MCQs on Medical-Surgical Nursing (PN ATI 1-10)
1. A nurse is caring for a client with a new diagnosis of congestive
heart failure (CHF). Which of the following interventions should the
nurse prioritize?
A) Administering antibiotics
B) Providing supplemental oxygen
C) Encouraging fluid intake
D) Restricting sodium intake
Answer: D) Restricting sodium intake
Rationale: Clients with congestive heart failure need sodium restriction
to prevent fluid retention, which could exacerbate symptoms like
edema and shortness of breath. Sodium contributes to fluid retention,
and reducing intake helps in managing fluid balance and decreasing the
heart's workload.
2. A nurse is assessing a postoperative client who had a total hip
replacement. Which of the following findings should the nurse report
to the healthcare provider immediately?
A) Incision redness
B) Clear drainage from the incision
C) Increased pain at the surgical site
D) Shortening and external rotation of the affected leg
Answer: D) Shortening and external rotation of the affected leg
Rationale: Shortening and external rotation of the affected leg are signs
of hip dislocation, which is a medical emergency following a total hip
replacement. This could indicate that the hip has become dislocated
and needs immediate intervention.
,3. A nurse is caring for a client with a diagnosis of chronic obstructive
pulmonary disease (COPD). Which of the following interventions
should be implemented to prevent complications?
A) Encourage deep breathing and coughing exercises
B) Limit fluid intake to reduce pulmonary secretions
C) Instruct the client to avoid using a humidifier
D) Keep the client in a supine position for comfort
Answer: A) Encourage deep breathing and coughing exercises
Rationale: Deep breathing and coughing exercises help clear secretions
from the airways, preventing atelectasis and promoting ventilation in
patients with COPD. These exercises are crucial in preventing
respiratory complications, like pneumonia.
4. A nurse is providing discharge teaching to a client who is prescribed
warfarin. Which of the following statements by the client indicates an
understanding of the teaching?
A) "I will take aspirin every day to prevent blood clots."
B) "I should increase my intake of vitamin K-rich foods, like spinach."
C) "I will notify my healthcare provider if I notice any unusual bruising."
D) "I can stop the medication if I experience a headache."
Answer: C) "I will notify my healthcare provider if I notice any unusual
bruising."
Rationale: Warfarin is an anticoagulant, and bruising is a sign of
potential bleeding. Clients should monitor for signs of bleeding and
notify their healthcare provider immediately. The client should also
, avoid taking aspirin and monitor vitamin K intake, as it can interfere
with warfarin's effectiveness.
5. A nurse is caring for a client with a diagnosis of appendicitis. The
nurse understands that which of the following is a common sign of
this condition?
A) Left lower quadrant abdominal pain
B) Pain that increases with coughing
C) Abdominal pain that improves after vomiting
D) Tenderness at the umbilicus
Answer: B) Pain that increases with coughing
Rationale: Appendicitis often presents with right lower quadrant pain,
but coughing or moving can exacerbate the pain due to peritoneal
irritation. This pain is usually sharp and localized to the area of the
appendix.
6. A nurse is caring for a client who is scheduled for a mastectomy.
Which of the following actions should the nurse take to prepare the
client for the surgery?
A) Teach the client to use a drain to remove excess fluid postoperatively
B) Instruct the client to avoid taking pain medication before the surgery
C) Explain the possible need for a lymph node dissection
D) Advise the client to limit oral intake for 12 hours before surgery
Answer: C) Explain the possible need for a lymph node dissection
Rationale: Clients undergoing a mastectomy may also require lymph
node dissection to assess for metastasis. It is essential to educate the
1. A nurse is caring for a client with a new diagnosis of congestive
heart failure (CHF). Which of the following interventions should the
nurse prioritize?
A) Administering antibiotics
B) Providing supplemental oxygen
C) Encouraging fluid intake
D) Restricting sodium intake
Answer: D) Restricting sodium intake
Rationale: Clients with congestive heart failure need sodium restriction
to prevent fluid retention, which could exacerbate symptoms like
edema and shortness of breath. Sodium contributes to fluid retention,
and reducing intake helps in managing fluid balance and decreasing the
heart's workload.
2. A nurse is assessing a postoperative client who had a total hip
replacement. Which of the following findings should the nurse report
to the healthcare provider immediately?
A) Incision redness
B) Clear drainage from the incision
C) Increased pain at the surgical site
D) Shortening and external rotation of the affected leg
Answer: D) Shortening and external rotation of the affected leg
Rationale: Shortening and external rotation of the affected leg are signs
of hip dislocation, which is a medical emergency following a total hip
replacement. This could indicate that the hip has become dislocated
and needs immediate intervention.
,3. A nurse is caring for a client with a diagnosis of chronic obstructive
pulmonary disease (COPD). Which of the following interventions
should be implemented to prevent complications?
A) Encourage deep breathing and coughing exercises
B) Limit fluid intake to reduce pulmonary secretions
C) Instruct the client to avoid using a humidifier
D) Keep the client in a supine position for comfort
Answer: A) Encourage deep breathing and coughing exercises
Rationale: Deep breathing and coughing exercises help clear secretions
from the airways, preventing atelectasis and promoting ventilation in
patients with COPD. These exercises are crucial in preventing
respiratory complications, like pneumonia.
4. A nurse is providing discharge teaching to a client who is prescribed
warfarin. Which of the following statements by the client indicates an
understanding of the teaching?
A) "I will take aspirin every day to prevent blood clots."
B) "I should increase my intake of vitamin K-rich foods, like spinach."
C) "I will notify my healthcare provider if I notice any unusual bruising."
D) "I can stop the medication if I experience a headache."
Answer: C) "I will notify my healthcare provider if I notice any unusual
bruising."
Rationale: Warfarin is an anticoagulant, and bruising is a sign of
potential bleeding. Clients should monitor for signs of bleeding and
notify their healthcare provider immediately. The client should also
, avoid taking aspirin and monitor vitamin K intake, as it can interfere
with warfarin's effectiveness.
5. A nurse is caring for a client with a diagnosis of appendicitis. The
nurse understands that which of the following is a common sign of
this condition?
A) Left lower quadrant abdominal pain
B) Pain that increases with coughing
C) Abdominal pain that improves after vomiting
D) Tenderness at the umbilicus
Answer: B) Pain that increases with coughing
Rationale: Appendicitis often presents with right lower quadrant pain,
but coughing or moving can exacerbate the pain due to peritoneal
irritation. This pain is usually sharp and localized to the area of the
appendix.
6. A nurse is caring for a client who is scheduled for a mastectomy.
Which of the following actions should the nurse take to prepare the
client for the surgery?
A) Teach the client to use a drain to remove excess fluid postoperatively
B) Instruct the client to avoid taking pain medication before the surgery
C) Explain the possible need for a lymph node dissection
D) Advise the client to limit oral intake for 12 hours before surgery
Answer: C) Explain the possible need for a lymph node dissection
Rationale: Clients undergoing a mastectomy may also require lymph
node dissection to assess for metastasis. It is essential to educate the
