RN Medical-Surgical Nursing Final Exam Practice |Questions |Answers
|Rationales
1. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The
patient reports sudden shortness of breath and chest pain. Which of the
following is the priority action?
A. Administer the prescribed PRN analgesic
B. Check the surgical incision for signs of evisceration
C. Encourage the patient to use the incentive spirometer
D. Apply oxygen via nasal cannula and check pulse oximetry
Answer: D
Rationale: Shortness of breath and chest pain in a post-op patient are red flags for
pulmonary embolism. Immediate oxygenation assessment and support take priority (ABC -
Airway, Breathing, Circulation).
2. A patient with Type 1 Diabetes Mellitus is found unresponsive and clammy.
What should the nurse’s first action be?
A. Administer 15g of oral glucose gel
B. Draw a blood sample for a stat HbA1c test
C. Administer Glucagon IM or SQ according to protocol
D. Check the patient’s urine for ketones
Answer: C
Rationale: In an unresponsive patient with suspected hypoglycemia, the nurse must
provide glucose via a parenteral route (Glucagon or IV Dextrose) since oral intake is unsafe.
,3. A patient is diagnosed with Left-sided Heart Failure. Which clinical
manifestation should the nurse expect to assess?
A. Jugular venous distention (JVD)
B. Crackles in the lungs upon auscultation
C. Peripheral edema in the lower extremities
D. Hepatomegaly and ascites
Answer: B
Rationale: Left-sided heart failure leads to pulmonary congestion, resulting in symptoms
like crackles, dyspnea, and orthopnea. Right-sided failure causes systemic congestion (JVD,
edema).
4. When caring for a patient with a chest tube, the nurse notes continuous
bubbling in the water-seal chamber. This likely indicates:
A. A normal finding for a patient with a pneumothorax
B. The suction pressure is too high
C. The lung has fully re-expanded
D. An air leak in the drainage system
Answer: D
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak.
Intermittent bubbling is expected in a patient with a pneumothorax until the lung expands.
5. Which lab value is most critical to monitor for a patient receiving Warfarin
therapy?
A. Partial Thromboplastin Time (aPTT)
B. Platelet count
C. Prothrombin Time and International Normalized Ratio (PT/INR)
D. White blood cell count
Answer: C
, Rationale: PT and INR are used to monitor the effectiveness and safety of Warfarin
(Coumadin). aPTT is used for Heparin.
6. A patient with Chronic Renal Failure (CRF) has a potassium level of 6.8 mEq/L.
Which medication should the nurse anticipate administering to lower the
potassium quickly?
A. Regular Insulin and D50W IV
B. Sodium Polystyrene Sulfonate (Kayexalate)
C. Furosemide (Lasix)
D. Spironolactone
Answer: A
Rationale: Regular insulin and D50W shift potassium into the cells quickly. Kayexalate
removes potassium from the body but takes longer to act.
7. Which of the following is a classic early sign of increased intracranial pressure
(ICP)?
A. Cushing’s Triad
B. Decreased level of consciousness (LOC)
C. Fixed and dilated pupils
D. Decerebrate posturing
Answer: B
Rationale: A change in LOC is the earliest and most sensitive indicator of increasing ICP.
Cushing’s Triad and pupillary changes are late signs.
|Rationales
1. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The
patient reports sudden shortness of breath and chest pain. Which of the
following is the priority action?
A. Administer the prescribed PRN analgesic
B. Check the surgical incision for signs of evisceration
C. Encourage the patient to use the incentive spirometer
D. Apply oxygen via nasal cannula and check pulse oximetry
Answer: D
Rationale: Shortness of breath and chest pain in a post-op patient are red flags for
pulmonary embolism. Immediate oxygenation assessment and support take priority (ABC -
Airway, Breathing, Circulation).
2. A patient with Type 1 Diabetes Mellitus is found unresponsive and clammy.
What should the nurse’s first action be?
A. Administer 15g of oral glucose gel
B. Draw a blood sample for a stat HbA1c test
C. Administer Glucagon IM or SQ according to protocol
D. Check the patient’s urine for ketones
Answer: C
Rationale: In an unresponsive patient with suspected hypoglycemia, the nurse must
provide glucose via a parenteral route (Glucagon or IV Dextrose) since oral intake is unsafe.
,3. A patient is diagnosed with Left-sided Heart Failure. Which clinical
manifestation should the nurse expect to assess?
A. Jugular venous distention (JVD)
B. Crackles in the lungs upon auscultation
C. Peripheral edema in the lower extremities
D. Hepatomegaly and ascites
Answer: B
Rationale: Left-sided heart failure leads to pulmonary congestion, resulting in symptoms
like crackles, dyspnea, and orthopnea. Right-sided failure causes systemic congestion (JVD,
edema).
4. When caring for a patient with a chest tube, the nurse notes continuous
bubbling in the water-seal chamber. This likely indicates:
A. A normal finding for a patient with a pneumothorax
B. The suction pressure is too high
C. The lung has fully re-expanded
D. An air leak in the drainage system
Answer: D
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak.
Intermittent bubbling is expected in a patient with a pneumothorax until the lung expands.
5. Which lab value is most critical to monitor for a patient receiving Warfarin
therapy?
A. Partial Thromboplastin Time (aPTT)
B. Platelet count
C. Prothrombin Time and International Normalized Ratio (PT/INR)
D. White blood cell count
Answer: C
, Rationale: PT and INR are used to monitor the effectiveness and safety of Warfarin
(Coumadin). aPTT is used for Heparin.
6. A patient with Chronic Renal Failure (CRF) has a potassium level of 6.8 mEq/L.
Which medication should the nurse anticipate administering to lower the
potassium quickly?
A. Regular Insulin and D50W IV
B. Sodium Polystyrene Sulfonate (Kayexalate)
C. Furosemide (Lasix)
D. Spironolactone
Answer: A
Rationale: Regular insulin and D50W shift potassium into the cells quickly. Kayexalate
removes potassium from the body but takes longer to act.
7. Which of the following is a classic early sign of increased intracranial pressure
(ICP)?
A. Cushing’s Triad
B. Decreased level of consciousness (LOC)
C. Fixed and dilated pupils
D. Decerebrate posturing
Answer: B
Rationale: A change in LOC is the earliest and most sensitive indicator of increasing ICP.
Cushing’s Triad and pupillary changes are late signs.
