MEDSURG Complete exam
with correct answers
A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following
findings should the nurse identify as a risk factor for falls?
a) Instructs the client to wear their own socks to
the bathroom
b) Keeps the client's bed in the low position
c) Positions the bedside table close to the client
d) Attaches the call light to the side rail of the
client's bed - CORRECT ANSWER-A. Instructs the client to wear their own socks to the
bathroom
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following
actions should the nurse take first?
a) Activate the fire alarm system.
b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. - CORRECT ANSWER-C. Assist the client to a nearby common area.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is
agitated. Which of the following interventions should the nurse implement?
a) Encourage the client to ambulate with a staff member.
b) Isolate the client in their room.
c) Apply bilateral wrist restraints to the client.
d) Administer a prescribed oral dose of trazodone to the client. - CORRECT ANSWER-A. Encourage the client to
ambulate with a staff
member.
A nurse is assisting care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the
following is the priority nursing action?
a) Determine palpable pulse.
b) Begin chest compressions.
c) Perform immediate defibrillation.
d) Provide pulmonary ventilation. - CORRECT ANSWER-A. Determine palpable pulse.
A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the
following interventions should the nurse contribute to the plan of care?
a) Offer oral fluids every 4 hr.
b) Check for neck vein distention.
c) Limit oral fluids prior to bedtime.
d) Monitor pulse pressure every 6 hr. - CORRECT ANSWER-B. Check for neck vein distention.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following
actions should the nurse take?
a) Replace the unit when the drainage chamber is full.
b) Clamp the tube for 30 min every 8 hr.
c) Pin the tubing to the client's bed sheets.
, d) Monitor for at least 150 mL of drainage every hour. - CORRECT ANSWER-D. Monitor for at least 150 mL of drainage
every hour.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the
following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
a) Hypertension
b) Vomiting
c) Distended neck veins
d) Polyuria - CORRECT ANSWER-B. Vomiting
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the
following interventions should the nurse include?
a) Encourage the client to eat a low-protein diet.
b) Prohibit fresh flowers in the client's room.
c) Obtain the client's rectal temperature every 4
hr.
d) Initiate airborne precautions for the client. - CORRECT ANSWER-B. Prohibit fresh flowers in the client's room.
A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following
interventions should the nurse include in the plan?
a) Keep a stethoscope at the client's bedside for
the duration of her hospital stay.
b) Wear an N95 mask when entering the room.
c) Use an alcohol swab to clean the
temperature probe before removing it from
the room.
d) Remove personal protective equipment
immediately after leaving the client's room. - CORRECT ANSWER-A. Keep a stethoscope at the client's bedside for
the duration of her hospital stay.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine.
Which of the following information should the nurse include in the plan of care?
a) Advise the client about increased dry mouth.
b) Check the client for increased
hypopigmentation under the patch.
c) Monitor the client for weight loss.
d) Inform the client of the adverse effect of
diarrhea. - CORRECT ANSWER-B. Check the client for increased hypopigmentation under the patch.
A nurse is assisting with the transfer of a client from
a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should
the nurse include in the transfer
documentation? (Select all that apply.)
a) Primary health problem
b) Scheduled times for dressing changes
c) Current medication prescriptions
d) Number of family members who have visited
e) Admission vital signs from 1 week ago - CORRECT ANSWER-A. Primary health problem
B. Scheduled times for dressing changes
C. Current medication prescriptions
A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is
sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?
a) "Encourage your partner to wake up to interact with family members."
b) "Sitting quietly near the bedside can provide comfort and support."
c) "I will call the provider to discuss your concerns."
d) "I can ask the provider to prescribe a medication that will minimize drowsiness." - CORRECT ANSWER-B. "Sitting
quietly near the bedside can provide comfort and support."
