NURS 320 Med Surge Exam Questions
with Verified Answers
Which action should the nurse perform first when caring for a client who begins to
experience a sudden onset of chest pain, shortness of breath, wheezing, cough and
watery eyes and the nurse suspects an allergic reaction?
a. Transfer the patient to the intensive care unit
b. Remove all allergens from the room
c. Notify the doctor
d. Administer Epinephrine
e. Assess the pulse ox - ANSWER-D
rationale: If you see to administer something, you pick that answer. From now on,
you can assume you have everything. You can transfer patient to ICU if the
epinephrine doesn't work. You can remove all allergens but not first. You can notify
the doctor if there's nothing else you can do as a nurse, which is to provide the best
care for the patient. You don't need the pulse ox to know that the patient is having an
anaphylaxis reaction.
A triage nurse, working in the Emergency Room received four admissions. Which
patient should the nurse see first?
a. A 40 year old client who is diaphoretic and complains of chest pain
b. A 18 year old client who thinks he might have a broken tooth from playin football
c. A 35 year old client who cut her finger with a knife while preparing food
d. A 60 year old client who is dyspneic and has swollen lips after being stung by a
bee - ANSWER-D
rationale: Dyspneic- not breathing or able to breath except with difficulty; ABCs = 1st
priority
Which patient should the emergency room nurse list as urgent?
a. Patient A admitted to ER with chest discomfort and shortness of breath
b. Patient B admitted with slurred speech and left side weakness
c. Patient C admitted with abdominal pain and right-sided rebound tenderness
d. Patient D admitted with ear pain and sinus congestion with fever - ANSWER-C
rationale: Appendicitis: rebound tenderness -- not emergent but urgent; Patient A is
having a heart attack which is emergent
A 58 year old patient presents in the ER a BP of 210/140, vomiting and confusion.
Which category should the nurse assign to this patient?
a. Urgent
b. Non-urgent
c. Emergent
d. Semi-urgent - ANSWER-C
The registered nurse (RN) requests the unlicensed assistive personnel (UAP)
ambulate a patient with orthostatic hypotension and weakness, up and down the hall
,after breakfast and lunch for 10 minutes and to report back when task completed.
Which right of delegation did the RN violate?
a. Right task
b. Right circumstance
c. Right direction
d. Right supervision - ANSWER-B
rationale: UAP should not ambulate an unstable patient
The RN delegated the task of teaching the patient about the new ostomy to the UAP.
Which statement is correct regarding this delegation?
a. The RN violated several rights of delegation
b. The delegation is appropriate once the RN provides the correct instruction to the
UAP
c. The UAP can complete this task as long as the RN provides appropriate
supervision
d. The RN needs to delegate this task the LPN since the UAP cannot complete
ostomy care - ANSWER-A
Which patient task can the registered nurse assign to the unlicensed assistive
personnel (UAP)?
a. Assist a client with a new colostomy with his colostomy irrigation
b. Obtain a stool sample from a pathetic reporting diarrhea
c. Obtain a urine sample from an indwelling catheter
d. Obtain a diet history from a patient complaining of heartburn - ANSWER-B
rationale: C would be correct if the patient didn't have an indwelling catheter. That
requires a sterile procedure, which a UAP cannot do.
The RN is working with an UAP and LPN. Which assignment is most appropriate to
assign to the LPN?
a. Emptying a urine catheter bag on a immobile patient
b. Assessing the lungs on a patient with leg cellulitis
c. Taking vital signs on the post-op patient
d. Teaching a newly diagnosed patient about diabetes - ANSWER-B
Which tasks are appropriate to delegate to the UAP? Select all that apply
a. Taking vital signs on the patients on the unit
b. Recording intake and output on the patient admitted with dehydration
c. Offering the patient Tylenol for a headache
d. Apply antiembolic stockings to the patient on bedrest - ANSWER-A,B,D
Which task is most appropriate for the RN to delegate to the UAP?
a. Monitor the post-op patient for shortness of breath after ambulating the patient in
the hallway
b. Obtain the pulse ox on a patient who became short of breath while ambulating in
the hallway
c. Determine when it is appropriate for the patient to rest during the ambulation
d. Reinforce with the patient the need to balance rest with activity - ANSWER-B
rationale: they can take the vital signs
, A nurse is caring for a group of patients on the medical-surgical unit with the help of
one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one
licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by
the nurse, would be inappropriate?
