Lewis’s Medical-Surgical Nursing Advanced
Prep: Master Clinical Judgment & Patient
Management Practice Questions & Detailed
Explanations
Subject: Medical-Surgical Nursing - Clinical Assessment and Management
Question 1: A 68-year-old patient with a history of heart failure is admitted with acute dyspnea
and orthopnea. Physical assessment reveals bilateral crackles in the bases, a third heart sound
(S3), and 2+ pitting edema. Which nursing intervention is the highest priority to optimize the
patient’s cardiac output and respiratory status?
A) Place the patient in a high-Fowler’s position.
B) Administer the prescribed oral diuretic immediately.
C) Initiate continuous pulse oximetry monitoring.
D) Weigh the patient to establish a baseline.
Correct Answer: A) Place the patient in a high-Fowler’s position.
Explanation: In a patient with acute heart failure exacerbation, the highest priority is to
decrease venous return (preload) and reduce the work of breathing. High-Fowler's position
allows for maximum lung expansion and uses gravity to pool blood in the periphery, thereby
reducing the workload on the heart. While administering diuretics (B) is essential, positioning is
an immediate, non-invasive intervention that provides rapid symptomatic relief of dyspnea. Pulse
oximetry (C) is a monitoring action, not a therapeutic intervention to optimize output, and
weighing (D) is necessary but secondary to respiratory stabilization.
Question 2: A patient recovering from an abdominal aortic aneurysm (AAA) repair suddenly
develops a urine output of 15 mL/hr over the past two hours. The patient’s blood pressure is
105/65 mmHg and the pulse is 112 bpm. What is the nurse's most appropriate next action?
A) Increase the rate of the maintenance IV fluids.
B) Perform a bladder scan to check for urinary retention.
C) Assess the patient’s peripheral pulses and skin temperature.
D) Notify the healthcare provider immediately of suspected renal hypoperfusion.
,Correct Answer: D) Notify the healthcare provider immediately of suspected renal
hypoperfusion.
Explanation: Post-AAA repair, acute oliguria combined with tachycardia is a classic indicator of
potential hypovolemia or renal artery compromise (e.g., emboli or graft occlusion). The patient’s
condition is unstable, and early notification of the provider is critical to prevent permanent acute
kidney injury (AKI). While assessing peripheral pulses (C) provides more data, the priority is
flagging the urgent change in renal function to the surgical team for immediate intervention.
Question 3: Which laboratory result in a patient with chronic kidney disease (CKD) and a rising
serum potassium level requires the most immediate clinical intervention?
A) Serum creatinine of 4.2 mg/dL.
B) Electrocardiogram (ECG) showing peaked T-waves.
C) Blood urea nitrogen (BUN) of 85 mg/dL.
D) Serum calcium level of 8.2 mg/dL.
Correct Answer: B) Electrocardiogram (ECG) showing peaked T-waves.
Explanation: Hyperkalemia is life-threatening because it directly affects cardiac conduction.
Peaked T-waves are a hallmark sign of early potassium-induced cardiac toxicity, which can
rapidly progress to fatal arrhythmias like ventricular fibrillation. The other findings (A, C, D)
are expected or chronic manifestations of CKD that, while significant, do not pose the same
immediate threat to life as cardiac conduction disturbances.
Question 4: A patient is admitted with a suspected pulmonary embolism (PE). After initiating
oxygen therapy, the nurse observes the patient becoming increasingly anxious, with a heart rate
of 125 bpm and a blood pressure of 88/50 mmHg. What is the nurse's primary goal at this time?
A) Prepare the patient for an emergency CT angiogram.
B) Administer the prescribed heparin bolus.
C) Maintain hemodynamic stability and tissue perfusion.
D) Obtain an arterial blood gas (ABG) to assess for respiratory acidosis.
Correct Answer: C) Maintain hemodynamic stability and tissue perfusion.
