SHIFTKEY MEDICAL-SURGICAL
LPN/RN ASSESSMENT 1
QUESTIONS AND CORRECT
ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES
2026 Q&A | INSTANT
DOWNLOAD PDF.
Core Domains
• Medical-Surgical Nursing Principles
• Cardiovascular and Respiratory Care
• Neurological and Musculoskeletal Management
• Endocrine and Renal Systems
• Gastrointestinal and Integumentary Care
• Perioperative and Emergency Nursing
• Pharmacology and IV Therapy
• Legal, Ethical, and Professional Standards
Introduction
This assessment evaluates the critical thinking and clinical
judgment of practical and registered nurses in medical-surgical
settings. It focuses on the application of foundational theory,
evidence-based practice, and regulatory compliance to real-world
patient scenarios. The exam assesses skills in patient
,assessment, prioritization, intervention, and evaluation across
diverse body systems. Using multiple-choice and scenario-based
questions, it measures the nurse's ability to make safe, effective
decisions in complex healthcare environments. This tool ensures
candidates demonstrate the professional standards and ethical
decision-making required for competent practice.
Section One: Questions 1–100
1. A nurse is assessing a client who has been receiving
intravenous furosemide for heart failure. Which of the
following findings indicates a therapeutic response to the
medication?
A. Decreased urine output
B. Weight loss of 1 kg in 24 hours
C. Increased jugular venous distention
D. Presence of crackles in the lung bases
Correct answer: B. Weight loss of 1 kg in 24 hours
RATIONALE: A weight loss of 1 kg in 24 hours is equivalent to
a fluid loss of approximately 1 liter, indicating effective diuresis
and a therapeutic response to furosemide. Decreased urine
output, increased JVD, and crackles would indicate worsening
fluid retention.
2. A client with a new colostomy is being taught about dietary
management. Which statement by the client indicates a
need for further teaching?
A. "I should eat slowly and chew my food thoroughly."
B. "I will avoid foods that cause gas, like beans and broccoli."
C. "I can eat popcorn and nuts to help regulate my stool."
D. "I should drink plenty of fluids throughout the day."
, Correct answer: C. "I can eat popcorn and nuts to help
regulate my stool."
RATIONALE: Popcorn, nuts, and other high-fiber foods can
cause blockage in a new colostomy. The client needs further
teaching. The other statements are correct.
3. A nurse is caring for a client on a ventilator. The high-
pressure alarm sounds. Which action should the nurse take
first?
A. Assess the client's oxygen saturation.
B. Suction the client's airway.
C. Check for kinks in the ventilator tubing.
D. Administer a prescribed sedative.
Correct answer: B. Suction the client's airway.
RATIONALE: The most common cause of a high-pressure
alarm is a mucus plug or secretions in the airway. The nurse's
first action should be to assess the need for suctioning, as this is
a life-threatening situation.
4. A client is prescribed digoxin. Which assessment finding
requires immediate intervention?
A. Heart rate of 58 beats per minute.
B. Serum potassium level of 3.2 mEq/L.
C. Complaint of nausea and anorexia.
D. Blood pressure of 110/70 mm Hg.
Correct answer: B. Serum potassium level of 3.2 mEq/L.
RATIONALE: Hypokalemia increases the risk of digoxin
toxicity. Nausea and anorexia are also signs of toxicity, but
hypokalemia is a primary risk factor that must be corrected to
prevent life-threatening arrhythmias.
, 5. A nurse is performing an admission assessment on a client
with cirrhosis. Which finding should the nurse report to the
provider immediately?
A. Spider angiomas on the chest.
B. Blood pressure of 90/60 mm Hg.
C. Report of fatigue and pruritus.
D. Clay-colored stools.
Correct answer: D. Clay-colored stools.
RATIONALE: Clay-colored stools indicate a blockage of bile
flow, which is a sign of worsening liver function or a complication
like a gallstone. This is a new, potentially critical finding that
requires immediate provider notification.
6. Which nursing intervention is the priority for a client in the
immediate postoperative period following a thyroidectomy?
A. Monitor for signs of hypocalcemia.
B. Assess for difficulty swallowing.
C. Keep a tracheostomy tray at the bedside.
D. Maintain the client in a supine position.
Correct answer: C. Keep a tracheostomy tray at the bedside.
RATIONALE: The priority is airway management. Laryngeal
edema or nerve damage can cause airway obstruction. A
tracheostomy tray must be immediately available. Monitoring for
hypocalcemia is important but secondary to airway.
7. A client with a spinal cord injury at T6 suddenly reports a
severe headache and has a blood pressure of 220/110 mm
Hg. What is the nurse's first action?