a. Delegate the LPN to assess the bowel sounds on a post-op patient
b. Assign the LPN to administer the daily antihypertensive meds to a patient
scheduled for a chest X-RAY
c. Assign the float RN to a patient with diabetes and urinary frequency
d. Request that the UAP ask the patient about his arthritis pain - ANSWER-D
The charge nurse recognizes that the new RN's is in need of further education
regarding delegation of patient care when charge nurse overhears the RN makes
which statement to the nursing assistant?
a. "Make sure you wear gloves when you emptying the foley bag"
b. "Prepare a sitz bath for Mrs. Jones who has a perineal laceration"
c. "When changing Mr. Jones socks, let me know if there is any further drainage on
the toes"
d. "The supplies to perform post mortem care are in the closet down the hall" -
ANSWER-c
The nurse is providing care to the patient with cystitis. Which task can be delegated
to the UAP?
a. Teach the patient the manifestations of cystitis
b. Check the patient's urine for color and odor
c. Review the plan of care to correct the cystitis
d. Provide the patient with a clean-catch urine container - ANSWER-D
The nurse is starting the 7am-3pm sift. Which nursing actin takes priority?
a. Bathing the patient scheduled for the OR in an hour
b. Checking on the patient who was admitted with chest discomfort and received
Nitroglycerin 30min ago
c. Consulting with physical therapy on the patient who underwent a knee
replacement yesterday
d. Teaching insulin administration to the newly diagnosed patient with diabetes -
ANSWER-B
rationale: the patient had chest discomfort and had drug administered so status
needs to be checked
An adult patient is brought in by ambulance after a motor vehicle accident. He is
unconscious, on a backboard with his neck immobilized and is bleeding profusely
from a large gash on his head. What action should the nurse take first?
a. Stop the bleeding
b. Check his airway
c. Take his vital signs
d. Verify his neurological status - ANSWER-B
List in oder of priority which patient the nurse should assess 1st, 2nd, 3rd, and last.
a. Patient admitted with chronic bronchitis and reports cough with green sputum
b. Patient post-op day #2 fracture hip repair who reports not having a bowel
movement since before surgery
with Verified Answers
Which action should the nurse perform first when caring for a client who begins to
experience a sudden onset of chest pain, shortness of breath, wheezing, cough and
watery eyes and the nurse suspects an allergic reaction?
a. Transfer the patient to the intensive care unit
b. Remove all allergens from the room
c. Notify the doctor
d. Administer Epinephrine
e. Assess the pulse ox - ANSWER-D
rationale: If you see to administer something, you pick that answer. From now on,
you can assume you have everything. You can transfer patient to ICU if the
epinephrine doesn't work. You can remove all allergens but not first. You can notify
the doctor if there's nothing else you can do as a nurse, which is to provide the best
care for the patient. You don't need the pulse ox to know that the patient is having an
anaphylaxis reaction.
A triage nurse, working in the Emergency Room received four admissions. Which
patient should the nurse see first?
a. A 40 year old client who is diaphoretic and complains of chest pain
b. A 18 year old client who thinks he might have a broken tooth from playin football
c. A 35 year old client who cut her finger with a knife while preparing food
d. A 60 year old client who is dyspneic and has swollen lips after being stung by a
bee - ANSWER-D
rationale: Dyspneic- not breathing or able to breath except with difficulty; ABCs = 1st
priority
Which patient should the emergency room nurse list as urgent?
a. Patient A admitted to ER with chest discomfort and shortness of breath
b. Patient B admitted with slurred speech and left side weakness
c. Patient C admitted with abdominal pain and right-sided rebound tenderness
d. Patient D admitted with ear pain and sinus congestion with fever - ANSWER-C
rationale: Appendicitis: rebound tenderness -- not emergent but urgent; Patient A is
having a heart attack which is emergent
A 58 year old patient presents in the ER a BP of 210/140, vomiting and confusion.
Which category should the nurse assign to this patient?
a. Urgent
b. Non-urgent
c. Emergent
d. Semi-urgent - ANSWER-C
The registered nurse (RN) requests the unlicensed assistive personnel (UAP)
ambulate a patient with orthostatic hypotension and weakness, up and down the hall
,after breakfast and lunch for 10 minutes and to report back when task completed.
