Galen College NU 189 Exam 3 (pdf) | 2026/2027 | Med-Surg II Q&A |
Medical-Surgical Nursing
1. The nurse notes fluctuation of the water level in the water seal chamber of
a chest tube with each respiration. Which action is required?
A) Clamp the chest tube immediately
B) Notify the health care provider
C) Continue to monitor; this is a normal finding
D) Prepare for chest tube removal
Correct Answer: Continue to monitor; this is a normal finding
Rationale: Tidaling (fluctuation of the water level with breathing) indicates
that the chest tube is patent and the system is functioning properly. No
intervention is needed; the nurse should document the finding and continue
routine monitoring. Clamping or notifying the provider is unnecessary for
expected function.
2. A client with a chest tube suddenly becomes disconnected from the
drainage system. What is the priority action?
A) Clamp the chest tube immediately
B) Place the end of the chest tube in a container of sterile water
C) Reconnect the tube to the drainage system and tape it
D) Notify the provider and prepare for a new chest tube insertion
Correct Answer: Place the end of the chest tube in a container of sterile
water
Rationale: Placing the disconnected end under sterile water creates an
underwater seal, preventing air from entering the pleural space and causing
,a tension pneumothorax. Clamping can lead to tension pneumothorax if air is
trapped. The provider is notified after immediate action is taken.
3. A client with a chest tube accidentally pulls the tube partially out of the
insertion site. What should the nurse do first?
A) Push the tube back into the insertion site
B) Apply a sterile occlusive dressing over the site
C) Clamp the chest tube immediately
D) Notify the healthcare provider
Correct Answer: Apply a sterile occlusive dressing over the site
Rationale: If a chest tube is partially dislodged, the nurse should immediately
apply a sterile occlusive dressing over the insertion site to prevent air from
entering the pleural space. The tube should not be pushed back in, and
clamping may cause tension pneumothorax.
4. A client is diagnosed with a left-sided pneumothorax. Which type of shock
is most likely to occur?
A) Cardiogenic shock
B) Hypovolemic shock
C) Obstructive shock
D) Septic shock
Correct Answer: Obstructive shock
Rationale: A tension pneumothorax can cause obstructive shock by
compressing the heart and great vessels, reducing cardiac output. Air
trapped in the pleural space shifts mediastinal structures and impairs venous
return.
,5. Which set of findings is most consistent with cardiac tamponade?
A) Hypertension, bounding pulses, and fever
B) Hypotension, muffled heart sounds, and distended neck veins
C) Tachycardia, hypertension, and crackles
D) Bradycardia, hypotension, and cyanosis
Correct Answer: Hypotension, muffled heart sounds, and distended neck
veins
Rationale: Beck's triad (hypotension, muffled heart sounds, and distended
neck veins) is classic for cardiac tamponade. Fluid accumulation in the
pericardial sac compresses the heart, reducing cardiac output and venous
return.
6. The nurse is caring for a client who had a thoracentesis. Which finding
requires immediate intervention?
A) Client reports mild discomfort at the insertion site
B) Client develops sudden shortness of breath and tracheal deviation
C) Client has a small amount of serosanguinous drainage
D) Client's oxygen saturation is 95%
Correct Answer: Client develops sudden shortness of breath and tracheal
deviation
Rationale: Sudden shortness of breath and tracheal deviation indicate a
tension pneumothorax, a life-threatening complication of thoracentesis.
Immediate intervention is required. Mild discomfort and small amounts of
drainage are expected.
, 7. A client is scheduled for an emergency cardioversion. Which action should
the nurse take first?
A) Obtain signed informed consent
B) Ensure the defibrillator is in "sync" mode
C) Grab the crash cart
D) Administer sedation
Correct Answer: Grab the crash cart
Rationale: Emergency cardioversion requires immediate action. Grabbing the
crash cart ensures that all necessary equipment, including the defibrillator,
medications, and airway supplies, is readily available. The defibrillator should
be set to "sync" mode to deliver the shock on the R wave.
8. A client is being prepared for a chemical stress test. The nurse
understands that this test involves:
A) Having the client exercise on a treadmill
B) Administering a drug that mimics physical activity on the heart
C) Measuring oxygen consumption during rest
D) Monitoring blood pressure during sleep
Correct Answer: Administering a drug that mimics physical activity on the
heart
Rationale: A chemical stress test uses medications such as adenosine or
dobutamine to increase myocardial oxygen demand, simulating the effects of
physical exercise in clients who cannot exercise on a treadmill.
