SHIFTKEY MEDICAL-SURGICAL LPN/RN ASSESSMENT 1 | SHIFTKEY | ACADEMIC
YEAR 2026/2027 | COMPREHENSIVE COMPETENCY ASSESSMENT | VERIFIED
QUESTIONS AND CORRECT ANSWER RATIONALES
1. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis
and a new prescription for rifampin. Which of the following instructions should the
nurse include? - ANSWERS-"Expect your urine and other secretions to be orange
while taking this medication."
The nurse should inform the client that rifampin will turn urine and other
secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the
client to notify the provider if manifestations of hepatitis occur, including
jaundice, fatigue, or malaise.
2. A nurse is caring for a client in acute respiratory failure who is receiving mechanical
ventilation. Which of the following assessments is the best method for the nurse to
use to determine the effectiveness of the current treatment regimen? - ANSWERS-
Arterial blood gases
When using the airway, breathing, circulation approach to client care, the nurse
should place priority on evaluating arterial blood gases to determine serum
oxygen saturation and acid-base balance.
3. A nurse is assessing a client who has bacterial pneumonia. Which of the following
clinical manifestations should the nurse expect? - ANSWERS-Temperature 38.8° C
(101.8° F)
An elevated temperature is an expected finding for a client who has bacterial
pneumonia.
4. A nurse is caring for a newly-admitted client who has emphysema. The nurse should
place the client in which of the following positions to promote effective breathing? -
ANSWERS-High-Fowler's position with the arms supported on the overbed table
The nurse should place the client in a position that allows for greater expansion
of the chest, such as sitting upright and leaning slightly forward while supporting
both arms with pillows for comfort on the overbed table.
5. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse report to the provider? - ANSWERS-
Intercostal retractions
The nurse should report intercostal retractions to the provider because this
finding indicates increasing respiratory compromise in a client who has ARDS.
6. A nurse is caring for a client who has a pulmonary embolism. Which of the following
interventions is the priority? - ANSWERS-Administer heparin via continuous IV
infusion.
When using the airway, breathing, circulation approach to client care, the nurse
should place priority on stabilizing circulation to the lungs by administering
heparin to prevent further clot formation. Therefore, this is the priority
intervention.
, 7. A nurse is providing teaching to a client who has chronic asthma and a new
prescription for montelukast. Which of the following client statements indicates an
understanding of the teaching? - ANSWERS-"I will take this medication every night
even if I don't have symptoms."
Montelukast is used for the prophylactic treatment of asthma and is taken on a
daily basis in the evening.
8. A nurse is creating a plan of care for a client who has COPD. Which of the following
interventions should the nurse include? - ANSWERS-Provide a diet that is high in
calories and protein.
The nurse should provide a client who has COPD with a diet that is high in calories
and protein and low in carbohydrates
9. A nurse is assessing a client who has emphysema. Which of the following findings
should the nurse report to the provider? - ANSWERS-Elevated temperature
The nurse should report an elevated temperature to the provider because it can
indicate a possible respiratory infection. Clients who have emphysema are at
risk for the development of pneumonia and other respiratory infections.
10. A charge nurse is reviewing the care of a client who has a chest tube connected to a
water seal drainage system in place following thoracic surgery with a newly licensed
nurse. Which of the following statements by the newly licensed nurse indicated an
understanding of when to notify the provider? - ANSWERS-"I will notify the provider if
there is continuous bubbling in the water seal chamber."
Continuous bubbling in the water seal chamber suggests an air leak and requires
notification of the provider. The nurse should check the system for external,
correctable leaks while waiting for instructions from the provider.
11. A nurse is planning care for a client who has asthma. Which of the following
medications should the nurse plan to administer during an acute asthma attack? -
ANSWERS-Albuterol
The nurse should administer albuterol because it acts quickly to produce
bronchodilation during an acute asthma attack.
12. A nurse is caring for a client who is postoperative and has a RR of 9/min secondary to
general anesthesia effects and incisional pain. Which of the following ABG values
indicates the client is experiencing respiratory acidosis? - ANSWERS-ph 7.30, PO2 80
mm Hg, paco2 55 mm Hg, HCO3- 22 meq/L
These ABG values indicate respiratory acidosis. The ph is less than 7.35 and the
paco2 is greater than 45 mm Hg, which indicates respiratory acidosis.
13. A nurse is caring for a client who is receiving mechanical ventilation when the low-
pressure alarm sounds. Which of the following situations should the nurse recognize
as a possible cause of the alarm? - ANSWERS-Artificial airway cuff leak
An artificial airway cuff leak interferes with oxygenation and causes the low-
pressure alarm to sound.