Which right of delegation did the RN violate?
a. Right task
b. Right circumstance
c. Right direction
d. Right supervision - ANSWER-B
rationale: UAP should not ambulate an unstable patient
The RN delegated the task of teaching the patient about the new ostomy to the UAP.
Which statement is correct regarding this delegation?
a. The RN violated several rights of delegation
b. The delegation is appropriate once the RN provides the correct instruction to the
UAP
c. The UAP can complete this task as long as the RN provides appropriate
supervision
d. The RN needs to delegate this task the LPN since the UAP cannot complete
ostomy care - ANSWER-A
Which patient task can the registered nurse assign to the unlicensed assistive
personnel (UAP)?
a. Assist a client with a new colostomy with his colostomy irrigation
b. Obtain a stool sample from a pathetic reporting diarrhea
c. Obtain a urine sample from an indwelling catheter
d. Obtain a diet history from a patient complaining of heartburn - ANSWER-B
rationale: C would be correct if the patient didn't have an indwelling catheter. That
requires a sterile procedure, which a UAP cannot do.
The RN is working with an UAP and LPN. Which assignment is most appropriate to
assign to the LPN?
a. Emptying a urine catheter bag on a immobile patient
b. Assessing the lungs on a patient with leg cellulitis
c. Taking vital signs on the post-op patient
d. Teaching a newly diagnosed patient about diabetes - ANSWER-B
Which tasks are appropriate to delegate to the UAP? Select all that apply
a. Taking vital signs on the patients on the unit
b. Recording intake and output on the patient admitted with dehydration
c. Offering the patient Tylenol for a headache
d. Apply antiembolic stockings to the patient on bedrest - ANSWER-A,B,D
Which task is most appropriate for the RN to delegate to the UAP?
a. Monitor the post-op patient for shortness of breath after ambulating the patient in
the hallway
b. Obtain the pulse ox on a patient who became short of breath while ambulating in
the hallway
c. Determine when it is appropriate for the patient to rest during the ambulation
d. Reinforce with the patient the need to balance rest with activity - ANSWER-B
rationale: they can take the vital signs
, A nurse is caring for a group of patients on the medical-surgical unit with the help of
one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one
licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by
the nurse, would be inappropriate?
a. Delegate the LPN to assess the bowel sounds on a post-op patient
b. Assign the LPN to administer the daily antihypertensive meds to a patient
scheduled for a chest X-RAY
c. Assign the float RN to a patient with diabetes and urinary frequency
d. Request that the UAP ask the patient about his arthritis pain - ANSWER-D
The charge nurse recognizes that the new RN's is in need of further education
regarding delegation of patient care when charge nurse overhears the RN makes
which statement to the nursing assistant?
a. "Make sure you wear gloves when you emptying the foley bag"
b. "Prepare a sitz bath for Mrs. Jones who has a perineal laceration"
c. "When changing Mr. Jones socks, let me know if there is any further drainage on
the toes"
d. "The supplies to perform post mortem care are in the closet down the hall" -
ANSWER-c
The nurse is providing care to the patient with cystitis. Which task can be delegated
to the UAP?
a. Teach the patient the manifestations of cystitis
b. Check the patient's urine for color and odor
c. Review the plan of care to correct the cystitis
d. Provide the patient with a clean-catch urine container - ANSWER-D
The nurse is starting the 7am-3pm sift. Which nursing actin takes priority?
a. Bathing the patient scheduled for the OR in an hour
b. Checking on the patient who was admitted with chest discomfort and received
Nitroglycerin 30min ago
c. Consulting with physical therapy on the patient who underwent a knee
replacement yesterday
d. Teaching insulin administration to the newly diagnosed patient with diabetes -
ANSWER-B
rationale: the patient had chest discomfort and had drug administered so status
needs to be checked
An adult patient is brought in by ambulance after a motor vehicle accident. He is
unconscious, on a backboard with his neck immobilized and is bleeding profusely
from a large gash on his head. What action should the nurse take first?
a. Stop the bleeding
b. Check his airway
c. Take his vital signs
d. Verify his neurological status - ANSWER-B
List in oder of priority which patient the nurse should assess 1st, 2nd, 3rd, and last.
a. Patient admitted with chronic bronchitis and reports cough with green sputum
b. Patient post-op day #2 fracture hip repair who reports not having a bowel
movement since before surgery