A nurse is caring for a client who has a prescription for a sequential compression device (SCD). Which of the following
actions should the nurse take when applying the SCD?
a) Ensure two fingers fit between the leg and the sleeve.
b) Wrap excess tubing to the side of each leg.
c) Ensure pressure of the device is at 25 mmHg.
d) Place each service under each leg with theopening at the calf. - CORRECT ANSWER-A. Ensure two fingers fit
between the leg and the
sleeve.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the
following actions should the nurse take?
a) Request a dosage increase of the apical
with correct answers
A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following
findings should the nurse identify as a risk factor for falls?
a) Instructs the client to wear their own socks to
the bathroom
b) Keeps the client's bed in the low position
c) Positions the bedside table close to the client
d) Attaches the call light to the side rail of the
client's bed - CORRECT ANSWER-A. Instructs the client to wear their own socks to the
bathroom
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following
actions should the nurse take first?
a) Activate the fire alarm system.
b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. - CORRECT ANSWER-C. Assist the client to a nearby common area.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is
agitated. Which of the following interventions should the nurse implement?
a) Encourage the client to ambulate with a staff member.
b) Isolate the client in their room.
c) Apply bilateral wrist restraints to the client.
d) Administer a prescribed oral dose of trazodone to the client. - CORRECT ANSWER-A. Encourage the client to
ambulate with a staff
member.
A nurse is assisting care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the
following is the priority nursing action?
a) Determine palpable pulse.
b) Begin chest compressions.
c) Perform immediate defibrillation.
d) Provide pulmonary ventilation. - CORRECT ANSWER-A. Determine palpable pulse.
A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the
following interventions should the nurse contribute to the plan of care?
a) Offer oral fluids every 4 hr.
b) Check for neck vein distention.
c) Limit oral fluids prior to bedtime.
d) Monitor pulse pressure every 6 hr. - CORRECT ANSWER-B. Check for neck vein distention.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following
actions should the nurse take?
a) Replace the unit when the drainage chamber is full.
b) Clamp the tube for 30 min every 8 hr.
c) Pin the tubing to the client's bed sheets.
, d) Monitor for at least 150 mL of drainage every hour. - CORRECT ANSWER-D. Monitor for at least 150 mL of drainage
every hour.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the
following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
a) Hypertension
b) Vomiting
c) Distended neck veins
d) Polyuria - CORRECT ANSWER-B. Vomiting
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the
following interventions should the nurse include?
a) Encourage the client to eat a low-protein diet.
b) Prohibit fresh flowers in the client's room.
c) Obtain the client's rectal temperature every 4
hr.
d) Initiate airborne precautions for the client. - CORRECT ANSWER-B. Prohibit fresh flowers in the client's room.
A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following
interventions should the nurse include in the plan?
a) Keep a stethoscope at the client's bedside for
the duration of her hospital stay.
b) Wear an N95 mask when entering the room.
c) Use an alcohol swab to clean the
temperature probe before removing it from
the room.
d) Remove personal protective equipment
immediately after leaving the client's room. - CORRECT ANSWER-A. Keep a stethoscope at the client's bedside for
the duration of her hospital stay.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine.
Which of the following information should the nurse include in the plan of care?
a) Advise the client about increased dry mouth.
b) Check the client for increased
hypopigmentation under the patch.
c) Monitor the client for weight loss.
d) Inform the client of the adverse effect of
diarrhea. - CORRECT ANSWER-B. Check the client for increased hypopigmentation under the patch.
A nurse is assisting with the transfer of a client from
a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should
the nurse include in the transfer
documentation? (Select all that apply.)
a) Primary health problem
b) Scheduled times for dressing changes
c) Current medication prescriptions
d) Number of family members who have visited
e) Admission vital signs from 1 week ago - CORRECT ANSWER-A. Primary health problem
B. Scheduled times for dressing changes
C. Current medication prescriptions
A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is
sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?
a) "Encourage your partner to wake up to interact with family members."
b) "Sitting quietly near the bedside can provide comfort and support."
c) "I will call the provider to discuss your concerns."
d) "I can ask the provider to prescribe a medication that will minimize drowsiness." - CORRECT ANSWER-B. "Sitting
quietly near the bedside can provide comfort and support."
A nurse is caring for a client who has a prescription for a sequential compression device (SCD). Which of the following
actions should the nurse take when applying the SCD?
a) Ensure two fingers fit between the leg and the sleeve.
b) Wrap excess tubing to the side of each leg.
c) Ensure pressure of the device is at 25 mmHg.
d) Place each service under each leg with theopening at the calf. - CORRECT ANSWER-A. Ensure two fingers fit
between the leg and the
sleeve.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the
following actions should the nurse take?
a) Request a dosage increase of the apical
