RN Adult Medical–Surgical Assessment
Exam Questions and Answers with
Rationales Latest Version Top Rated
1.
A nurse is assessing a client with suspected pneumonia. Which findings
should the nurse expect? (Select all that apply.)
A. Fever
B. Bradycardia
C. Productive cough
D. Increased white blood cell count
Correct: A, C, D
Rationales:
• A (Fever): Common in infection/inflammation.
• C (Productive cough): Often present in pneumonia due to airway
secretions.
• D (WBC ↑): Typical indicator of infection.
• B (Bradycardia): More consistent with certain other conditions;
pneumonia more often causes tachycardia from stress/fever.
2.
A client with heart failure is receiving oxygen and diuretics. Which
assessments indicate the plan is effective? (Select all that apply.)
A. Decreased crackles on auscultation
B. Urine output increases
C. Peripheral edema worsens
D. Oxygen saturation improves
,Correct: A, B, D
Rationales:
• A: Less pulmonary congestion → fewer crackles.
• B: Diuretics increase urine output.
• D: Improved oxygenation reflects reduced congestion.
• C: Edema should improve, not worsen.
3.
Which nursing assessments are highest priority for a client after a new
stroke symptom change? (Select all that apply.)
A. Check airway patency
B. Assess level of consciousness (LOC)
C. Obtain capillary blood glucose
D. Reassure the family first
Correct: A, B, C
Rationales:
• A: Airway/oxygenation before other needs—immediate safety.
• B: Stroke progression can compromise airway/brain perfusion.
• C: Hypoglycemia can mimic or worsen neuro deficits; treatable
rapidly.
• D: Family reassurance is important but not before
airway/LOC/glucose.
4.
A nurse is caring for a client with diabetic ketoacidosis (DKA). Which
findings support diagnosis/ongoing severity? (Select all that apply.)
A. Kussmaul respirations
B. Serum glucose 300 mg/dL
,C. pH 7.25
D. Potassium 3.8 mEq/L
Correct: A, B, C
Rationales:
• A: Deep, rapid respirations to compensate for metabolic acidosis.
• B: DKA usually has significant hyperglycemia.
• C: pH < 7.3 consistent with acidosis.
• D: Potassium often starts normal/high but may become low; 3.8 is
not classic support for severity.
5.
A client with acute abdominal pain arrives at the ED. Which actions
should the nurse do first? (Select all that apply.)
A. Assess pain severity and characteristics
B. Obtain baseline vital signs
C. Start oxygen and monitor SpO₂ if hypoxic
D. Ask about diet preferences
Correct: A, B, C
Rationales:
• A: Pain assessment helps triage and escalation.
• B: Vitals guide stability/possible shock.
• C: Oxygen if hypoxic is safety/priority.
• D: Diet preferences are not time-critical for acute pain triage.
6.
For a post-op client with a new fever, which assessments help evaluate
potential causes? (Select all that apply.)
, A. Review surgical site for redness/drainage
B. Auscultate lungs for new crackles
C. Check for urinary burning during each void
D. Review last pain medication administration time
Correct: A, B, C
Rationales:
• A: Surgical site infection signs.
• B: Atelectasis/pneumonia assessment.
• C: UTI indicators.
• D: Useful generally, but doesn’t directly identify common fever
causes.
7.
A client with COPD is using a prescribed inhaler. Which actions ensure
correct technique? (Select all that apply.)
A. Inhale quickly and deeply after actuation
B. Hold breath for 5–10 seconds if able
C. Shake inhaler well before use
D. Exhale directly into the mouthpiece to clear airway secretions
Correct: A, B, C
Rationales:
• A: Improves medication delivery to lungs.
• B: Enhances deposition.
• C: Many inhalers require shaking.
• D: Not appropriate technique; can reduce delivery.
8.
Exam Questions and Answers with
Rationales Latest Version Top Rated
1.
A nurse is assessing a client with suspected pneumonia. Which findings
should the nurse expect? (Select all that apply.)
A. Fever
B. Bradycardia
C. Productive cough
D. Increased white blood cell count
Correct: A, C, D
Rationales:
• A (Fever): Common in infection/inflammation.
• C (Productive cough): Often present in pneumonia due to airway
secretions.
• D (WBC ↑): Typical indicator of infection.
• B (Bradycardia): More consistent with certain other conditions;
pneumonia more often causes tachycardia from stress/fever.
2.
A client with heart failure is receiving oxygen and diuretics. Which
assessments indicate the plan is effective? (Select all that apply.)
A. Decreased crackles on auscultation
B. Urine output increases
C. Peripheral edema worsens
D. Oxygen saturation improves
,Correct: A, B, D
Rationales:
• A: Less pulmonary congestion → fewer crackles.
• B: Diuretics increase urine output.
• D: Improved oxygenation reflects reduced congestion.
• C: Edema should improve, not worsen.
3.
Which nursing assessments are highest priority for a client after a new
stroke symptom change? (Select all that apply.)
A. Check airway patency
B. Assess level of consciousness (LOC)
C. Obtain capillary blood glucose
D. Reassure the family first
Correct: A, B, C
Rationales:
• A: Airway/oxygenation before other needs—immediate safety.
• B: Stroke progression can compromise airway/brain perfusion.
• C: Hypoglycemia can mimic or worsen neuro deficits; treatable
rapidly.
• D: Family reassurance is important but not before
airway/LOC/glucose.
4.
A nurse is caring for a client with diabetic ketoacidosis (DKA). Which
findings support diagnosis/ongoing severity? (Select all that apply.)
A. Kussmaul respirations
B. Serum glucose 300 mg/dL
,C. pH 7.25
D. Potassium 3.8 mEq/L
Correct: A, B, C
Rationales:
• A: Deep, rapid respirations to compensate for metabolic acidosis.
• B: DKA usually has significant hyperglycemia.
• C: pH < 7.3 consistent with acidosis.
• D: Potassium often starts normal/high but may become low; 3.8 is
not classic support for severity.
5.
A client with acute abdominal pain arrives at the ED. Which actions
should the nurse do first? (Select all that apply.)
A. Assess pain severity and characteristics
B. Obtain baseline vital signs
C. Start oxygen and monitor SpO₂ if hypoxic
D. Ask about diet preferences
Correct: A, B, C
Rationales:
• A: Pain assessment helps triage and escalation.
• B: Vitals guide stability/possible shock.
• C: Oxygen if hypoxic is safety/priority.
• D: Diet preferences are not time-critical for acute pain triage.
6.
For a post-op client with a new fever, which assessments help evaluate
potential causes? (Select all that apply.)
, A. Review surgical site for redness/drainage
B. Auscultate lungs for new crackles
C. Check for urinary burning during each void
D. Review last pain medication administration time
Correct: A, B, C
Rationales:
• A: Surgical site infection signs.
• B: Atelectasis/pneumonia assessment.
• C: UTI indicators.
• D: Useful generally, but doesn’t directly identify common fever
causes.
7.
A client with COPD is using a prescribed inhaler. Which actions ensure
correct technique? (Select all that apply.)
A. Inhale quickly and deeply after actuation
B. Hold breath for 5–10 seconds if able
C. Shake inhaler well before use
D. Exhale directly into the mouthpiece to clear airway secretions
Correct: A, B, C
Rationales:
• A: Improves medication delivery to lungs.
• B: Enhances deposition.
• C: Many inhalers require shaking.
• D: Not appropriate technique; can reduce delivery.
8.