Explanation: The patient is exhibiting signs of obstructive shock due to the PE. Hemodynamic
instability (hypotension and tachycardia) is the primary threat to the patient's life. While
anticoagulation (B) is part of long-term management and imaging (A) is for diagnosis, the
,immediate priority is to support perfusion—often via fluid resuscitation or inotropes as
ordered—to prevent cardiovascular collapse.
Question 5: A nurse is caring for a patient who sustained a severe burn injury 12 hours ago. The
patient’s urine output has dropped to 20 mL/hr, and the serum potassium is 5.8 mEq/L. The
nurse recognizes that these findings are primarily due to:
A) Pre-renal failure from hypovolemic shock.
B) Massive cellular destruction and release of intracellular contents.
C) Excessive administration of intravenous potassium replacement.
D) Decreased glomerular filtration due to systemic inflammation.
Correct Answer: B) Massive cellular destruction and release of intracellular contents.
Explanation: In the emergent phase of burn injury, massive cell damage leads to the release of
intracellular potassium into the extracellular fluid (causing hyperkalemia) and significant fluid
shifts (causing hypovolemia and decreased urine output). This is a physiologic consequence of
the thermal injury rather than solely pre-renal failure or potassium infusion.
Question 6: A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations, fruity
breath odor, and a blood glucose of 480 mg/dL. Which order should the nurse question as
inappropriate for this patient's current status?
A) Intravenous insulin infusion (regular insulin).
B) Intravenous potassium chloride 20 mEq/hr.
C) Intravenous normal saline bolus.
D) Subcutaneous NPH insulin every 12 hours.
Correct Answer: D) Subcutaneous NPH insulin every 12 hours.
Explanation: This patient is in Diabetic Ketoacidosis (DKA). DKA requires rapid-acting insulin
delivered via intravenous infusion to stabilize blood glucose and stop ketone production.
Subcutaneous NPH insulin is intermediate-acting and has a delayed onset, making it entirely
inappropriate for the acute, life-threatening management of DKA. The other treatments are
standard components of the DKA resuscitation protocol.
Question 7: A patient with suspected meningitis exhibits a positive Brudzinski’s sign. What is
the nurse’s priority action following this assessment?
A) Administer an antipyretic to lower the fever.
, B) Implement droplet precautions immediately.
C) Dim the lights and reduce environmental stimuli.
D) Prepare the patient for a lumbar puncture.
Correct Answer: B) Implement droplet precautions immediately.
Explanation: A positive Brudzinski’s sign is highly suggestive of meningeal irritation. Bacterial
meningitis is a medical emergency that can be transmitted through respiratory droplets;
therefore, isolating the patient is the priority to protect other patients and staff. While a lumbar
puncture (D) is necessary for diagnosis, protecting the environment takes precedence.
Question 8: A patient on long-term corticosteroid therapy for rheumatoid arthritis is scheduled
for a total hip arthroplasty. The nurse should be most concerned about which post-operative
complication?
A) Excessive intraoperative bleeding.
B) Adrenal crisis due to physiological stress.
C) Delayed wound healing and infection.
D) Hypercalcemia secondary to bone resorption.
Correct Answer: B) Adrenal crisis due to physiological stress.
Explanation: Long-term corticosteroid use suppresses the hypothalamic-pituitary-adrenal axis.
When the body undergoes the stress of surgery, it cannot produce the necessary endogenous
cortisol, which can lead to life-threatening adrenal crisis if supplemental "stress doses" of
steroids are not provided. While wound healing (C) is a concern, adrenal crisis is a more
immediate, life-threatening emergency.
Question 9: A patient is admitted with blunt chest trauma. The nurse notes paradoxical chest
wall movement. What is the priority nursing intervention?
A) Prepare for chest tube insertion to drain a hemothorax.
B) Administer high-flow oxygen and maintain positive airway pressure.
C) Perform a needle decompression for suspected tension pneumothorax.
D) Tape a sterile occlusive dressing over the area.
Correct Answer: B) Administer high-flow oxygen and maintain positive airway pressure.