9. A client who received epinephrine during anaphylaxis continues to
wheeze. According to priority triage, this client should be:
Medical-Surgical Nursing
1. The nurse notes fluctuation of the water level in the water seal chamber of
a chest tube with each respiration. Which action is required?
A) Clamp the chest tube immediately
B) Notify the health care provider
C) Continue to monitor; this is a normal finding
D) Prepare for chest tube removal
Correct Answer: Continue to monitor; this is a normal finding
Rationale: Tidaling (fluctuation of the water level with breathing) indicates
that the chest tube is patent and the system is functioning properly. No
intervention is needed; the nurse should document the finding and continue
routine monitoring. Clamping or notifying the provider is unnecessary for
expected function.
2. A client with a chest tube suddenly becomes disconnected from the
drainage system. What is the priority action?
A) Clamp the chest tube immediately
B) Place the end of the chest tube in a container of sterile water
C) Reconnect the tube to the drainage system and tape it
D) Notify the provider and prepare for a new chest tube insertion
Correct Answer: Place the end of the chest tube in a container of sterile
water
Rationale: Placing the disconnected end under sterile water creates an
underwater seal, preventing air from entering the pleural space and causing
,a tension pneumothorax. Clamping can lead to tension pneumothorax if air is
trapped. The provider is notified after immediate action is taken.
3. A client with a chest tube accidentally pulls the tube partially out of the
insertion site. What should the nurse do first?
A) Push the tube back into the insertion site
B) Apply a sterile occlusive dressing over the site
C) Clamp the chest tube immediately
D) Notify the healthcare provider
Correct Answer: Apply a sterile occlusive dressing over the site
Rationale: If a chest tube is partially dislodged, the nurse should immediately
apply a sterile occlusive dressing over the insertion site to prevent air from
entering the pleural space. The tube should not be pushed back in, and
clamping may cause tension pneumothorax.
4. A client is diagnosed with a left-sided pneumothorax. Which type of shock
is most likely to occur?
A) Cardiogenic shock
B) Hypovolemic shock
C) Obstructive shock
D) Septic shock
Correct Answer: Obstructive shock
Rationale: A tension pneumothorax can cause obstructive shock by
compressing the heart and great vessels, reducing cardiac output. Air
trapped in the pleural space shifts mediastinal structures and impairs venous
return.
,5. Which set of findings is most consistent with cardiac tamponade?
A) Hypertension, bounding pulses, and fever
B) Hypotension, muffled heart sounds, and distended neck veins
C) Tachycardia, hypertension, and crackles
D) Bradycardia, hypotension, and cyanosis
Correct Answer: Hypotension, muffled heart sounds, and distended neck
veins
Rationale: Beck's triad (hypotension, muffled heart sounds, and distended
neck veins) is classic for cardiac tamponade. Fluid accumulation in the
pericardial sac compresses the heart, reducing cardiac output and venous
return.
6. The nurse is caring for a client who had a thoracentesis. Which finding
requires immediate intervention?
A) Client reports mild discomfort at the insertion site
B) Client develops sudden shortness of breath and tracheal deviation
C) Client has a small amount of serosanguinous drainage
D) Client's oxygen saturation is 95%
Correct Answer: Client develops sudden shortness of breath and tracheal
deviation
Rationale: Sudden shortness of breath and tracheal deviation indicate a
tension pneumothorax, a life-threatening complication of thoracentesis.
Immediate intervention is required. Mild discomfort and small amounts of
drainage are expected.
, 7. A client is scheduled for an emergency cardioversion. Which action should
the nurse take first?
A) Obtain signed informed consent
B) Ensure the defibrillator is in "sync" mode
C) Grab the crash cart
D) Administer sedation
Correct Answer: Grab the crash cart
Rationale: Emergency cardioversion requires immediate action. Grabbing the
crash cart ensures that all necessary equipment, including the defibrillator,
medications, and airway supplies, is readily available. The defibrillator should
be set to "sync" mode to deliver the shock on the R wave.
8. A client is being prepared for a chemical stress test. The nurse
understands that this test involves:
A) Having the client exercise on a treadmill
B) Administering a drug that mimics physical activity on the heart
C) Measuring oxygen consumption during rest
D) Monitoring blood pressure during sleep
Correct Answer: Administering a drug that mimics physical activity on the
heart
Rationale: A chemical stress test uses medications such as adenosine or
dobutamine to increase myocardial oxygen demand, simulating the effects of
physical exercise in clients who cannot exercise on a treadmill.
9. A client who received epinephrine during anaphylaxis continues to
wheeze. According to priority triage, this client should be:
