Test Bank Medical-Surgical Nursing_ Focus on Clinical Judgment 3RD by Linda Honan .pdf

Test Bank Medical-Surgical
Nursing: Focus on Clinical
Judgment 3RD by Linda Honan


📘 Medical-Surgical Nursing (Clinical Judgment
Style)
Questions & Answers with Rationales



🔹 Respiratory System
1. A patient with asthma presents with wheezing and shortness of breath. What is the
priority nursing action?​
A. Give oral fluids​
B. Administer bronchodilator​
C. Encourage rest only​

✅
D. Apply cold compress​

💡
Answer: B​
Rationale: Bronchodilators open narrowed airways and are the first-line treatment for acute
asthma symptoms.



2. Which finding indicates respiratory distress?​
A. RR 16/min​
B. Oxygen saturation 98%​
C. Use of accessory muscles​
D. Pink skin color​

,✅ Answer: C​
💡 Rationale: Accessory muscle use shows increased work of breathing and respiratory
distress.



3. A patient has pneumonia. Which assessment finding is expected?​
A. Clear lung sounds​
B. Crackles on auscultation​
C. Bradycardia​

✅
D. Dry skin​

💡
Answer: B​
Rationale: Crackles occur due to fluid in the alveoli in pneumonia.




🔹 Cardiovascular System
4. A patient reports chest pain radiating to the left arm. What is the priority action?​
A. Give food​
B. Call provider immediately​
C. Encourage walking​

✅
D. Give antacid​

💡
Answer: B​
Rationale: Radiating chest pain suggests myocardial infarction (emergency).



5. Which sign is most consistent with heart failure?​
A. Dry skin​
B. Jugular vein distention​
C. Low temperature​

✅
D. Increased appetite​

💡
Answer: B​
Rationale: JVD indicates fluid backup due to poor heart pumping.



6. What does an S3 heart sound indicate?​
A. Normal finding in all adults​
B. Heart failure​
C. Lung infection​

✅
D. Kidney disease​

💡
Answer: B​
Rationale: S3 often indicates fluid overload and heart failure.

,🔹 Neurological System
7. A patient has unequal pupils after head injury. What does this indicate?​
A. Normal finding​
B. Possible brain herniation​
C. Eye infection​

✅
D. Anxiety​

💡
Answer: B​
Rationale: Unequal pupils may indicate increased intracranial pressure or brain injury.



8. What does a Glasgow Coma Scale score of 8 indicate?​
A. Fully alert​
B. Mild confusion​
C. Severe neurological impairment​

✅
D. Normal response​

💡
Answer: C​
Rationale: A GCS ≤8 indicates severe impairment and possible need for airway support.



9. What is the priority action for seizure activity?​
A. Restrain patient​
B. Place patient in side-lying position​
C. Give food​

✅
D. Raise bed height​

💡
Answer: B​
Rationale: Side-lying position prevents aspiration and airway obstruction.




🔹 Gastrointestinal System
10. A patient has rebound tenderness in the abdomen. What does this suggest?​
A. Normal finding​
B. Peritonitis​
C. Constipation​

✅
D. Gas pain​

💡
Answer: B​
Rationale: Rebound tenderness indicates peritoneal inflammation.

, 11. Which stool finding suggests GI bleeding?​
A. Yellow stool​
B. Black tarry stool​
C. Hard stool​

✅
D. White stool​

💡
Answer: B​
Rationale: Melena indicates upper GI bleeding.



12. Which action is priority before abdominal palpation?​
A. Palpation first​
B. Auscultation​
C. Percussion last​

✅
D. Inspection last​

💡
Answer: B​
Rationale: Auscultation must be done before palpation to avoid altering bowel sounds.




🔹 Renal System
13. Which finding suggests urinary tract infection?​
A. Clear urine​
B. Dysuria and fever​
C. Increased appetite​

✅
D. Slow pulse​

💡
Answer: B​
Rationale: Dysuria and fever are classic UTI signs.



14. What is oliguria?​
A. Excess urine​
B. Low urine output​
C. No breathing​

✅
D. High BP​

💡
Answer: B​
Rationale: Oliguria = decreased urine output (<400 mL/day).