,NSG 233 Medical-Surgical Nursing III Exam 1 |
Herzing University | Latest 2026/2027 Update
1. A triage nurse in the emergency department must prioritize care for multiple incoming patients.
Which patient should receive the highest priority based on the Emergency Severity Index (ESI)?
A) A 34-year-old with a sprained ankle reporting pain at 4/10
B) A 56-year-old who is diaphoretic and reporting substernal chest pain
C) A 22-year-old with a laceration requiring sutures
D) An 8-year-old with a fever of 101°F and mild cough
Correct Answer: A 56-year-old who is diaphoretic and reporting substernal chest pain
Rationale: The ESI assigns patients to Level 1 (most urgent) based on acuity and anticipated resource
needs. A diaphoretic patient with chest pain may indicate an acute myocardial infarction, requiring
immediate life-saving interventions. This patient has the highest acuity. The other patients present
with non-life-threatening conditions that can be managed with lower urgency.
2. A client is brought to the emergency department after a suicide attempt via carbon monoxide
poisoning. The client is confused, has cherry red lips, and states they still wish to die. Which action
should the nurse perform first?
A) Initiate a 1:1 suicide observation
B) Administer 100% oxygen via non-rebreather mask
C) Assess the client's carboxyhemoglobin level
D) Prepare for hyperbaric oxygen therapy
Correct Answer: Assess the client's carboxyhemoglobin level
Rationale: The priority is to assess the carboxyhemoglobin level to determine the severity of carbon
monoxide poisoning. This laboratory value guides subsequent treatment decisions. While oxygen
administration, suicide precautions, and hyperbaric therapy are important, the immediate diagnostic
assessment is the priority to establish the baseline severity of poisoning.
,3. A nurse is caring for a patient who sustained a crush injury from a building collapse. Which
assessment finding should alert the nurse to the development of rhabdomyolysis as a complication?
A) Dark urine and myalgia
B) Hypertension and tachycardia
C) Hyperthermia and dry skin
D) Polyuria and polydipsia
Correct Answer: Dark urine and myalgia
Rationale: Rhabdomyolysis is a complication of crush injuries characterized by the breakdown of
skeletal muscle, releasing myoglobin into the bloodstream. Dark (tea-colored) urine results from
myoglobinuria, and myalgia with muscle weakness are classic signs. Hypertension, hyperthermia, and
polyuria are not characteristic findings of this condition.
4. In the emergency department, the family of a deceased client asks to see the patient's body. Which
therapeutic response by the nurse is most appropriate?
A) "I'm sorry, but visiting the deceased is not permitted in the emergency department."
B) "Let me make arrangements and see what I can do to allow you to spend time with your loved
one."
C) "You should wait until the funeral home has prepared the body for viewing."
D) "I understand your grief, but we need to complete our post-mortem care first."
Correct Answer: "Let me make arrangements and see what I can do to allow you to spend time with
your loved one."
Rationale: This response demonstrates therapeutic communication by acknowledging the family's
need and offering to facilitate their request. It conveys empathy, respect, and a willingness to
accommodate the family's wishes within the constraints of the clinical setting. The other responses
are dismissive or create unnecessary barriers to the grieving process.
5. A nurse is providing care to a client in hypovolemic shock secondary to a gastrointestinal
hemorrhage. Which intervention should the nurse implement first?
A) Administer crystalloid fluids via a large-bore IV catheter
, B) Place the client in the modified Trendelenburg position
C) Stop the source of fluid loss
D) Type and cross-match for packed red blood cells
Correct Answer: Stop the source of fluid loss
Rationale: The priority intervention in hypovolemic shock is to stop the source of fluid loss (e.g.,
applying pressure to a bleeding site, administering medications to stop vomiting or diarrhea). Without
controlling the hemorrhage, fluid resuscitation will be ineffective. After the source is controlled, the
nurse should insert large-bore IVs, administer fluids, and prepare for blood products.
6. A client with hypovolemic shock requires massive transfusion of blood products. Which nursing
action is essential to prevent a life-threatening complication?
A) Administer the blood products rapidly via a pressure bag
B) Warm the blood products before infusion
C) Infuse the blood products through a small-gauge IV catheter
D) Administer the blood products with calcium gluconate
Correct Answer: Warm the blood products before infusion
Rationale: Massive transfusion of cold blood products can lead to hypothermia, cardiac dysrhythmias,
and coagulopathy. Blood products should be warmed using an approved blood warmer before
infusion. Rapid infusion via pressure bag is appropriate but warming is the essential safety measure.
Small-gauge catheters are insufficient for rapid volume resuscitation.
7. A client in hypovolemic shock is receiving isotonic fluid resuscitation. Which fluid should the nurse
anticipate administering first?
