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Medical-Surgical Nursing Assessment 1 Newest Exam
Preparation With Complete Questions And Correct Answers
With Rationales Already Graded A+ Brand New Version!!
1. A patient with heart failure is prescribed furosemide. Which
laboratory value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Answer: B) Serum potassium
Explanation: Furosemide is a loop diuretic that inhibits sodium and
chloride reabsorption in the ascending loop of Henle, leading to
increased potassium excretion. Hypokalemia is a common and
potentially dangerous adverse effect that can precipitate cardiac
dysrhythmias, especially in patients taking digitalis. While sodium,
calcium, and magnesium may also be affected, potassium monitoring is
most critical due to its direct impact on cardiac function.
2. A postoperative patient develops chest pain, dyspnea, and
tachycardia. The nurse suspects a pulmonary embolism. What is the
priority nursing action?
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A) Administer oxygen
B) Notify the healthcare provider
C) Elevate the head of the bed
D) Obtain a spiral CT scan
Answer: A) Administer oxygen
Explanation: The priority action is to address the impaired gas exchange
by administering oxygen. Airway, breathing, and circulation (ABCs)
always take precedence. While notifying the healthcare provider and
elevating the head of the bed are important, oxygenation is the
immediate life-saving measure. A spiral CT scan is a diagnostic tool that
would be ordered later.
3. Which finding in a patient with diabetic ketoacidosis (DKA) indicates
that treatment is effective?
A) Serum pH increases from 7.20 to 7.35
B) Serum glucose decreases from 800 to 400 mg/dL
C) Serum bicarbonate increases from 12 to 18 mEq/L
D) Urine output increases to 50 mL/hour
Answer: A) Serum pH increases from 7.20 to 7.35
Explanation: DKA is characterized by metabolic acidosis. An increasing
pH toward normal indicates that the acidosis is resolving, reflecting
effective insulin therapy and fluid resuscitation. While decreasing
glucose and increasing bicarbonate are also positive signs, the primary
goal is correcting acidosis. Urine output improvement indicates
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adequate perfusion but is not the most specific indicator of DKA
resolution.
4. A patient with chronic obstructive pulmonary disease (COPD) has an
arterial blood gas (ABG) result showing pH 7.31, PaCO2 58 mmHg,
HCO3 28 mEq/L. The nurse interprets this as:
A) Uncompensated respiratory acidosis
B) Partially compensated respiratory acidosis
C) Fully compensated respiratory acidosis
D) Combined metabolic and respiratory acidosis
Answer: B) Partially compensated respiratory acidosis
Explanation: The pH is low (acidemia), PaCO2 is elevated (respiratory
acidosis), and HCO3 is elevated (metabolic compensation). Since the pH
remains below normal despite the compensatory increase in
bicarbonate, the compensation is partial. Full compensation would
return the pH to normal range (7.35–7.45).
5. A patient receiving intravenous heparin therapy for a deep vein
thrombosis develops epistaxis and hematuria. The nurse should
anticipate which medication order?
A) Vitamin K
B) Protamine sulfate
C) Aminocaproic acid
D) Fresh frozen plasma
Answer: B) Protamine sulfate
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Explanation: Protamine sulfate is the specific antidote for heparin. It
binds to heparin, forming a stable complex that neutralizes its
anticoagulant effects. Vitamin K is the antidote for warfarin.
Aminocaproic acid is used for hyperfibrinolysis. Fresh frozen plasma
replaces clotting factors but is not the first-line antidote for heparin.
6. A patient with acute pancreatitis reports severe abdominal pain that
radiates to the back. Which position would best relieve this pain?
A) Supine with legs extended
B) Prone with a pillow under the abdomen
C) Side-lying with knees flexed to the chest
D) High Fowler’s position
Answer: C) Side-lying with knees flexed to the chest
Explanation: The fetal position (side-lying with knees flexed) reduces
tension on the abdominal wall and pancreas, often decreasing pain.
Supine position may increase pain because the pancreas lies
retroperitoneally and pressure from the spine worsens discomfort.
Prone is impractical, and High Fowler’s does not specifically reduce
pancreatic tension.
7. The nurse is caring for a patient with a chest tube connected to a
water-seal drainage system. Which observation indicates a potential
complication?
