Medical-Surgical RN A Prophecy
Relias Latest 2026 Questions and
Answers(Scored 100%)
Course
Medical-Surgical RN A Prophecy Relias
1. A client with heart failure suddenly develops severe dyspnea, crackles throughout both
lung fields, and an oxygen saturation of 84%. What should the nurse do first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position and administer oxygen as prescribed
C. Obtain the client's daily weight
D. Restrict sodium intake
Answer: B. Place the client in high-Fowler's position and administer oxygen as prescribed
Rationale: Severe dyspnea and hypoxemia indicate impaired gas exchange. Airway and
oxygenation take priority. Positioning upright improves lung expansion and oxygen should be
administered according to the patient's order/protocol.
2. Which finding in a client receiving digoxin requires the nurse's immediate attention?
A. Heart rate of 52/min
B. Blood pressure of 128/74 mmHg
C. Respiratory rate of 18/min
D. Potassium level of 4.2 mEq/L
Answer: A. Heart rate of 52/min
Rationale: Digoxin can cause bradycardia. A significantly low heart rate should prompt holding
the medication and further assessment according to the prescription and facility protocol.
3. A client with COPD has an oxygen saturation of 86%. Which nursing intervention is most
appropriate?
A. Withhold oxygen because oxygen is contraindicated in COPD
B. Administer prescribed oxygen and monitor the client's response
C. Place the client flat in bed
D. Encourage rapid, shallow breathing
Answer: B. Administer prescribed oxygen and monitor the client's response
,Rationale: Hypoxemia must be treated. Oxygen is not routinely withheld from clients with
COPD. The nurse should administer prescribed oxygen and monitor respiratory status and
oxygenation.
4. A client with diabetes mellitus is confused, diaphoretic, and trembling. What should the
nurse do first?
A. Administer long-acting insulin
B. Check the client's blood glucose level
C. Encourage exercise
D. Restrict carbohydrates
Answer: B. Check the client's blood glucose level
Rationale: The symptoms are consistent with hypoglycemia. Blood glucose should be assessed
immediately when possible. If hypoglycemia is confirmed and the client can safely swallow,
rapid-acting carbohydrate is generally appropriate.
5. Which finding is most concerning in a client with pneumonia?
A. Temperature of 38.1°C (100.6°F)
B. Productive cough
C. Respiratory rate of 32/min with increasing confusion
D. Chest discomfort when coughing
Answer: C. Respiratory rate of 32/min with increasing confusion
Rationale: Tachypnea and acute mental-status changes can indicate significant hypoxemia or
deterioration. These findings require immediate assessment and intervention.
6. A client receiving IV potassium chloride reports burning at the IV site. What should the
nurse do?
A. Increase the infusion rate
B. Stop the infusion and assess the IV site
C. Apply pressure and continue the infusion
D. Flush rapidly with normal saline
Answer: B. Stop the infusion and assess the IV site
Rationale: IV potassium is irritating to veins, and pain or burning can indicate infiltration or
phlebitis. The infusion should be stopped and the IV site assessed.
7. Which assessment finding is most consistent with hypokalemia?
, A. Muscle weakness
B. Bounding pulse
C. Hyperactive reflexes
D. Severe hypertension
Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, dysrhythmias, and decreased
gastrointestinal motility.
8. A client with suspected stroke develops sudden facial drooping and difficulty speaking.
What is the priority nursing action?
A. Give the client oral fluids
B. Place the client on a regular diet
C. Activate the facility's stroke response and rapidly assess the client
D. Allow the client to sleep
Answer: C. Activate the facility's stroke response and rapidly assess the client
Rationale: Sudden neurologic deficits may indicate an acute stroke. Rapid recognition and
treatment are essential because time-sensitive interventions may be possible.
9. A client with a suspected stroke has difficulty swallowing. Which intervention is
appropriate?
A. Give water to assess swallowing
B. Keep the client NPO until swallowing safety is evaluated
C. Provide thin liquids
D. Place food at the bedside
Answer: B. Keep the client NPO until swallowing safety is evaluated
Rationale: Dysphagia after stroke increases aspiration risk. Oral intake should be withheld until
swallowing ability has been appropriately assessed.
