,Medical-Surgical Nursing: Concepts & Practice Test Bank (Fifth Edition)
— Holly K. Stromberg
1. Which nursing action is the highest priority when caring for a
patient experiencing acute respiratory distress?
A. Encourage oral fluids.
B. Assess oxygen saturation and airway patency.
C. Administer prescribed stool softeners.
D. Document the patient's intake and output.
Answer: B. Assess oxygen saturation and airway patency.
Rationale: Airway assessment is always the first priority according to
the ABCs (Airway, Breathing, Circulation). Determining airway
patency and oxygenation allows the nurse to identify life-threatening
respiratory compromise and intervene promptly.
2. A nurse is caring for a patient with dehydration. Which laboratory
value most strongly supports this diagnosis?
A. Hematocrit of 55%
B. Potassium of 3.6 mEq/L
C. Calcium of 9.2 mg/dL
D. Platelet count of 250,000/mm³
Answer: A. Hematocrit of 55%.
,Rationale: Hemoconcentration caused by fluid loss increases the
hematocrit. Elevated hematocrit is a common finding in dehydration,
whereas the other values are within normal limits.
3. Which assessment finding should the nurse recognize as an early
indication of hypoxia?
A. Cyanosis
B. Bradycardia
C. Restlessness
D. Peripheral edema
Answer: C. Restlessness.
Rationale: Restlessness and anxiety are early signs of inadequate
oxygen delivery to the brain. Cyanosis and bradycardia are late
findings that indicate worsening hypoxia.
4. Which electrolyte imbalance places a patient at greatest risk for
cardiac dysrhythmias?
A. Mild hypercalcemia
B. Hypokalemia
C. Hypermagnesemia
D. Hyponatremia
Answer: B. Hypokalemia.
Rationale: Potassium plays a vital role in cardiac electrical conduction.
Low potassium levels increase the risk of ventricular dysrhythmias and
cardiac arrest.
, 5. Which intervention best prevents healthcare-associated infections?
A. Administer antibiotics routinely.
B. Perform proper hand hygiene before and after patient contact.
C. Wear gloves at all times.
D. Limit patient mobility.
Answer: B. Perform proper hand hygiene before and after patient
contact.
Rationale: Hand hygiene remains the single most effective
intervention for preventing healthcare-associated infections and
interrupting transmission of pathogens.
6. A patient reports chest pain rated 9/10. What is the nurse's priority
action?
A. Notify dietary services.
B. Assess pain characteristics and obtain vital signs.
C. Encourage ambulation.
D. Reassure the patient that anxiety causes chest pain.
Answer: B. Assess pain characteristics and obtain vital signs.
Rationale: The nurse must rapidly assess the pain and associated
symptoms to determine whether the patient may be experiencing
acute coronary syndrome or another life-threatening condition.
7. Which laboratory test best evaluates long-term glucose control?
— Holly K. Stromberg
1. Which nursing action is the highest priority when caring for a
patient experiencing acute respiratory distress?
A. Encourage oral fluids.
B. Assess oxygen saturation and airway patency.
C. Administer prescribed stool softeners.
D. Document the patient's intake and output.
Answer: B. Assess oxygen saturation and airway patency.
Rationale: Airway assessment is always the first priority according to
the ABCs (Airway, Breathing, Circulation). Determining airway
patency and oxygenation allows the nurse to identify life-threatening
respiratory compromise and intervene promptly.
2. A nurse is caring for a patient with dehydration. Which laboratory
value most strongly supports this diagnosis?
A. Hematocrit of 55%
B. Potassium of 3.6 mEq/L
C. Calcium of 9.2 mg/dL
D. Platelet count of 250,000/mm³
Answer: A. Hematocrit of 55%.
,Rationale: Hemoconcentration caused by fluid loss increases the
hematocrit. Elevated hematocrit is a common finding in dehydration,
whereas the other values are within normal limits.
3. Which assessment finding should the nurse recognize as an early
indication of hypoxia?
A. Cyanosis
B. Bradycardia
C. Restlessness
D. Peripheral edema
Answer: C. Restlessness.
Rationale: Restlessness and anxiety are early signs of inadequate
oxygen delivery to the brain. Cyanosis and bradycardia are late
findings that indicate worsening hypoxia.
4. Which electrolyte imbalance places a patient at greatest risk for
cardiac dysrhythmias?
A. Mild hypercalcemia
B. Hypokalemia
C. Hypermagnesemia
D. Hyponatremia
Answer: B. Hypokalemia.
Rationale: Potassium plays a vital role in cardiac electrical conduction.
Low potassium levels increase the risk of ventricular dysrhythmias and
cardiac arrest.
, 5. Which intervention best prevents healthcare-associated infections?
A. Administer antibiotics routinely.
B. Perform proper hand hygiene before and after patient contact.
C. Wear gloves at all times.
D. Limit patient mobility.
Answer: B. Perform proper hand hygiene before and after patient
contact.
Rationale: Hand hygiene remains the single most effective
intervention for preventing healthcare-associated infections and
interrupting transmission of pathogens.
6. A patient reports chest pain rated 9/10. What is the nurse's priority
action?
A. Notify dietary services.
B. Assess pain characteristics and obtain vital signs.
C. Encourage ambulation.
D. Reassure the patient that anxiety causes chest pain.
Answer: B. Assess pain characteristics and obtain vital signs.
Rationale: The nurse must rapidly assess the pain and associated
symptoms to determine whether the patient may be experiencing
acute coronary syndrome or another life-threatening condition.
7. Which laboratory test best evaluates long-term glucose control?
