RN MEDICAL SURGICAL NEUROSENSORY AND
IMMUNE SYSTEM SCRIPT 2026 QUESTIONS
AND SOLUTIONS COMPREHENSIVE STUDY
SHEET FULL PRACTICE SET 140
◉ A physical therapist (PT) places a gait belt on a client and is
assisting them with ambulation from the bed to the chair. As they get
up out of the bed, they report being dizzy and begin to fall. The PT
carefully allows them to fall back to the bed and notifies the primary
nurse. Which written documentation should the nurse put in the
client's record?
A) Client experienced orthostatic hypotension when getting out of
bed.
B) PT reported client complained of dizziness when getting out of
bed, and gait belt was used to allow client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate
at this time because of dizziness.
D) Client had difficulty ambulating from the bed to the chair when
accompanied by the PT, variance report completed..
Answer: B) PT reported client complained of dizziness when getting
out of bed, and gait belt was used to allow client to fall back onto the
bed.
,Rationale: This documentation provides the factual data of the
events that occurred. A)The nurse is making an assumption that the
dizziness was caused by orthostatic hypotension. C) Not all the
pertinent facts are included in this documentation.
D) A variance report should never be documented in the client's
record.
◉ A new nurse graduate is caring for a postoperative client with the
following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg;
PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%.
Which of these actions by the new graduate is indicated?
A) Encourage the client to use the incentive spirometer and to
cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bicarbonate from the health
care provider.
D) Inform the charge nurse that no changes in therapy are needed..
Answer: A) Encourage the client to use the incentive spirometer and
to cough.
Rationale: Respiratory acidosis is caused by CO2 retention and
impaired chest expansion secondary to anesthesia. The nurse takes
steps to promote CO2 elimination, including maintaining a patent
airway and expanding the lungs through breathing techniques. O2 is
,not indicated because Po2 and oxygen saturation are within the
normal range. Sodium bicarbonate is not indicated because the
bicarbonate level is in the normal range; promoting excretion of
respiratory acids is the priority in respiratory acidosis. Post
anesthesia, the client will need interventions as described in A above
or may progress to a state of somnolence and unresponsiveness.
◉ The nurse is providing dietary instructions to a 68-year-old client
who is at high risk for development of coronary heart disease (CHD).
Which information should the nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake..
Answer: B) Increase intake of soluble fiber to 10 to 25 grams per
day.
Rationale: To reduce risk factors associated with coronary heart
disease, the daily intake of soluble fiber (B) should be increased to
between 10 and 25 gm. Cholesterol intake (A) should be limited to
180 mg/day or less. Intake of plant stanols and sterols is
recommended at 2 g/day (C). Saturated fat (D) intake should be
limited to 7% of total daily calories.
, ◉ A splint is prescribed for nighttime use by a client with
rheumatoid arthritis. Which statement by the nurse provides the
most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength..
Answer: A) Prevention of deformities.
Rationale: Splints may be used at night by clients with rheumatoid
arthritis to prevent deformities (A) caused by muscle spasms and
contractures. Splints are not used for (B). (C) is usually treated with
medications, particularly those classified as non-steroidal
antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise
program is indicated.
◉ A 32-year-old female client complains of severe abdominal pain
each month before her menstrual period, painful intercourse, and
painful defecation. Which additional history should the nurse obtain
that is consistent with the client's complaints?
A) Frequent urinary tract infections.
B) Inability to get pregnant.
IMMUNE SYSTEM SCRIPT 2026 QUESTIONS
AND SOLUTIONS COMPREHENSIVE STUDY
SHEET FULL PRACTICE SET 140
◉ A physical therapist (PT) places a gait belt on a client and is
assisting them with ambulation from the bed to the chair. As they get
up out of the bed, they report being dizzy and begin to fall. The PT
carefully allows them to fall back to the bed and notifies the primary
nurse. Which written documentation should the nurse put in the
client's record?
A) Client experienced orthostatic hypotension when getting out of
bed.
B) PT reported client complained of dizziness when getting out of
bed, and gait belt was used to allow client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate
at this time because of dizziness.
D) Client had difficulty ambulating from the bed to the chair when
accompanied by the PT, variance report completed..
Answer: B) PT reported client complained of dizziness when getting
out of bed, and gait belt was used to allow client to fall back onto the
bed.
,Rationale: This documentation provides the factual data of the
events that occurred. A)The nurse is making an assumption that the
dizziness was caused by orthostatic hypotension. C) Not all the
pertinent facts are included in this documentation.
D) A variance report should never be documented in the client's
record.
◉ A new nurse graduate is caring for a postoperative client with the
following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg;
PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%.
Which of these actions by the new graduate is indicated?
A) Encourage the client to use the incentive spirometer and to
cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bicarbonate from the health
care provider.
D) Inform the charge nurse that no changes in therapy are needed..
Answer: A) Encourage the client to use the incentive spirometer and
to cough.
Rationale: Respiratory acidosis is caused by CO2 retention and
impaired chest expansion secondary to anesthesia. The nurse takes
steps to promote CO2 elimination, including maintaining a patent
airway and expanding the lungs through breathing techniques. O2 is
,not indicated because Po2 and oxygen saturation are within the
normal range. Sodium bicarbonate is not indicated because the
bicarbonate level is in the normal range; promoting excretion of
respiratory acids is the priority in respiratory acidosis. Post
anesthesia, the client will need interventions as described in A above
or may progress to a state of somnolence and unresponsiveness.
◉ The nurse is providing dietary instructions to a 68-year-old client
who is at high risk for development of coronary heart disease (CHD).
Which information should the nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake..
Answer: B) Increase intake of soluble fiber to 10 to 25 grams per
day.
Rationale: To reduce risk factors associated with coronary heart
disease, the daily intake of soluble fiber (B) should be increased to
between 10 and 25 gm. Cholesterol intake (A) should be limited to
180 mg/day or less. Intake of plant stanols and sterols is
recommended at 2 g/day (C). Saturated fat (D) intake should be
limited to 7% of total daily calories.
, ◉ A splint is prescribed for nighttime use by a client with
rheumatoid arthritis. Which statement by the nurse provides the
most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength..
Answer: A) Prevention of deformities.
Rationale: Splints may be used at night by clients with rheumatoid
arthritis to prevent deformities (A) caused by muscle spasms and
contractures. Splints are not used for (B). (C) is usually treated with
medications, particularly those classified as non-steroidal
antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise
program is indicated.
◉ A 32-year-old female client complains of severe abdominal pain
each month before her menstrual period, painful intercourse, and
painful defecation. Which additional history should the nurse obtain
that is consistent with the client's complaints?
A) Frequent urinary tract infections.
B) Inability to get pregnant.