A) 5% Dextrose in Water (D5W)
B) 0.9% Normal Saline
C) 3% Normal Saline
D) 0.45% Normal Saline
Herzing University | Latest 2026/2027 Update
1. A triage nurse in the emergency department must prioritize care for multiple incoming patients.
Which patient should receive the highest priority based on the Emergency Severity Index (ESI)?
A) A 34-year-old with a sprained ankle reporting pain at 4/10
B) A 56-year-old who is diaphoretic and reporting substernal chest pain
C) A 22-year-old with a laceration requiring sutures
D) An 8-year-old with a fever of 101°F and mild cough
Correct Answer: A 56-year-old who is diaphoretic and reporting substernal chest pain
Rationale: The ESI assigns patients to Level 1 (most urgent) based on acuity and anticipated resource
needs. A diaphoretic patient with chest pain may indicate an acute myocardial infarction, requiring
immediate life-saving interventions. This patient has the highest acuity. The other patients present
with non-life-threatening conditions that can be managed with lower urgency.
2. A client is brought to the emergency department after a suicide attempt via carbon monoxide
poisoning. The client is confused, has cherry red lips, and states they still wish to die. Which action
should the nurse perform first?
A) Initiate a 1:1 suicide observation
B) Administer 100% oxygen via non-rebreather mask
C) Assess the client's carboxyhemoglobin level
D) Prepare for hyperbaric oxygen therapy
Correct Answer: Assess the client's carboxyhemoglobin level
Rationale: The priority is to assess the carboxyhemoglobin level to determine the severity of carbon
monoxide poisoning. This laboratory value guides subsequent treatment decisions. While oxygen
administration, suicide precautions, and hyperbaric therapy are important, the immediate diagnostic
assessment is the priority to establish the baseline severity of poisoning.
,3. A nurse is caring for a patient who sustained a crush injury from a building collapse. Which
assessment finding should alert the nurse to the development of rhabdomyolysis as a complication?
A) Dark urine and myalgia
B) Hypertension and tachycardia
C) Hyperthermia and dry skin
D) Polyuria and polydipsia
Correct Answer: Dark urine and myalgia
Rationale: Rhabdomyolysis is a complication of crush injuries characterized by the breakdown of
skeletal muscle, releasing myoglobin into the bloodstream. Dark (tea-colored) urine results from
myoglobinuria, and myalgia with muscle weakness are classic signs. Hypertension, hyperthermia, and
polyuria are not characteristic findings of this condition.
4. In the emergency department, the family of a deceased client asks to see the patient's body. Which
therapeutic response by the nurse is most appropriate?
A) "I'm sorry, but visiting the deceased is not permitted in the emergency department."
B) "Let me make arrangements and see what I can do to allow you to spend time with your loved
one."
C) "You should wait until the funeral home has prepared the body for viewing."
D) "I understand your grief, but we need to complete our post-mortem care first."
Correct Answer: "Let me make arrangements and see what I can do to allow you to spend time with
your loved one."
Rationale: This response demonstrates therapeutic communication by acknowledging the family's
need and offering to facilitate their request. It conveys empathy, respect, and a willingness to
accommodate the family's wishes within the constraints of the clinical setting. The other responses
are dismissive or create unnecessary barriers to the grieving process.
5. A nurse is providing care to a client in hypovolemic shock secondary to a gastrointestinal
hemorrhage. Which intervention should the nurse implement first?
A) Administer crystalloid fluids via a large-bore IV catheter
, B) Place the client in the modified Trendelenburg position
C) Stop the source of fluid loss
D) Type and cross-match for packed red blood cells
Correct Answer: Stop the source of fluid loss
Rationale: The priority intervention in hypovolemic shock is to stop the source of fluid loss (e.g.,
applying pressure to a bleeding site, administering medications to stop vomiting or diarrhea). Without
controlling the hemorrhage, fluid resuscitation will be ineffective. After the source is controlled, the
nurse should insert large-bore IVs, administer fluids, and prepare for blood products.
6. A client with hypovolemic shock requires massive transfusion of blood products. Which nursing
action is essential to prevent a life-threatening complication?
A) Administer the blood products rapidly via a pressure bag
B) Warm the blood products before infusion
C) Infuse the blood products through a small-gauge IV catheter
D) Administer the blood products with calcium gluconate
Correct Answer: Warm the blood products before infusion
Rationale: Massive transfusion of cold blood products can lead to hypothermia, cardiac dysrhythmias,
and coagulopathy. Blood products should be warmed using an approved blood warmer before
infusion. Rapid infusion via pressure bag is appropriate but warming is the essential safety measure.
Small-gauge catheters are insufficient for rapid volume resuscitation.
7. A client in hypovolemic shock is receiving isotonic fluid resuscitation. Which fluid should the nurse
anticipate administering first?
A) 5% Dextrose in Water (D5W)
B) 0.9% Normal Saline
C) 3% Normal Saline
D) 0.45% Normal Saline
