RN VATI ADULT MEDICAL SURGICAL
ASSESSMENT EXAM QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES
1. A patient with a history of COPD is admitted with acute respiratory distress.
Which arterial blood gas (ABG) finding is most consistent with this patient's
chronic condition?
A) pH 7.30, PaCO2 55, HCO3 24
B) pH 7.38, PaCO2 60, HCO3 34
C) pH 7.45, PaCO2 30, HCO3 18
D) pH 7.28, PaCO2 48, HCO3 22
Answer: B
Rationale: A patient with chronic COPD often retains CO2, leading to a
compensated respiratory acidosis. The kidneys retain bicarbonate (HCO3) to
compensate. Option B shows a near-normal pH with elevated CO2 and HCO3,
indicating full metabolic compensation.
2. A nurse is caring for a patient post-thyroidectomy. What is the priority
assessment to detect a life-threatening complication?
A) Monitor for hoarseness of voice.
B) Assess for difficulty swallowing.
C) Check for tingling around the mouth and fingertips.
D) Observe for signs of wound infection.
Answer: C
,Rationale: Tingling around the mouth and fingertips (paresthesia) is an early
sign of hypocalcemia, which can occur if the parathyroid glands are
accidentally removed or damaged during surgery. This can lead to
laryngospasm and respiratory distress, making it a priority.
3. A 2-year-old child is brought to the ER with a croupy cough, stridor, and a
temperature of 102°F. The mother states the child woke up in the middle of
the night with these symptoms. What is the most likely diagnosis?
A) Epiglottitis
B) Bronchiolitis
C) Laryngotracheobronchitis (LTB)
D) Foreign body aspiration
Answer: C
Rationale: LTB (croup) is a viral infection that causes inflammation of the
larynx, trachea, and bronchi. It is characterized by a "barking" cough, stridor,
and is often worse at night. Epiglottitis presents with a rapid onset, high fever,
drooling, and a tripod position, and is a more emergent condition.
4. A client with heart failure is prescribed furosemide (Lasix). Which
electrolyte imbalance should the nurse monitor for most closely?
A) Hyperkalemia
B) Hyponatremia
C) Hypercalcemia
D) Hypokalemia
Answer: D
Rationale: Furosemide is a loop diuretic that inhibits sodium and chloride
reabsorption in the ascending loop of Henle. This leads to increased excretion
of potassium and hydrogen ions, making hypokalemia a common and serious
side effect.
,5. A patient is receiving a blood transfusion and develops flushing, hives, and
wheezing. What is the priority action by the nurse?
A) Slow the transfusion rate.
B) Stop the transfusion.
C) Administer an antihistamine.
D) Notify the physician.
Answer: B
Rationale: These symptoms indicate a mild to moderate allergic transfusion
reaction. The priority action is to stop the transfusion immediately to prevent
further exposure to the allergen. Starting normal saline with new tubing is the
next step to maintain IV access.
6. Which of the following is a primary prevention strategy for pressure ulcers?
A) Applying a moisture barrier to the skin.
B) Repositioning the patient every 2 hours.
C) Using a pressure-relieving mattress.
D) Turning the patient every 4 hours.
Answer: A
Rationale: Primary prevention aims to prevent the problem from occurring.
Applying a moisture barrier (e.g., barrier cream) prevents skin breakdown
from incontinence, which is a primary cause of pressure ulcers. Repositioning
and pressure-relieving devices are secondary or tertiary interventions once
risk is identified or a wound is present. (While repositioning is crucial,
applying a barrier is the most direct primary prevention of moisture-
associated skin damage).
, 7. A patient with type 1 diabetes is found unresponsive, with a blood glucose
level of 28 mg/dL. After administering glucagon IM, the patient regains
consciousness. What should the nurse provide next?
A) A glass of orange juice.
B) A complex carbohydrate with protein, like peanut butter and crackers.
C) An injection of 50% dextrose.
D) Nothing by mouth until the next meal.
Answer: B
Rationale: After glucagon administration, the liver releases glycogen, which
raises blood glucose. To prevent a recurrence of hypoglycemia, the patient
should be given a complex carbohydrate with protein once they are alert and
can swallow safely. This provides a sustained source of glucose.
8. Which of the following clients is at the highest risk for developing deep vein
thrombosis (DVT)?
A) A 45-year-old post-operative hip replacement patient.
B) A 30-year-old with a fractured arm.
C) A 22-year-old marathon runner.
D) A 60-year-old with osteoarthritis.
Answer: A
Rationale: Major orthopedic surgery (hip replacement) is a significant risk
factor for DVT due to immobility, trauma to the vessels, and the
hypercoagulable state from surgery.
9. A nurse is preparing to administer a tuberculin skin test. Which route of
administration is correct?