YEAR 2026/2027 | COMPREHENSIVE COMPETENCY ASSESSMENT | VERIFIED
QUESTIONS AND CORRECT ANSWER RATIONALES
1. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis
and a new prescription for rifampin. Which of the following instructions should the
nurse include? - ANSWERS-"Expect your urine and other secretions to be orange
while taking this medication."
The nurse should inform the client that rifampin will turn urine and other
secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the
client to notify the provider if manifestations of hepatitis occur, including
jaundice, fatigue, or malaise.
2. A nurse is caring for a client in acute respiratory failure who is receiving mechanical
ventilation. Which of the following assessments is the best method for the nurse to
use to determine the effectiveness of the current treatment regimen? - ANSWERS-
Arterial blood gases
When using the airway, breathing, circulation approach to client care, the nurse
should place priority on evaluating arterial blood gases to determine serum
oxygen saturation and acid-base balance.
3. A nurse is assessing a client who has bacterial pneumonia. Which of the following
clinical manifestations should the nurse expect? - ANSWERS-Temperature 38.8° C
(101.8° F)
An elevated temperature is an expected finding for a client who has bacterial
pneumonia.
4. A nurse is caring for a newly-admitted client who has emphysema. The nurse should
place the client in which of the following positions to promote effective breathing? -
ANSWERS-High-Fowler's position with the arms supported on the overbed table
The nurse should place the client in a position that allows for greater expansion
of the chest, such as sitting upright and leaning slightly forward while supporting
both arms with pillows for comfort on the overbed table.
5. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse report to the provider? - ANSWERS-
Intercostal retractions
The nurse should report intercostal retractions to the provider because this
finding indicates increasing respiratory compromise in a client who has ARDS.
6. A nurse is caring for a client who has a pulmonary embolism. Which of the following
interventions is the priority? - ANSWERS-Administer heparin via continuous IV
infusion.
When using the airway, breathing, circulation approach to client care, the nurse
should place priority on stabilizing circulation to the lungs by administering
heparin to prevent further clot formation. Therefore, this is the priority
intervention.
, 7. A nurse is providing teaching to a client who has chronic asthma and a new
prescription for montelukast. Which of the following client statements indicates an
understanding of the teaching? - ANSWERS-"I will take this medication every night
even if I don't have symptoms."
Montelukast is used for the prophylactic treatment of asthma and is taken on a
daily basis in the evening.
8. A nurse is creating a plan of care for a client who has COPD. Which of the following
interventions should the nurse include? - ANSWERS-Provide a diet that is high in
calories and protein.
The nurse should provide a client who has COPD with a diet that is high in calories
and protein and low in carbohydrates
9. A nurse is assessing a client who has emphysema. Which of the following findings
should the nurse report to the provider? - ANSWERS-Elevated temperature
The nurse should report an elevated temperature to the provider because it can
indicate a possible respiratory infection. Clients who have emphysema are at
risk for the development of pneumonia and other respiratory infections.
10. A charge nurse is reviewing the care of a client who has a chest tube connected to a
water seal drainage system in place following thoracic surgery with a newly licensed
nurse. Which of the following statements by the newly licensed nurse indicated an
understanding of when to notify the provider? - ANSWERS-"I will notify the provider if
there is continuous bubbling in the water seal chamber."
Continuous bubbling in the water seal chamber suggests an air leak and requires
notification of the provider. The nurse should check the system for external,
correctable leaks while waiting for instructions from the provider.
11. A nurse is planning care for a client who has asthma. Which of the following
medications should the nurse plan to administer during an acute asthma attack? -
ANSWERS-Albuterol
The nurse should administer albuterol because it acts quickly to produce
bronchodilation during an acute asthma attack.
12. A nurse is caring for a client who is postoperative and has a RR of 9/min secondary to
general anesthesia effects and incisional pain. Which of the following ABG values
indicates the client is experiencing respiratory acidosis? - ANSWERS-ph 7.30, PO2 80
mm Hg, paco2 55 mm Hg, HCO3- 22 meq/L
These ABG values indicate respiratory acidosis. The ph is less than 7.35 and the
paco2 is greater than 45 mm Hg, which indicates respiratory acidosis.
13. A nurse is caring for a client who is receiving mechanical ventilation when the low-
pressure alarm sounds. Which of the following situations should the nurse recognize
as a possible cause of the alarm? - ANSWERS-Artificial airway cuff leak
An artificial airway cuff leak interferes with oxygenation and causes the low-
pressure alarm to sound.