A. Administer a prescribed antihypertensive.
B. Place the client in a high Fowler's position.
LPN/RN ASSESSMENT 1
QUESTIONS AND CORRECT
ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES
2026 Q&A | INSTANT
DOWNLOAD PDF.
Core Domains
• Medical-Surgical Nursing Principles
• Cardiovascular and Respiratory Care
• Neurological and Musculoskeletal Management
• Endocrine and Renal Systems
• Gastrointestinal and Integumentary Care
• Perioperative and Emergency Nursing
• Pharmacology and IV Therapy
• Legal, Ethical, and Professional Standards
Introduction
This assessment evaluates the critical thinking and clinical
judgment of practical and registered nurses in medical-surgical
settings. It focuses on the application of foundational theory,
evidence-based practice, and regulatory compliance to real-world
patient scenarios. The exam assesses skills in patient
,assessment, prioritization, intervention, and evaluation across
diverse body systems. Using multiple-choice and scenario-based
questions, it measures the nurse's ability to make safe, effective
decisions in complex healthcare environments. This tool ensures
candidates demonstrate the professional standards and ethical
decision-making required for competent practice.
Section One: Questions 1–100
1. A nurse is assessing a client who has been receiving
intravenous furosemide for heart failure. Which of the
following findings indicates a therapeutic response to the
medication?
A. Decreased urine output
B. Weight loss of 1 kg in 24 hours
C. Increased jugular venous distention
D. Presence of crackles in the lung bases
Correct answer: B. Weight loss of 1 kg in 24 hours
RATIONALE: A weight loss of 1 kg in 24 hours is equivalent to
a fluid loss of approximately 1 liter, indicating effective diuresis
and a therapeutic response to furosemide. Decreased urine
output, increased JVD, and crackles would indicate worsening
fluid retention.
2. A client with a new colostomy is being taught about dietary
management. Which statement by the client indicates a
need for further teaching?
A. "I should eat slowly and chew my food thoroughly."
B. "I will avoid foods that cause gas, like beans and broccoli."
C. "I can eat popcorn and nuts to help regulate my stool."
D. "I should drink plenty of fluids throughout the day."
, Correct answer: C. "I can eat popcorn and nuts to help
regulate my stool."
RATIONALE: Popcorn, nuts, and other high-fiber foods can
cause blockage in a new colostomy. The client needs further
teaching. The other statements are correct.
3. A nurse is caring for a client on a ventilator. The high-
pressure alarm sounds. Which action should the nurse take
first?
A. Assess the client's oxygen saturation.
B. Suction the client's airway.
C. Check for kinks in the ventilator tubing.
D. Administer a prescribed sedative.
Correct answer: B. Suction the client's airway.
RATIONALE: The most common cause of a high-pressure
alarm is a mucus plug or secretions in the airway. The nurse's
first action should be to assess the need for suctioning, as this is
a life-threatening situation.
4. A client is prescribed digoxin. Which assessment finding
requires immediate intervention?
A. Heart rate of 58 beats per minute.
B. Serum potassium level of 3.2 mEq/L.
C. Complaint of nausea and anorexia.
D. Blood pressure of 110/70 mm Hg.
Correct answer: B. Serum potassium level of 3.2 mEq/L.
RATIONALE: Hypokalemia increases the risk of digoxin
toxicity. Nausea and anorexia are also signs of toxicity, but
hypokalemia is a primary risk factor that must be corrected to
prevent life-threatening arrhythmias.
, 5. A nurse is performing an admission assessment on a client
with cirrhosis. Which finding should the nurse report to the
provider immediately?
A. Spider angiomas on the chest.
B. Blood pressure of 90/60 mm Hg.
C. Report of fatigue and pruritus.
D. Clay-colored stools.
Correct answer: D. Clay-colored stools.
RATIONALE: Clay-colored stools indicate a blockage of bile
flow, which is a sign of worsening liver function or a complication
like a gallstone. This is a new, potentially critical finding that
requires immediate provider notification.
6. Which nursing intervention is the priority for a client in the
immediate postoperative period following a thyroidectomy?
A. Monitor for signs of hypocalcemia.
B. Assess for difficulty swallowing.
C. Keep a tracheostomy tray at the bedside.
D. Maintain the client in a supine position.
Correct answer: C. Keep a tracheostomy tray at the bedside.
RATIONALE: The priority is airway management. Laryngeal
edema or nerve damage can cause airway obstruction. A
tracheostomy tray must be immediately available. Monitoring for
hypocalcemia is important but secondary to airway.
7. A client with a spinal cord injury at T6 suddenly reports a
severe headache and has a blood pressure of 220/110 mm
Hg. What is the nurse's first action?
A. Administer a prescribed antihypertensive.
B. Place the client in a high Fowler's position.