Prep: Master Clinical Judgment & Patient
Management Practice Questions & Detailed
Explanations
Subject: Medical-Surgical Nursing - Clinical Assessment and Management
Question 1: A 68-year-old patient with a history of heart failure is admitted with acute dyspnea
and orthopnea. Physical assessment reveals bilateral crackles in the bases, a third heart sound
(S3), and 2+ pitting edema. Which nursing intervention is the highest priority to optimize the
patient’s cardiac output and respiratory status?
A) Place the patient in a high-Fowler’s position.
B) Administer the prescribed oral diuretic immediately.
C) Initiate continuous pulse oximetry monitoring.
D) Weigh the patient to establish a baseline.
Correct Answer: A) Place the patient in a high-Fowler’s position.
Explanation: In a patient with acute heart failure exacerbation, the highest priority is to
decrease venous return (preload) and reduce the work of breathing. High-Fowler's position
allows for maximum lung expansion and uses gravity to pool blood in the periphery, thereby
reducing the workload on the heart. While administering diuretics (B) is essential, positioning is
an immediate, non-invasive intervention that provides rapid symptomatic relief of dyspnea. Pulse
oximetry (C) is a monitoring action, not a therapeutic intervention to optimize output, and
weighing (D) is necessary but secondary to respiratory stabilization.
Question 2: A patient recovering from an abdominal aortic aneurysm (AAA) repair suddenly
develops a urine output of 15 mL/hr over the past two hours. The patient’s blood pressure is
105/65 mmHg and the pulse is 112 bpm. What is the nurse's most appropriate next action?
A) Increase the rate of the maintenance IV fluids.
B) Perform a bladder scan to check for urinary retention.
C) Assess the patient’s peripheral pulses and skin temperature.
D) Notify the healthcare provider immediately of suspected renal hypoperfusion.
,Correct Answer: D) Notify the healthcare provider immediately of suspected renal
hypoperfusion.
Explanation: Post-AAA repair, acute oliguria combined with tachycardia is a classic indicator of
potential hypovolemia or renal artery compromise (e.g., emboli or graft occlusion). The patient’s
condition is unstable, and early notification of the provider is critical to prevent permanent acute
kidney injury (AKI). While assessing peripheral pulses (C) provides more data, the priority is
flagging the urgent change in renal function to the surgical team for immediate intervention.
Question 3: Which laboratory result in a patient with chronic kidney disease (CKD) and a rising
serum potassium level requires the most immediate clinical intervention?
A) Serum creatinine of 4.2 mg/dL.
B) Electrocardiogram (ECG) showing peaked T-waves.
C) Blood urea nitrogen (BUN) of 85 mg/dL.
D) Serum calcium level of 8.2 mg/dL.
Correct Answer: B) Electrocardiogram (ECG) showing peaked T-waves.
Explanation: Hyperkalemia is life-threatening because it directly affects cardiac conduction.
Peaked T-waves are a hallmark sign of early potassium-induced cardiac toxicity, which can
rapidly progress to fatal arrhythmias like ventricular fibrillation. The other findings (A, C, D)
are expected or chronic manifestations of CKD that, while significant, do not pose the same
immediate threat to life as cardiac conduction disturbances.
Question 4: A patient is admitted with a suspected pulmonary embolism (PE). After initiating
oxygen therapy, the nurse observes the patient becoming increasingly anxious, with a heart rate
of 125 bpm and a blood pressure of 88/50 mmHg. What is the nurse's primary goal at this time?
A) Prepare the patient for an emergency CT angiogram.
B) Administer the prescribed heparin bolus.
C) Maintain hemodynamic stability and tissue perfusion.
D) Obtain an arterial blood gas (ABG) to assess for respiratory acidosis.
Correct Answer: C) Maintain hemodynamic stability and tissue perfusion.
