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Section 1: Foundations of Med-Surg Nursing
12 Questions
Q1: A nurse is assessing a client who has anemia. Which of the following findings should the nurse
expect?
A. Bradycardia
B. Pallor
C. Hypertension
D. Weight gain
Correct Answer: B
Rationale: Pallor is a classic finding in anemia due to decreased hemoglobin and reduced oxygenation of
the skin. The best answer is pallor because this is one of the earliest and most visible signs of anemia.
This aligns with the pathophysiological changes seen when oxygen-carrying capacity is diminished.
Q2: A nurse is caring for a client who is postoperative following a colon resection. Which of the following
findings should indicate to the nurse that the client's wound is infected?
A. Purulent drainage
B. Serous drainage
C. Wound edges that are approximated
D. Pink granulation tissue
Correct Answer: A
Rationale: Purulent drainage is the hallmark sign of wound infection. This best answer is correct because
purulent drainage indicates the presence of bacteria and inflammatory cells. This aligns with standard
wound assessment protocols where any purulent discharge requires further evaluation.
,Q3: A nurse is providing teaching to a client who has a new diagnosis of hypertension. Which of the
following dietary recommendations should the nurse include?
A. Increase sodium intake to 3,000 mg daily
B. Reduce sodium intake to 2,000 mg daily
C. Increase fluid intake to 3 liters daily
D. Decrease potassium intake
Correct Answer: B
Rationale: Reducing sodium intake to 2,000 mg daily is a standard recommendation for managing
hypertension. The best answer is this choice because it aligns with DASH diet guidelines for blood
pressure management. This is consistent with current evidence-based practice for hypertension.
Q4: A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions
should the nurse take to prevent infection?
A. Empty the drainage bag daily
B. Maintain a closed drainage system
C. Clean the perineum with alcohol
D. Hang the drainage bag above the bladder
Correct Answer: B
Rationale: Maintaining a closed drainage system is the most important intervention to prevent catheter-
associated urinary tract infections. The best answer is this choice because it prevents bacteria from
entering the urinary tract. This aligns with current infection prevention standards for indwelling
catheters.
Q5: A nurse is assessing a client who has a new diagnosis of diabetes mellitus. Which of the following
findings should the nurse expect?
A. Bradycardia
B. Polyuria
C. Weight gain
D. Hypotension
Correct Answer: B
Rationale: Polyuria is a classic finding in diabetes mellitus due to osmotic diuresis from elevated blood
glucose. The best answer is polyuria because it is one of the hallmark symptoms of hyperglycemia. This
matches the typical presenting symptoms of diabetes mellitus.
, Q6: A nurse is preparing to administer a blood transfusion to a client who has a history of allergic
reactions. Which of the following actions should the nurse take first?
A. Verify the client's identity using two identifiers
B. Administer an antihistamine
C. Begin the transfusion at 50 mL/hour
D. Check the blood type with the provider
Correct Answer: A
Rationale: Verifying the client's identity using two identifiers is the priority action before any blood
transfusion. The best answer is this because patient identification is the critical step to prevent a life-
threatening transfusion reaction. This aligns with the priority of patient safety before any procedure.
Q7: A nurse is caring for a client who has a nasogastric tube and is receiving enteral feedings. Which of
the following actions should the nurse take to reduce the risk of aspiration?
A. Elevate the head of the bed to 30 degrees
B. Flush the tube with 30 mL of water after each feeding
C. Check gastric residual every 12 hours
D. Administer the feeding at room temperature
Correct Answer: A
Rationale: Elevating the head of the bed to 30 degrees is the most important intervention to reduce
aspiration risk. The best answer is this because gravity helps prevent gastric contents from refluxing into
the esophagus. This aligns with standard enteral feeding safety protocols.
Q8: A nurse is assessing a client who has heart failure. Which of the following findings should the nurse
expect?
A. Crackles in the lungs
B. Clear breath sounds
C. Decreased respiratory rate
D. Increased urine output
Correct Answer: A
Rationale: Crackles in the lungs are a classic finding in heart failure due to fluid accumulation in the
alveoli. The best answer is crackles because this is a hallmark sign of pulmonary congestion. This aligns
with the pathophysiology of left-sided heart failure.