ULTIMATE MEDICAL SURGICAL NURSING
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1. A postoperative patient is receiving morphine via IV PCA. Which
assessment finding requires immediate intervention?
A. Respiratory rate of 10 breaths per minute
B. Pain score of 4/10
C. Urine output of 30 mL/hour
D. Mild nausea
Opioids depress respiratory function, and a respiratory rate of 10 indicates
significant respiratory depression requiring immediate intervention. Pain score
4/10 is expected post-op, urine output is adequate, and mild nausea is a common
side effect.
2. A nurse is caring for a patient with heart failure. Which finding best
indicates fluid overload?
A. Dry mucous membranes
B. Crackles in lung bases
C. Bradycardia
D. Decreased blood pressure
Crackles indicate pulmonary congestion due to fluid overload. Dry mucous
membranes suggest dehydration, bradycardia is not specific, and decreased
blood pressure may occur in shock rather than fluid overload.
3. A patient with diabetes mellitus reports sweating, tremors, and confusion.
What is the nurse’s priority action?
A. Administer long-acting insulin
,B. Give 15g fast-acting carbohydrates
C. Check HbA1c level
D. Restrict oral intake
Symptoms indicate hypoglycemia, which requires immediate glucose
replacement. Long-acting insulin would worsen hypoglycemia, HbA1c is a long-
term marker, and restricting intake is unsafe.
4. Which laboratory result is most concerning in a patient receiving heparin
therapy?
A. aPTT elevated to 2.5 times control
B. Platelet count of 90,000/mm³
C. Hemoglobin 14 g/dL
D. Sodium 140 mEq/L
Low platelets may indicate heparin-induced thrombocytopenia (HIT), a serious
complication requiring immediate action. Elevated aPTT is expected therapeutic
effect.
5. A patient with COPD should be positioned in which way to promote
optimal breathing?
A. Supine with legs elevated
B. Trendelenburg position
C. High Fowler’s position
D. Prone position
High Fowler’s maximizes lung expansion and reduces work of breathing in
COPD patients. Other positions restrict ventilation.
6. A nurse is teaching a patient about warfarin therapy. Which statement
indicates correct understanding?
A. “I will increase leafy green vegetables.”
B. “I will avoid sudden dietary changes.”
C. “I will take aspirin daily for added protection.”
D. “I will double my dose if I miss one.”
, Vitamin K intake must remain consistent to maintain stable INR. Aspirin
increases bleeding risk, and doubling doses is unsafe.
7. A postoperative patient suddenly develops chest pain and dyspnea. What is
the nurse’s first action?
A. Encourage deep breathing
B. Elevate the head of bed and apply oxygen
C. Obtain a sputum sample
D. Administer analgesics
These symptoms suggest pulmonary embolism; airway and oxygenation are
priority. Other actions are secondary.
8. Which finding indicates early shock in a patient?
A. Hypertension
B. Bradycardia
C. Tachycardia
D. Warm flushed skin
Compensatory tachycardia is an early sign of shock as the body attempts to
maintain cardiac output.
9. A nurse is caring for a patient with hyperkalemia. Which ECG change is
expected?
A. Flattened T waves
B. Peaked T waves
C. ST depression
D. Prolonged QT interval
Hyperkalemia causes tall, peaked T waves due to altered cardiac conduction.
10. Which intervention is priority for a patient experiencing anaphylaxis?
A. Oral antihistamines
STUDY BUNDLE |NCLEX-STYLE QUIZ
BANK | QUICK CHEAT SHEETS | LATEST
UPDATE | EXAM PREP | STUDY GUIDE |
PRACTICE QUESTIONS| DOWNLOAD
INSTANT PDF
1. A postoperative patient is receiving morphine via IV PCA. Which
assessment finding requires immediate intervention?
A. Respiratory rate of 10 breaths per minute
B. Pain score of 4/10
C. Urine output of 30 mL/hour
D. Mild nausea
Opioids depress respiratory function, and a respiratory rate of 10 indicates
significant respiratory depression requiring immediate intervention. Pain score
4/10 is expected post-op, urine output is adequate, and mild nausea is a common
side effect.
2. A nurse is caring for a patient with heart failure. Which finding best
indicates fluid overload?
A. Dry mucous membranes
B. Crackles in lung bases
C. Bradycardia
D. Decreased blood pressure
Crackles indicate pulmonary congestion due to fluid overload. Dry mucous
membranes suggest dehydration, bradycardia is not specific, and decreased
blood pressure may occur in shock rather than fluid overload.
3. A patient with diabetes mellitus reports sweating, tremors, and confusion.
What is the nurse’s priority action?
A. Administer long-acting insulin
,B. Give 15g fast-acting carbohydrates
C. Check HbA1c level
D. Restrict oral intake
Symptoms indicate hypoglycemia, which requires immediate glucose
replacement. Long-acting insulin would worsen hypoglycemia, HbA1c is a long-
term marker, and restricting intake is unsafe.
4. Which laboratory result is most concerning in a patient receiving heparin
therapy?
A. aPTT elevated to 2.5 times control
B. Platelet count of 90,000/mm³
C. Hemoglobin 14 g/dL
D. Sodium 140 mEq/L
Low platelets may indicate heparin-induced thrombocytopenia (HIT), a serious
complication requiring immediate action. Elevated aPTT is expected therapeutic
effect.
5. A patient with COPD should be positioned in which way to promote
optimal breathing?
A. Supine with legs elevated
B. Trendelenburg position
C. High Fowler’s position
D. Prone position
High Fowler’s maximizes lung expansion and reduces work of breathing in
COPD patients. Other positions restrict ventilation.
6. A nurse is teaching a patient about warfarin therapy. Which statement
indicates correct understanding?
A. “I will increase leafy green vegetables.”
B. “I will avoid sudden dietary changes.”
C. “I will take aspirin daily for added protection.”
D. “I will double my dose if I miss one.”
, Vitamin K intake must remain consistent to maintain stable INR. Aspirin
increases bleeding risk, and doubling doses is unsafe.
7. A postoperative patient suddenly develops chest pain and dyspnea. What is
the nurse’s first action?
A. Encourage deep breathing
B. Elevate the head of bed and apply oxygen
C. Obtain a sputum sample
D. Administer analgesics
These symptoms suggest pulmonary embolism; airway and oxygenation are
priority. Other actions are secondary.
8. Which finding indicates early shock in a patient?
A. Hypertension
B. Bradycardia
C. Tachycardia
D. Warm flushed skin
Compensatory tachycardia is an early sign of shock as the body attempts to
maintain cardiac output.
9. A nurse is caring for a patient with hyperkalemia. Which ECG change is
expected?
A. Flattened T waves
B. Peaked T waves
C. ST depression
D. Prolonged QT interval
Hyperkalemia causes tall, peaked T waves due to altered cardiac conduction.
10. Which intervention is priority for a patient experiencing anaphylaxis?
A. Oral antihistamines