Explanation: The patient is exhibiting signs of obstructive shock due to the PE. Hemodynamic
instability (hypotension and tachycardia) is the primary threat to the patient's life. While
anticoagulation (B) is part of long-term management and imaging (A) is for diagnosis, the
,immediate priority is to support perfusion—often via fluid resuscitation or inotropes as
ordered—to prevent cardiovascular collapse.
Question 5: A nurse is caring for a patient who sustained a severe burn injury 12 hours ago. The
patient’s urine output has dropped to 20 mL/hr, and the serum potassium is 5.8 mEq/L. The
nurse recognizes that these findings are primarily due to:
A) Pre-renal failure from hypovolemic shock.
B) Massive cellular destruction and release of intracellular contents.
C) Excessive administration of intravenous potassium replacement.
D) Decreased glomerular filtration due to systemic inflammation.
Correct Answer: B) Massive cellular destruction and release of intracellular contents.
Explanation: In the emergent phase of burn injury, massive cell damage leads to the release of
intracellular potassium into the extracellular fluid (causing hyperkalemia) and significant fluid
shifts (causing hypovolemia and decreased urine output). This is a physiologic consequence of
the thermal injury rather than solely pre-renal failure or potassium infusion.
Question 6: A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations, fruity
breath odor, and a blood glucose of 480 mg/dL. Which order should the nurse question as
inappropriate for this patient's current status?
A) Intravenous insulin infusion (regular insulin).
B) Intravenous potassium chloride 20 mEq/hr.
C) Intravenous normal saline bolus.
D) Subcutaneous NPH insulin every 12 hours.
Correct Answer: D) Subcutaneous NPH insulin every 12 hours.
Explanation: This patient is in Diabetic Ketoacidosis (DKA). DKA requires rapid-acting insulin
delivered via intravenous infusion to stabilize blood glucose and stop ketone production.
Subcutaneous NPH insulin is intermediate-acting and has a delayed onset, making it entirely
inappropriate for the acute, life-threatening management of DKA. The other treatments are
standard components of the DKA resuscitation protocol.
Question 7: A patient with suspected meningitis exhibits a positive Brudzinski’s sign. What is
the nurse’s priority action following this assessment?
A) Administer an antipyretic to lower the fever.
, B) Implement droplet precautions immediately.
C) Dim the lights and reduce environmental stimuli.
D) Prepare the patient for a lumbar puncture.
Correct Answer: B) Implement droplet precautions immediately.
Explanation: A positive Brudzinski’s sign is highly suggestive of meningeal irritation. Bacterial
meningitis is a medical emergency that can be transmitted through respiratory droplets;
therefore, isolating the patient is the priority to protect other patients and staff. While a lumbar
puncture (D) is necessary for diagnosis, protecting the environment takes precedence.
Question 8: A patient on long-term corticosteroid therapy for rheumatoid arthritis is scheduled
for a total hip arthroplasty. The nurse should be most concerned about which post-operative
complication?
A) Excessive intraoperative bleeding.
B) Adrenal crisis due to physiological stress.
C) Delayed wound healing and infection.
D) Hypercalcemia secondary to bone resorption.
Correct Answer: B) Adrenal crisis due to physiological stress.
Explanation: Long-term corticosteroid use suppresses the hypothalamic-pituitary-adrenal axis.
When the body undergoes the stress of surgery, it cannot produce the necessary endogenous
cortisol, which can lead to life-threatening adrenal crisis if supplemental "stress doses" of
steroids are not provided. While wound healing (C) is a concern, adrenal crisis is a more
immediate, life-threatening emergency.
Question 9: A patient is admitted with blunt chest trauma. The nurse notes paradoxical chest
wall movement. What is the priority nursing intervention?
A) Prepare for chest tube insertion to drain a hemothorax.
B) Administer high-flow oxygen and maintain positive airway pressure.
C) Perform a needle decompression for suspected tension pneumothorax.
D) Tape a sterile occlusive dressing over the area.
Correct Answer: B) Administer high-flow oxygen and maintain positive airway pressure.
