NSG 223 MEDICAL-SURGICAL NURSING II
EXAMINATION COMPLETE QUESTIONS
AND DETAILED SOLUTIONS LATEST
UPDATE THIS YEAR JUST RELEASED
1.
A patient admitted with an acute myocardial infarction
reports worsening crushing chest pain despite receiving
prescribed nitroglycerin and oxygen therapy. Which
nursing action should be performed first?
A. Obtain a dietary history
B. Assess vital signs and cardiac rhythm immediately
C. Encourage fluid intake
D. Request physical therapy consultation
Answer: B
Rationale: Persistent chest pain may indicate ongoing
myocardial ischemia. Immediate assessment of vital signs
and cardiac rhythm helps determine hemodynamic
stability and guides urgent interventions. Airway,
breathing, and circulation priorities take precedence.
2.
,A patient diagnosed with acute heart failure develops
increasing shortness of breath and bilateral crackles while
receiving intravenous fluids. Which action should the
nurse implement first?
A. Slow the infusion and assess respiratory status
B. Encourage ambulation
C. Increase oral fluids
D. Place the patient flat in bed
Answer: A
Rationale: Crackles and dyspnea suggest worsening
pulmonary congestion. Assessment and reduction of fluid
administration may prevent respiratory deterioration and
pulmonary edema.
3.
A client with diabetic ketoacidosis arrives in the
emergency department with severe dehydration and
hypotension. Which intervention should the nurse
anticipate implementing first?
A. Intravenous isotonic fluid administration
B. Potassium restriction
C. Oral hypoglycemic medication
D. Long-acting insulin administration
,Answer: A
Rationale: Fluid replacement is the initial priority because
dehydration and hypovolemia threaten perfusion. Insulin
therapy follows after adequate fluid resuscitation has
begun.
4.
A postoperative patient receiving opioid medication
becomes restless, confused, and difficult to arouse. Which
assessment should occur immediately?
A. Bowel sounds
B. Respiratory rate and oxygen saturation
C. Incision appearance
D. Intake and output
Answer: B
Rationale: Opioids can depress respiration. Restlessness
and confusion may signal hypoxia. Respiratory assessment
is the highest priority.
5.
A patient experiencing a cerebrovascular accident
suddenly develops difficulty swallowing and drooling.
Which intervention best promotes patient safety?
, A. Offer thickened liquids immediately
B. Keep patient NPO until swallowing evaluation
C. Encourage drinking through a straw
D. Administer oral medications
Answer: B
Rationale: Dysphagia increases aspiration risk. A
swallowing evaluation should occur before oral intake.
6.
A nurse reviews laboratory results for a patient with
chronic kidney disease. Which finding requires immediate
intervention?
A. Potassium 6.4 mEq/L
B. Hemoglobin 10 g/dL
C. Calcium 8.4 mg/dL
D. Creatinine 3.0 mg/dL
Answer: A
Rationale: Severe hyperkalemia may cause fatal cardiac
dysrhythmias and requires urgent treatment.
7.
EXAMINATION COMPLETE QUESTIONS
AND DETAILED SOLUTIONS LATEST
UPDATE THIS YEAR JUST RELEASED
1.
A patient admitted with an acute myocardial infarction
reports worsening crushing chest pain despite receiving
prescribed nitroglycerin and oxygen therapy. Which
nursing action should be performed first?
A. Obtain a dietary history
B. Assess vital signs and cardiac rhythm immediately
C. Encourage fluid intake
D. Request physical therapy consultation
Answer: B
Rationale: Persistent chest pain may indicate ongoing
myocardial ischemia. Immediate assessment of vital signs
and cardiac rhythm helps determine hemodynamic
stability and guides urgent interventions. Airway,
breathing, and circulation priorities take precedence.
2.
,A patient diagnosed with acute heart failure develops
increasing shortness of breath and bilateral crackles while
receiving intravenous fluids. Which action should the
nurse implement first?
A. Slow the infusion and assess respiratory status
B. Encourage ambulation
C. Increase oral fluids
D. Place the patient flat in bed
Answer: A
Rationale: Crackles and dyspnea suggest worsening
pulmonary congestion. Assessment and reduction of fluid
administration may prevent respiratory deterioration and
pulmonary edema.
3.
A client with diabetic ketoacidosis arrives in the
emergency department with severe dehydration and
hypotension. Which intervention should the nurse
anticipate implementing first?
A. Intravenous isotonic fluid administration
B. Potassium restriction
C. Oral hypoglycemic medication
D. Long-acting insulin administration
,Answer: A
Rationale: Fluid replacement is the initial priority because
dehydration and hypovolemia threaten perfusion. Insulin
therapy follows after adequate fluid resuscitation has
begun.
4.
A postoperative patient receiving opioid medication
becomes restless, confused, and difficult to arouse. Which
assessment should occur immediately?
A. Bowel sounds
B. Respiratory rate and oxygen saturation
C. Incision appearance
D. Intake and output
Answer: B
Rationale: Opioids can depress respiration. Restlessness
and confusion may signal hypoxia. Respiratory assessment
is the highest priority.
5.
A patient experiencing a cerebrovascular accident
suddenly develops difficulty swallowing and drooling.
Which intervention best promotes patient safety?
, A. Offer thickened liquids immediately
B. Keep patient NPO until swallowing evaluation
C. Encourage drinking through a straw
D. Administer oral medications
Answer: B
Rationale: Dysphagia increases aspiration risk. A
swallowing evaluation should occur before oral intake.
6.
A nurse reviews laboratory results for a patient with
chronic kidney disease. Which finding requires immediate
intervention?
A. Potassium 6.4 mEq/L
B. Hemoglobin 10 g/dL
C. Calcium 8.4 mg/dL
D. Creatinine 3.0 mg/dL
Answer: A
Rationale: Severe hyperkalemia may cause fatal cardiac
dysrhythmias and requires urgent treatment.
7.
