Complex Adult Health - Critical Care & Medical-Surgical
Nursing Exam With Correct Questions And Answers
*1. A nurse is caring for a client who is 8 hours postoperative
following a coronary artery bypass grafting (CABG). Which of the
following assessments should the nurse plan to perform FIRST?**
- A) Check the client's pain level
- B) Auscultate breath sounds
- C) Assess the incision site for drainage
- D) Review the client's telemetry rhythm
**Correct Answer: B**
**Rationale:** After CABG, the priority assessment is airway and
breathing. Auscultating breath sounds helps identify pulmonary
complications such as atelectasis, pneumonia, or pulmonary edema.
The ABCs (Airway, Breathing, Circulation) framework guides priority
nursing actions .
---
**2. A nurse is admitting a client to a medical unit following
placement of a pacemaker. Which of the following findings requires
further assessment by the nurse?**
,- A) Heart rate of 72 bpm
- B) Hiccups
- C) Small amount of serous drainage at insertion site
- D) Bruising around the insertion site
**Correct Answer: B**
**Rationale:** Hiccups after pacemaker placement can indicate that
the pacemaker lead is stimulating the diaphragm (phrenic nerve),
which may require repositioning. This finding requires further
assessment. Heart rate of 72 bpm, serous drainage, and bruising are
expected findings .
---
**3. A nurse is providing discharge teaching to a client who has heart
failure and instructs the client to limit sodium intake to 2g per day.
Which of the following statements by the client indicates an
understanding of the teaching?**
- A) "I can have a frozen fruit juice with a meal."
- B) "I should avoid using fresh herbs in my cooking."
- C) "Canned soup is a good low-sodium option."
- D) "I can add salt to my food at the table as long as I don't cook with
it."
,**Correct Answer: A**
**Rationale:** Frozen fruit juice is a low-sodium beverage choice.
Canned soups are typically high in sodium. Fresh herbs are
acceptable for flavoring without adding sodium. Table salt should be
avoided entirely, not just during cooking .
---
**4. A nurse is caring for a client following a cardiac catheterization.
The client's blood pressure is 88/56 mm Hg. Which of the following
actions should the nurse take FIRST?**
- A) Notify the provider
- B) Elevate the head of the bed
- C) Assess the access site for bleeding
- D) Administer IV fluids
**Correct Answer: C**
**Rationale:** Hypotension following cardiac catheterization may
indicate bleeding or retroperitoneal hematoma at the arterial access
site. Assessment of the access site for hematoma, bleeding, or
pseudoaneurysm is the priority before other interventions .
, ---
**5. A nurse is planning care for a client following a cardiac
catheterization. Which of the following actions should the nurse
take?**
- A) Maintain the client's affected extremity in extension
- B) Keep the head of the bed elevated to 90 degrees
- C) Encourage the client to flex the affected leg every hour
- D) Apply heat to the insertion site to reduce bruising
**Correct Answer: A**
**Rationale:** After cardiac catheterization via the femoral artery,
the affected extremity must be kept straight (extended) to prevent
arterial bleeding. The HOB should be no higher than 30 degrees .
---
**6. What does a low central venous pressure (CVP) typically
indicate?**
- A) The patient needs more volume
- B) The patient has fluid overload
- C) The patient has right-sided heart failure
Nursing Exam With Correct Questions And Answers
*1. A nurse is caring for a client who is 8 hours postoperative
following a coronary artery bypass grafting (CABG). Which of the
following assessments should the nurse plan to perform FIRST?**
- A) Check the client's pain level
- B) Auscultate breath sounds
- C) Assess the incision site for drainage
- D) Review the client's telemetry rhythm
**Correct Answer: B**
**Rationale:** After CABG, the priority assessment is airway and
breathing. Auscultating breath sounds helps identify pulmonary
complications such as atelectasis, pneumonia, or pulmonary edema.
The ABCs (Airway, Breathing, Circulation) framework guides priority
nursing actions .
---
**2. A nurse is admitting a client to a medical unit following
placement of a pacemaker. Which of the following findings requires
further assessment by the nurse?**
,- A) Heart rate of 72 bpm
- B) Hiccups
- C) Small amount of serous drainage at insertion site
- D) Bruising around the insertion site
**Correct Answer: B**
**Rationale:** Hiccups after pacemaker placement can indicate that
the pacemaker lead is stimulating the diaphragm (phrenic nerve),
which may require repositioning. This finding requires further
assessment. Heart rate of 72 bpm, serous drainage, and bruising are
expected findings .
---
**3. A nurse is providing discharge teaching to a client who has heart
failure and instructs the client to limit sodium intake to 2g per day.
Which of the following statements by the client indicates an
understanding of the teaching?**
- A) "I can have a frozen fruit juice with a meal."
- B) "I should avoid using fresh herbs in my cooking."
- C) "Canned soup is a good low-sodium option."
- D) "I can add salt to my food at the table as long as I don't cook with
it."
,**Correct Answer: A**
**Rationale:** Frozen fruit juice is a low-sodium beverage choice.
Canned soups are typically high in sodium. Fresh herbs are
acceptable for flavoring without adding sodium. Table salt should be
avoided entirely, not just during cooking .
---
**4. A nurse is caring for a client following a cardiac catheterization.
The client's blood pressure is 88/56 mm Hg. Which of the following
actions should the nurse take FIRST?**
- A) Notify the provider
- B) Elevate the head of the bed
- C) Assess the access site for bleeding
- D) Administer IV fluids
**Correct Answer: C**
**Rationale:** Hypotension following cardiac catheterization may
indicate bleeding or retroperitoneal hematoma at the arterial access
site. Assessment of the access site for hematoma, bleeding, or
pseudoaneurysm is the priority before other interventions .
, ---
**5. A nurse is planning care for a client following a cardiac
catheterization. Which of the following actions should the nurse
take?**
- A) Maintain the client's affected extremity in extension
- B) Keep the head of the bed elevated to 90 degrees
- C) Encourage the client to flex the affected leg every hour
- D) Apply heat to the insertion site to reduce bruising
**Correct Answer: A**
**Rationale:** After cardiac catheterization via the femoral artery,
the affected extremity must be kept straight (extended) to prevent
arterial bleeding. The HOB should be no higher than 30 degrees .
---
**6. What does a low central venous pressure (CVP) typically
indicate?**
- A) The patient needs more volume
- B) The patient has fluid overload
- C) The patient has right-sided heart failure