10. Which finding is most characteristic of fluid volume overload?
A. Flat neck veins
B. Crackles and peripheral edema
C. Dry mucous membranes
D. Poor skin turgor
Answer: B. Crackles and peripheral edema
Relias Latest 2026 Questions and
Answers(Scored 100%)
Course
Medical-Surgical RN A Prophecy Relias
1. A client with heart failure suddenly develops severe dyspnea, crackles throughout both
lung fields, and an oxygen saturation of 84%. What should the nurse do first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position and administer oxygen as prescribed
C. Obtain the client's daily weight
D. Restrict sodium intake
Answer: B. Place the client in high-Fowler's position and administer oxygen as prescribed
Rationale: Severe dyspnea and hypoxemia indicate impaired gas exchange. Airway and
oxygenation take priority. Positioning upright improves lung expansion and oxygen should be
administered according to the patient's order/protocol.
2. Which finding in a client receiving digoxin requires the nurse's immediate attention?
A. Heart rate of 52/min
B. Blood pressure of 128/74 mmHg
C. Respiratory rate of 18/min
D. Potassium level of 4.2 mEq/L
Answer: A. Heart rate of 52/min
Rationale: Digoxin can cause bradycardia. A significantly low heart rate should prompt holding
the medication and further assessment according to the prescription and facility protocol.
3. A client with COPD has an oxygen saturation of 86%. Which nursing intervention is most
appropriate?
A. Withhold oxygen because oxygen is contraindicated in COPD
B. Administer prescribed oxygen and monitor the client's response
C. Place the client flat in bed
D. Encourage rapid, shallow breathing
Answer: B. Administer prescribed oxygen and monitor the client's response
,Rationale: Hypoxemia must be treated. Oxygen is not routinely withheld from clients with
COPD. The nurse should administer prescribed oxygen and monitor respiratory status and
oxygenation.
4. A client with diabetes mellitus is confused, diaphoretic, and trembling. What should the
nurse do first?
A. Administer long-acting insulin
B. Check the client's blood glucose level
C. Encourage exercise
D. Restrict carbohydrates
Answer: B. Check the client's blood glucose level
Rationale: The symptoms are consistent with hypoglycemia. Blood glucose should be assessed
immediately when possible. If hypoglycemia is confirmed and the client can safely swallow,
rapid-acting carbohydrate is generally appropriate.
5. Which finding is most concerning in a client with pneumonia?
A. Temperature of 38.1°C (100.6°F)
B. Productive cough
C. Respiratory rate of 32/min with increasing confusion
D. Chest discomfort when coughing
Answer: C. Respiratory rate of 32/min with increasing confusion
Rationale: Tachypnea and acute mental-status changes can indicate significant hypoxemia or
deterioration. These findings require immediate assessment and intervention.
6. A client receiving IV potassium chloride reports burning at the IV site. What should the
nurse do?
A. Increase the infusion rate
B. Stop the infusion and assess the IV site
C. Apply pressure and continue the infusion
D. Flush rapidly with normal saline
Answer: B. Stop the infusion and assess the IV site
Rationale: IV potassium is irritating to veins, and pain or burning can indicate infiltration or
phlebitis. The infusion should be stopped and the IV site assessed.
7. Which assessment finding is most consistent with hypokalemia?
, A. Muscle weakness
B. Bounding pulse
C. Hyperactive reflexes
D. Severe hypertension
Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, dysrhythmias, and decreased
gastrointestinal motility.
8. A client with suspected stroke develops sudden facial drooping and difficulty speaking.
What is the priority nursing action?
A. Give the client oral fluids
B. Place the client on a regular diet
C. Activate the facility's stroke response and rapidly assess the client
D. Allow the client to sleep
Answer: C. Activate the facility's stroke response and rapidly assess the client
Rationale: Sudden neurologic deficits may indicate an acute stroke. Rapid recognition and
treatment are essential because time-sensitive interventions may be possible.
9. A client with a suspected stroke has difficulty swallowing. Which intervention is
appropriate?
A. Give water to assess swallowing
B. Keep the client NPO until swallowing safety is evaluated
C. Provide thin liquids
D. Place food at the bedside
Answer: B. Keep the client NPO until swallowing safety is evaluated
Rationale: Dysphagia after stroke increases aspiration risk. Oral intake should be withheld until
swallowing ability has been appropriately assessed.
10. Which finding is most characteristic of fluid volume overload?
A. Flat neck veins
B. Crackles and peripheral edema
C. Dry mucous membranes
D. Poor skin turgor
Answer: B. Crackles and peripheral edema
