NU 185 Medical-Surgical Nursing II Comprehensive
Exam Prep Comprehensive Study Guide
UPDATE Actual Questions & Verified Answers with
Detailed Clinical Rationales
A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client?
A) "Avoid using aspirin-containing products."
B) "Take your medication with food."
C) "Check your pulse daily."
D) "Avoid using salt substitutes." - Correct Answer :D
Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-
threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of
potassium chloride.
The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a
painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with?
P 1
, • NUR 6001 09/15/2026
A) Peripheral arterial disease
B) Deep vein thrombosis
C) Diabetic foot ulceration
D) Peripheral venous disease - Correct Answer :A
Arterial disease is characterized by claudication after walking short distances. Ulcerations caused by peripheral
arterial disease are painful and initially are located at the most distal points on the extremity. Diabetic ulcers and
venous ulcers are seldom painful and usually tend to occur where pressure is applied.
Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing
exercises. The nurse's best response would be:
A. "Pain will become less each day."
B. "This is a normal reaction after surgery."
C. "With a pillow, apply pressure against the incision."
D. "I will give you the pain medication the physician ordered." - Correct Answer :Answer: (C) "With a pillow,
apply pressure against the incision."
Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by
coughing which causes tension on the incision that leads to pain.
The nurse needs to carefully assess the complaint of pain of the elderly because older people
A. are expected to experience chronic pain
B. have a decreased pain threshold
C. experience reduced sensory perception
D. have altered mental function - Correct Answer :Answer: (C) experience reduced sensory perception
Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of
reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.
When describing patient education approaches, the nurse educator would explain that informal teaching is an
approach that
a. follows formalized plans
P 2
, • NUR 6001 09/15/2026
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - Correct Answer :C. Informal teaching is individualized one on one teaching which
represents the majority of patient education done by nurses that occurs when an intervention is explained or a
question is answered. Group needs are often the focus of formal patient education courses or classes. Informal
teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is
individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with
standardized content.
A patient expresses a strong interest in returning to their work, family, and hobbies after having a stroke. Which
theory type would the nurse use to develop a plan of care for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic - Correct Answer :C. Cognitive theorists believe that attention, relevance, confidence, and
satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn. Field theorists place
significance on how achievement, power, the need for affiliation, and avoidance motives influence individual
behavior. Sociologic theories are not involved in motivation.
The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (select all
that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic - Correct Answer :C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who
smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.
P 3
, • NUR 6001 09/15/2026
Which statement made by a nurse represents the need for further education regarding pain management in
older adult clients?
a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much - Correct Answer :D
There is no evidence to support the idea that older adult clients perceive pain any differently than younger
clients. The other statements are accurate regarding older clients and pain.
The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting
that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure
106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink - Correct Answer :C
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to
the ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and
sponging his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not
as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline.
The client states that the area around the IV site burns. What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion - Correct Answer :D
P 4