• Medical-Surgical 09/01/2026
Nursing
Medical-Surgical Nursing Complete Study
Guide | Exam Prep | 1,500+
Comprehensive Q-bank Questions, Detailed
Rationales, Predictor Exams, Clinical Case
Studies, Practice Questions and Answers
with Rationales| (A+ Guarantee) | PDF
P 1
, • Medical-Surgical 09/01/2026
Nursing
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results
reveal a platelet count of 10,000/ml. What action should the nurse implement?
A) Encourage fluids to 3000 ml/day.
B) Check stools for occult blood.
C) Provide oral hygiene every 2 hours.
D) Check for fever every 4 hours. –
Correct Answer :B) Check stools for occult blood.
Rationale:
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of
chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis,
sputum, feces (B), urine, nasogastric secretions, or wounds. (A) does not minimize the risk for bleeding
associated with thrombocytopenia. (C) may cause increased bleeding in a client with thromobcytopenia. (D)
assesses for infection, not risk for bleeding.
The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To
assess the client for asterixis, what position should the nurse ask the client to demonstrate?
A) Extend the left arm laterally with the left palm upward.
B) Extend the arm, dorsiflex the wrist, and extend the fingers.
C) Extend the arms and hold this position for 30 seconds.
D) Extend arms with both legs adducted to shoulder width. –
Correct Answer :B) Extend the arm, dorsiflex the wrist, and extend the fingers.
Rationale:
P 2
, • Medical-Surgical 09/01/2026
Nursing
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic
encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-
rhythmic extension and flexion of the wrist while attempting to hold position (B). (A, C, and D) do not illicit
axterixis.
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse
determines that the client's stoma is dry and dark red in color. What action should the nurse implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma. –
Correct Answer :A) Notify the surgeon.
* The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion
of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the
surgeon should be notified immediately (A). Although (B, C, and D) may be implemented, the findings require
immediate medical attention.
What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is
beginning to improve after treatment?
A) Wheezing becomes louder.
B) Cough remains unproductive.
C) Vesicular breath sounds decrease.
D) Bronchodilators stimulate coughing. –
Correct Answer :A) Wheezing becomes louder.
P 3
, • Medical-Surgical 09/01/2026
Nursing
* In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is
successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder (A) as air flow
increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough
becomes more productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over
lung fields (C) and is not an indicator of improvement during asthma treatment. Bronchodilators do not
stimulate coughing (D).
A client is admitted to the emergency department after being lost for four days while hiking in a national forest.
Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating
hormone (TSH) is elevated. Which additional assessment should the nurse make?
A) Body mass index.
B) Skin elasticity and turgor.
C) Thought processes and speech.
D) Exposure to cold environmental temperatures.
- Correct Answer :D) Exposure to cold environmental temperatures.
* TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body
temperature near normal. Prolonged exposure to cold environmental temperatures (D) stimulates the
hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH.
(A) may reflect weight loss from lack of food. Tenting of the skin (B) is indicative of dehydration. Slow or
confused thought processes (C) or speech patterns may be related to sleep deprivation.
Which method elicits the most accurate information during a physical assessment of an older client?
A) Ask the client to recount one's health history.
B) Obtain the client's information from a caregiver.
C) Review the past medical record for medications.
D) Use reliable assessment tools for older adults.
P 4
Nursing
Medical-Surgical Nursing Complete Study
Guide | Exam Prep | 1,500+
Comprehensive Q-bank Questions, Detailed
Rationales, Predictor Exams, Clinical Case
Studies, Practice Questions and Answers
with Rationales| (A+ Guarantee) | PDF
P 1
, • Medical-Surgical 09/01/2026
Nursing
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results
reveal a platelet count of 10,000/ml. What action should the nurse implement?
A) Encourage fluids to 3000 ml/day.
B) Check stools for occult blood.
C) Provide oral hygiene every 2 hours.
D) Check for fever every 4 hours. –
Correct Answer :B) Check stools for occult blood.
Rationale:
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of
chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis,
sputum, feces (B), urine, nasogastric secretions, or wounds. (A) does not minimize the risk for bleeding
associated with thrombocytopenia. (C) may cause increased bleeding in a client with thromobcytopenia. (D)
assesses for infection, not risk for bleeding.
The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To
assess the client for asterixis, what position should the nurse ask the client to demonstrate?
A) Extend the left arm laterally with the left palm upward.
B) Extend the arm, dorsiflex the wrist, and extend the fingers.
C) Extend the arms and hold this position for 30 seconds.
D) Extend arms with both legs adducted to shoulder width. –
Correct Answer :B) Extend the arm, dorsiflex the wrist, and extend the fingers.
Rationale:
P 2
, • Medical-Surgical 09/01/2026
Nursing
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic
encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-
rhythmic extension and flexion of the wrist while attempting to hold position (B). (A, C, and D) do not illicit
axterixis.
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse
determines that the client's stoma is dry and dark red in color. What action should the nurse implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma. –
Correct Answer :A) Notify the surgeon.
* The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion
of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the
surgeon should be notified immediately (A). Although (B, C, and D) may be implemented, the findings require
immediate medical attention.
What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is
beginning to improve after treatment?
A) Wheezing becomes louder.
B) Cough remains unproductive.
C) Vesicular breath sounds decrease.
D) Bronchodilators stimulate coughing. –
Correct Answer :A) Wheezing becomes louder.
P 3
, • Medical-Surgical 09/01/2026
Nursing
* In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is
successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder (A) as air flow
increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough
becomes more productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over
lung fields (C) and is not an indicator of improvement during asthma treatment. Bronchodilators do not
stimulate coughing (D).
A client is admitted to the emergency department after being lost for four days while hiking in a national forest.
Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating
hormone (TSH) is elevated. Which additional assessment should the nurse make?
A) Body mass index.
B) Skin elasticity and turgor.
C) Thought processes and speech.
D) Exposure to cold environmental temperatures.
- Correct Answer :D) Exposure to cold environmental temperatures.
* TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body
temperature near normal. Prolonged exposure to cold environmental temperatures (D) stimulates the
hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH.
(A) may reflect weight loss from lack of food. Tenting of the skin (B) is indicative of dehydration. Slow or
confused thought processes (C) or speech patterns may be related to sleep deprivation.
Which method elicits the most accurate information during a physical assessment of an older client?
A) Ask the client to recount one's health history.
B) Obtain the client's information from a caregiver.
C) Review the past medical record for medications.
D) Use reliable assessment tools for older adults.
P 4
