CORRECT ANSWER: D. Serum sodium 125 mEq/L
Rationale: SIADH results in excessive water retention due to inappropriate secretion of
ADH, leading to dilutional hyponatremia. Therefore, serum sodium levels are low
(hyponatremia), and serum osmolality is decreased. Urine specific gravity is typically
high because the urine is concentrated despite low serum osmolality. A serum sodium
of 150 mEq/L indicates hypernatremia, which is seen in diabetes insipidus, not SIADH.
Question 8: A patient with chronic obstructive pulmonary disease (COPD) is being
discharged. Which instruction regarding oxygen therapy is most important for the
nurse to include?
A. Increase the oxygen flow rate if shortness of breath occurs
B. Use petroleum jelly to lubricate the nares
C. Avoid smoking or open flames near the oxygen source
D. Remove the nasal cannula during meals only
CORRECT ANSWER: C. Avoid smoking or open flames near the oxygen source
Rationale: Oxygen supports combustion, creating a significant fire hazard. Patients
must be strictly instructed to avoid smoking, candles, or any open flames while using
oxygen. Increasing oxygen flow rates without a prescription can suppress the hypoxic
drive in some COPD patients, leading to CO2 retention. Petroleum-based products are
flammable and should not be used with oxygen; water-soluble lubricants are preferred.
, Question 9: A patient is admitted with a diagnosis of diabetic ketoacidosis (DKA).
Which initial intervention is the highest priority?
A. Administer subcutaneous insulin
B. Initiate fluid resuscitation with normal saline
C. Monitor urinary ketones every hour
D. Administer potassium supplements
CORRECT ANSWER: B. Initiate fluid resuscitation with normal saline
Rationale: The primary pathophysiology in DKA involves severe dehydration due to
osmotic diuresis. Fluid resuscitation is the first priority to restore intravascular volume,
improve tissue perfusion, and help lower blood glucose levels. Insulin therapy is
initiated after fluid replacement has begun. Potassium levels must be monitored
closely, but replacement is only given if levels are low or normal, as insulin therapy will
shift potassium into cells.
Question 10: A nurse is caring for a patient with a chest tube connected to a water-
seal drainage system. The nurse observes continuous bubbling in the water-seal
chamber. What does this indicate?
A. The system is functioning normally
B. There is an air leak in the system
C. The lung has fully re-expanded
D. The suction pressure is too high
CORRECT ANSWER: B. There is an air leak in the system
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak
somewhere in the system or from the patient’s pleural space. Intermittent bubbling that
corresponds with respiration is normal. If the bubbling is continuous, the nurse should
check the connections and the insertion site to locate the leak. Tidaling (fluctuation of
water level with respiration) indicates the system is patent, but continuous bubbling is
abnormal.
Question 11: A patient with liver cirrhosis is exhibiting signs of hepatic
encephalopathy. Which medication is the nurse likely to anticipate being
prescribed?
A. Furosemide
B. Lactulose
C. Omeprazole
D. Metoprolol
CORRECT ANSWER: B. Lactulose
Rationale: Lactulose is a non-absorbable disaccharide that acidifies the colon,
converting ammonia (NH3) to ammonium (NH4+), which is then excreted in the feces.
This helps reduce serum ammonia levels, which are elevated in hepatic