A) Continuous bubbling in the water-seal chamber
Medical-Surgical Nursing Assessment 1 Newest Exam
Preparation With Complete Questions And Correct Answers
With Rationales Already Graded A+ Brand New Version!!
1. A patient with heart failure is prescribed furosemide. Which
laboratory value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Answer: B) Serum potassium
Explanation: Furosemide is a loop diuretic that inhibits sodium and
chloride reabsorption in the ascending loop of Henle, leading to
increased potassium excretion. Hypokalemia is a common and
potentially dangerous adverse effect that can precipitate cardiac
dysrhythmias, especially in patients taking digitalis. While sodium,
calcium, and magnesium may also be affected, potassium monitoring is
most critical due to its direct impact on cardiac function.
2. A postoperative patient develops chest pain, dyspnea, and
tachycardia. The nurse suspects a pulmonary embolism. What is the
priority nursing action?
,2|Page
A) Administer oxygen
B) Notify the healthcare provider
C) Elevate the head of the bed
D) Obtain a spiral CT scan
Answer: A) Administer oxygen
Explanation: The priority action is to address the impaired gas exchange
by administering oxygen. Airway, breathing, and circulation (ABCs)
always take precedence. While notifying the healthcare provider and
elevating the head of the bed are important, oxygenation is the
immediate life-saving measure. A spiral CT scan is a diagnostic tool that
would be ordered later.
3. Which finding in a patient with diabetic ketoacidosis (DKA) indicates
that treatment is effective?
A) Serum pH increases from 7.20 to 7.35
B) Serum glucose decreases from 800 to 400 mg/dL
C) Serum bicarbonate increases from 12 to 18 mEq/L
D) Urine output increases to 50 mL/hour
Answer: A) Serum pH increases from 7.20 to 7.35
Explanation: DKA is characterized by metabolic acidosis. An increasing
pH toward normal indicates that the acidosis is resolving, reflecting
effective insulin therapy and fluid resuscitation. While decreasing
glucose and increasing bicarbonate are also positive signs, the primary
goal is correcting acidosis. Urine output improvement indicates
,3|Page
adequate perfusion but is not the most specific indicator of DKA
resolution.
4. A patient with chronic obstructive pulmonary disease (COPD) has an
arterial blood gas (ABG) result showing pH 7.31, PaCO2 58 mmHg,
HCO3 28 mEq/L. The nurse interprets this as:
A) Uncompensated respiratory acidosis
B) Partially compensated respiratory acidosis
C) Fully compensated respiratory acidosis
D) Combined metabolic and respiratory acidosis
Answer: B) Partially compensated respiratory acidosis
Explanation: The pH is low (acidemia), PaCO2 is elevated (respiratory
acidosis), and HCO3 is elevated (metabolic compensation). Since the pH
remains below normal despite the compensatory increase in
bicarbonate, the compensation is partial. Full compensation would
return the pH to normal range (7.35–7.45).
5. A patient receiving intravenous heparin therapy for a deep vein
thrombosis develops epistaxis and hematuria. The nurse should
anticipate which medication order?
A) Vitamin K
B) Protamine sulfate
C) Aminocaproic acid
D) Fresh frozen plasma
Answer: B) Protamine sulfate
, 4|Page
Explanation: Protamine sulfate is the specific antidote for heparin. It
binds to heparin, forming a stable complex that neutralizes its
anticoagulant effects. Vitamin K is the antidote for warfarin.
Aminocaproic acid is used for hyperfibrinolysis. Fresh frozen plasma
replaces clotting factors but is not the first-line antidote for heparin.
6. A patient with acute pancreatitis reports severe abdominal pain that
radiates to the back. Which position would best relieve this pain?
A) Supine with legs extended
B) Prone with a pillow under the abdomen
C) Side-lying with knees flexed to the chest
D) High Fowler’s position
Answer: C) Side-lying with knees flexed to the chest
Explanation: The fetal position (side-lying with knees flexed) reduces
tension on the abdominal wall and pancreas, often decreasing pain.
Supine position may increase pain because the pancreas lies
retroperitoneally and pressure from the spine worsens discomfort.
Prone is impractical, and High Fowler’s does not specifically reduce
pancreatic tension.
7. The nurse is caring for a patient with a chest tube connected to a
water-seal drainage system. Which observation indicates a potential
complication?
A) Continuous bubbling in the water-seal chamber
