NURS 406 Capstone Med Surg Assessment
latest and completed A;
Course
Medical Surgery
1. A nurse assesses a postoperative patient who suddenly becomes short of breath and
restless. What is the priority action?
A. Elevate the head of the bed and assess oxygen saturation.
B. Encourage oral fluids.
C. Administer pain medication.
D. Assist the patient to ambulate.
Answer: A
Rationale: Sudden dyspnea may indicate hypoxemia or pulmonary embolism. Airway, breathing,
and oxygenation take priority.
2. Which assessment finding is most concerning in a patient with heart failure?
A. Mild ankle edema
B. Heart rate of 88 bpm
C. Crackles in both lung bases
D. Blood pressure of 132/78 mmHg
Answer: C
Rationale: Crackles indicate pulmonary congestion requiring prompt intervention.
3. A patient with COPD receives oxygen therapy. Which finding indicates effective treatment?
A. Respiratory rate increases to 34/min.
B. Oxygen saturation improves to the prescribed goal.
C. Cyanosis worsens.
D. Increased accessory muscle use.
Answer: B
Rationale: Improved oxygen saturation within the target range reflects effective oxygen therapy.
,4. Which laboratory value requires immediate follow-up?
A. Hemoglobin 13.8 g/dL
B. Sodium 140 mEq/L
C. Potassium 6.2 mEq/L
D. Platelets 220,000/mm³
Answer: C
Rationale: Severe hyperkalemia increases the risk of life-threatening cardiac dysrhythmias.
5. A patient with diabetes reports sweating, tremors, and confusion. What should the nurse
do first?
A. Administer insulin.
B. Check the blood glucose level.
C. Encourage exercise.
D. Notify dietary services.
Answer: B
Rationale: These symptoms suggest hypoglycemia and require immediate glucose assessment.
6. Which assessment finding suggests hypovolemic shock?
A. Warm, flushed skin
B. Bradycardia
C. Hypotension with tachycardia
D. Hypertension
Answer: C
7. A patient develops chest pain unrelieved by rest. What is the nurse's priority?
A. Encourage deep breathing.
B. Assess the patient and activate the emergency response as appropriate.
C. Offer food.
D. Delay assessment until the provider arrives.
, Answer: B
8. Which electrolyte imbalance commonly causes muscle weakness and cardiac
dysrhythmias?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C
9. Which intervention helps prevent postoperative atelectasis?
A. Bed rest
B. Fluid restriction
C. Incentive spirometry
D. Trendelenburg position
Answer: C
10. Which assessment finding is consistent with deep vein thrombosis?
A. Bilateral leg pain only
B. Unilateral calf swelling and tenderness
C. Cool extremities
D. Absent pedal pulses bilaterally
Answer: B
11. Which patient has the highest risk for infection?
A. Controlled hypertension
B. Neutropenia following chemotherapy
C. Stable asthma
D. Osteoarthritis
Answer: B
latest and completed A;
Course
Medical Surgery
1. A nurse assesses a postoperative patient who suddenly becomes short of breath and
restless. What is the priority action?
A. Elevate the head of the bed and assess oxygen saturation.
B. Encourage oral fluids.
C. Administer pain medication.
D. Assist the patient to ambulate.
Answer: A
Rationale: Sudden dyspnea may indicate hypoxemia or pulmonary embolism. Airway, breathing,
and oxygenation take priority.
2. Which assessment finding is most concerning in a patient with heart failure?
A. Mild ankle edema
B. Heart rate of 88 bpm
C. Crackles in both lung bases
D. Blood pressure of 132/78 mmHg
Answer: C
Rationale: Crackles indicate pulmonary congestion requiring prompt intervention.
3. A patient with COPD receives oxygen therapy. Which finding indicates effective treatment?
A. Respiratory rate increases to 34/min.
B. Oxygen saturation improves to the prescribed goal.
C. Cyanosis worsens.
D. Increased accessory muscle use.
Answer: B
Rationale: Improved oxygen saturation within the target range reflects effective oxygen therapy.
,4. Which laboratory value requires immediate follow-up?
A. Hemoglobin 13.8 g/dL
B. Sodium 140 mEq/L
C. Potassium 6.2 mEq/L
D. Platelets 220,000/mm³
Answer: C
Rationale: Severe hyperkalemia increases the risk of life-threatening cardiac dysrhythmias.
5. A patient with diabetes reports sweating, tremors, and confusion. What should the nurse
do first?
A. Administer insulin.
B. Check the blood glucose level.
C. Encourage exercise.
D. Notify dietary services.
Answer: B
Rationale: These symptoms suggest hypoglycemia and require immediate glucose assessment.
6. Which assessment finding suggests hypovolemic shock?
A. Warm, flushed skin
B. Bradycardia
C. Hypotension with tachycardia
D. Hypertension
Answer: C
7. A patient develops chest pain unrelieved by rest. What is the nurse's priority?
A. Encourage deep breathing.
B. Assess the patient and activate the emergency response as appropriate.
C. Offer food.
D. Delay assessment until the provider arrives.
, Answer: B
8. Which electrolyte imbalance commonly causes muscle weakness and cardiac
dysrhythmias?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C
9. Which intervention helps prevent postoperative atelectasis?
A. Bed rest
B. Fluid restriction
C. Incentive spirometry
D. Trendelenburg position
Answer: C
10. Which assessment finding is consistent with deep vein thrombosis?
A. Bilateral leg pain only
B. Unilateral calf swelling and tenderness
C. Cool extremities
D. Absent pedal pulses bilaterally
Answer: B
11. Which patient has the highest risk for infection?
A. Controlled hypertension
B. Neutropenia following chemotherapy
C. Stable asthma
D. Osteoarthritis
Answer: B