A) Subcutaneous
B) Intramuscular
ASSESSMENT EXAM QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES
1. A patient with a history of COPD is admitted with acute respiratory distress.
Which arterial blood gas (ABG) finding is most consistent with this patient's
chronic condition?
A) pH 7.30, PaCO2 55, HCO3 24
B) pH 7.38, PaCO2 60, HCO3 34
C) pH 7.45, PaCO2 30, HCO3 18
D) pH 7.28, PaCO2 48, HCO3 22
Answer: B
Rationale: A patient with chronic COPD often retains CO2, leading to a
compensated respiratory acidosis. The kidneys retain bicarbonate (HCO3) to
compensate. Option B shows a near-normal pH with elevated CO2 and HCO3,
indicating full metabolic compensation.
2. A nurse is caring for a patient post-thyroidectomy. What is the priority
assessment to detect a life-threatening complication?
A) Monitor for hoarseness of voice.
B) Assess for difficulty swallowing.
C) Check for tingling around the mouth and fingertips.
D) Observe for signs of wound infection.
Answer: C
,Rationale: Tingling around the mouth and fingertips (paresthesia) is an early
sign of hypocalcemia, which can occur if the parathyroid glands are
accidentally removed or damaged during surgery. This can lead to
laryngospasm and respiratory distress, making it a priority.
3. A 2-year-old child is brought to the ER with a croupy cough, stridor, and a
temperature of 102°F. The mother states the child woke up in the middle of
the night with these symptoms. What is the most likely diagnosis?
A) Epiglottitis
B) Bronchiolitis
C) Laryngotracheobronchitis (LTB)
D) Foreign body aspiration
Answer: C
Rationale: LTB (croup) is a viral infection that causes inflammation of the
larynx, trachea, and bronchi. It is characterized by a "barking" cough, stridor,
and is often worse at night. Epiglottitis presents with a rapid onset, high fever,
drooling, and a tripod position, and is a more emergent condition.
4. A client with heart failure is prescribed furosemide (Lasix). Which
electrolyte imbalance should the nurse monitor for most closely?
A) Hyperkalemia
B) Hyponatremia
C) Hypercalcemia
D) Hypokalemia
Answer: D
Rationale: Furosemide is a loop diuretic that inhibits sodium and chloride
reabsorption in the ascending loop of Henle. This leads to increased excretion
of potassium and hydrogen ions, making hypokalemia a common and serious
side effect.
,5. A patient is receiving a blood transfusion and develops flushing, hives, and
wheezing. What is the priority action by the nurse?
A) Slow the transfusion rate.
B) Stop the transfusion.
C) Administer an antihistamine.
D) Notify the physician.
Answer: B
Rationale: These symptoms indicate a mild to moderate allergic transfusion
reaction. The priority action is to stop the transfusion immediately to prevent
further exposure to the allergen. Starting normal saline with new tubing is the
next step to maintain IV access.
6. Which of the following is a primary prevention strategy for pressure ulcers?
A) Applying a moisture barrier to the skin.
B) Repositioning the patient every 2 hours.
C) Using a pressure-relieving mattress.
D) Turning the patient every 4 hours.
Answer: A
Rationale: Primary prevention aims to prevent the problem from occurring.
Applying a moisture barrier (e.g., barrier cream) prevents skin breakdown
from incontinence, which is a primary cause of pressure ulcers. Repositioning
and pressure-relieving devices are secondary or tertiary interventions once
risk is identified or a wound is present. (While repositioning is crucial,
applying a barrier is the most direct primary prevention of moisture-
associated skin damage).
, 7. A patient with type 1 diabetes is found unresponsive, with a blood glucose
level of 28 mg/dL. After administering glucagon IM, the patient regains
consciousness. What should the nurse provide next?
A) A glass of orange juice.
B) A complex carbohydrate with protein, like peanut butter and crackers.
C) An injection of 50% dextrose.
D) Nothing by mouth until the next meal.
Answer: B
Rationale: After glucagon administration, the liver releases glycogen, which
raises blood glucose. To prevent a recurrence of hypoglycemia, the patient
should be given a complex carbohydrate with protein once they are alert and
can swallow safely. This provides a sustained source of glucose.
8. Which of the following clients is at the highest risk for developing deep vein
thrombosis (DVT)?
A) A 45-year-old post-operative hip replacement patient.
B) A 30-year-old with a fractured arm.
C) A 22-year-old marathon runner.
D) A 60-year-old with osteoarthritis.
Answer: A
Rationale: Major orthopedic surgery (hip replacement) is a significant risk
factor for DVT due to immobility, trauma to the vessels, and the
hypercoagulable state from surgery.
9. A nurse is preparing to administer a tuberculin skin test. Which route of
administration is correct?
A) Subcutaneous
B) Intramuscular
