MEDICAL SURGICAL NURSING
COMPREHENSIVE EXAM 2026
◉ The patient's laboratory report today indicates severe
hypokalemia, and the nurse has notified the physician. Nursing
assessment indicates that heart rhythm is regular. What is the most
important nursing intervention for this patient now?
A) Examine sacral area and patient's heels for skin breakdown due
to potential edema.
B) Establish seizure precautions due to potential muscle twitching,
cramps, and seizures.
C) Institute fall precautions due to potential postural hypotension
and weak leg muscles.
D) Raise bed side rails due to potential decreased level of
consciousness and confusion.. Answer: C
Hypokalemia can cause postural hypotension and bilateral muscle
weakness, especially in the lower extremities. Both of these increase
the risk of falls. Hypokalemia does not cause edema, decreased level
of consciousness, or seizures.
◉ A nurse is assessing clients for fluid and electrolyte imbalances.
Which client is at greatest risk for developing hyponatremia?
,A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic. Answer: B
D5W contains no electrolytes. Because the client is not taking any
food or fluids by mouth, normal sodium excretion can lead to
hyponatremia. The antibiotic, Motrin, and digoxin will not put a
client at risk for hyponatremia.
◉ The nurse accidentally administers 10 mg of morphine
intravenously to a client who had been given another dose of
morphine, 5 mg IV, about 30 minutes earlier. What action must the
nurse be prepared to take?
A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan).. Answer: D
A combined dose of 15 mg of morphine may cause severe
respiratory depression in some clients. Naloxone is an opioid
antagonist that can be used (intravenously) as the first intervention
,to reverse respiratory depression due to a morphine overdose. Then
administration of oxygen may be needed if the client's oxygen
saturation decreases. Intubation may occur if the client does not
respond to the Narcan, and respiratory depression becomes a
respiratory arrest. Naloxone may be repeated, but the pain level of
the client needs to be monitored because Narcan can promote
withdrawal symptoms.
◉ Which action does the nurse teach a client to reduce the risk for
dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid
loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day. Answer: B
Although a fixed oral intake of 1500 mL daily is good, the key to
prevention of dehydration is to match all fluid losses with the same
volume for fluid intake. This is especially true in warm or dry
environments, or when conditions result in greater than usual fluid
loss through perspiration or ventilation.
◉ A client is taking furosemide (Lasix) and becomes confused.
Which potassium level does the nurse correlate with this condition?
, A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L. Answer: A
Hypokalemia decreases cerebral function and is manifested by
lethargy, confusion, inability to perform problem-solving tasks,
disorientation, and coma. Normal potassium levels are 3.5 to 5.0
mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to
neurologic manifestations.
◉ The most appropriate measure for a nurse to use in assessing core
body temperature when there are suspected problems with
thermoregulation is a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer.. Answer: A
The most reliable means available for assessing core temperature is
a rectal temperature, which is considered the standard of practice.
An oral temperature is a common measure but not the most reliable.
A temporal thermometer scan has some limitations and is not the
COMPREHENSIVE EXAM 2026
◉ The patient's laboratory report today indicates severe
hypokalemia, and the nurse has notified the physician. Nursing
assessment indicates that heart rhythm is regular. What is the most
important nursing intervention for this patient now?
A) Examine sacral area and patient's heels for skin breakdown due
to potential edema.
B) Establish seizure precautions due to potential muscle twitching,
cramps, and seizures.
C) Institute fall precautions due to potential postural hypotension
and weak leg muscles.
D) Raise bed side rails due to potential decreased level of
consciousness and confusion.. Answer: C
Hypokalemia can cause postural hypotension and bilateral muscle
weakness, especially in the lower extremities. Both of these increase
the risk of falls. Hypokalemia does not cause edema, decreased level
of consciousness, or seizures.
◉ A nurse is assessing clients for fluid and electrolyte imbalances.
Which client is at greatest risk for developing hyponatremia?
,A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic. Answer: B
D5W contains no electrolytes. Because the client is not taking any
food or fluids by mouth, normal sodium excretion can lead to
hyponatremia. The antibiotic, Motrin, and digoxin will not put a
client at risk for hyponatremia.
◉ The nurse accidentally administers 10 mg of morphine
intravenously to a client who had been given another dose of
morphine, 5 mg IV, about 30 minutes earlier. What action must the
nurse be prepared to take?
A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan).. Answer: D
A combined dose of 15 mg of morphine may cause severe
respiratory depression in some clients. Naloxone is an opioid
antagonist that can be used (intravenously) as the first intervention
,to reverse respiratory depression due to a morphine overdose. Then
administration of oxygen may be needed if the client's oxygen
saturation decreases. Intubation may occur if the client does not
respond to the Narcan, and respiratory depression becomes a
respiratory arrest. Naloxone may be repeated, but the pain level of
the client needs to be monitored because Narcan can promote
withdrawal symptoms.
◉ Which action does the nurse teach a client to reduce the risk for
dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid
loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day. Answer: B
Although a fixed oral intake of 1500 mL daily is good, the key to
prevention of dehydration is to match all fluid losses with the same
volume for fluid intake. This is especially true in warm or dry
environments, or when conditions result in greater than usual fluid
loss through perspiration or ventilation.
◉ A client is taking furosemide (Lasix) and becomes confused.
Which potassium level does the nurse correlate with this condition?
, A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L. Answer: A
Hypokalemia decreases cerebral function and is manifested by
lethargy, confusion, inability to perform problem-solving tasks,
disorientation, and coma. Normal potassium levels are 3.5 to 5.0
mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to
neurologic manifestations.
◉ The most appropriate measure for a nurse to use in assessing core
body temperature when there are suspected problems with
thermoregulation is a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer.. Answer: A
The most reliable means available for assessing core temperature is
a rectal temperature, which is considered the standard of practice.
An oral temperature is a common measure but not the most reliable.
A temporal thermometer scan has some limitations and is not the
