SWIFT RIVER MEDICAL SURGICAL REVISION EXAMS
PAPER QUESTIONS AND ANSWERS SURE A+
✔✔Arthur Thomason
The nurse administered morphine 4 mg IV for anxiety to the client. Respiratory therapist
placed the client on oxygen 7 L/min via simple face mask and SpO2 is now 94%. The
client is alert and oriented x 3 and appears calm. The client has prescriptions for
acetaminophen 650 mg PO every 4 hours PRN temperature greater than 38° C (100.4°
F) and furosemide (Lasix) 40 mg BID as diuretic. The nurse has administered
acetaminophen 650 mg PO for the client's fever and is preparing to administer
furosemide 40 mg IV to the client.
Which of the following nursing actions should the nurse take for the administration of
furosemide? (Select all that apply.) - ✔✔Assess client's blood pressure before
administration of furosemide
Ask client if they have allergies to sulfonamides.
Instruct client to change positions slowly.
✔✔Arthur Thomason
The nurse returns to the client's room one hour later to assess the client's status. When
the nurse walks in the client's room, the client is sitting up in bed with simple face mask
hanging off their face and reports sharp chest pain on inspiration rated as 10 on a scale
,of 0 to 10. The nurse observes the client sweating, several tissues with blood-tinged
sputum, and the client appears apprehensive and states "feels like I am not going to
make it". Lung sounds with crackles, increased respirations at 34/min, heart rate
112/min with S4 heart sounds auscultated.
The nurse suspects the client is experiencing a pulmonary embolism. Which of the
following actions should the nurse take? (Select all that apply.) - ✔✔Place the simple
face mask back on the client.
Prepare the client for transfer to the intensive care unit (ICU).
Remain with client and reassure them.
Assess capillary refill
✔✔Arthur Thomason
The nurse preparing a plan of care for the client who has just returned from the
intensive care unit (ICU) after six days following a pulmonary embolism. The client is
awake, alert, and oriented x 3. Breath sounds clear, respirations even and unlabored.
Abdomen soft with active bowel sounds x 4 quadrants. Active range of motion to all
extremities. No swelling or edema in lower extremities. The client reports they feel so
much better and cannot wait to be discharged home. The client's prescription for
heparin has been discontinued, but the prescription for warfarin (Coumadin) 5 mg PO
daily remains active.
Which of the following nursing interventions should the nurse include in the plan of care
for the client recovering from a pulmonary embolism? (Select all that apply.) -
✔✔Monitor the client's PTT.
Inform the client to report bleeding mouth or gums.
Assess vital signs frequently.
Monitor the client's platelet count.
✔✔Charlie Raymond, a 65-year-old client, was admitted to a negative pressure room on
COVID-19 precautions. Charlie is a retired postal worker who lives at home with their
partner. Charlie has a history of COPD, hypertension, type II diabetes, smoking, and a
recent myocardial infarction. Wheezing auscultated in bilateral lower lobes. Current
prescriptions include cefotaxime 2 g IV every 4 hours and insulin glargine 24 units at
bedtime. The client reports no pain but states they have some shortness of breath on
exertion. Vital Signs are blood pressure 145/78 mmHg, heart rate 89/min, respirations
24/min and slightly labored, temperature 100.2°F (37.9°C), and oxygen saturation 94%
on 2L nasal cannula. The client reports feeling very anxious about their diagnosis.
After receiving handoff report, the nurse should determine the client's priority needs.
Indicate if the client is a high priority or low priority using each of t - ✔✔Maslow's
Hierarchy of Needs- high
, Airway, Breathing, Circulation- high
Safety and Risk Reduction- high
Urgent vs Nonurgent- high
Chronic vs Acute/Stable vs Unstable- low
✔✔Charlie Raymond
Initial Nursing Assessment
The nurse reviews the information received in the report and enters the client's room to
perform a physical assessment. Upon assessment, the client is alert and oriented to
person, place, time, and event. Pupils are equal, round, reactive to light, and
accommodation. IV to left hand is heparin locked. Lung sounds reveal crackles and
wheezes in bilateral lower lobes. Shortness of breath on exertion noted with dry non-
productive cough. ABG results are pending. Client reports fatigue, headache rated as a
6 on a 0 to 10 pain scale, and loss of taste and smell. S1S2 heart tones noted. All
pulses palpable. Abdomen is soft and non-tender. Bowel sounds active in all 4
quadrants. Client is lying in semi-Fowler's position. Call light is within reach.
Which of the following concerns should the nurse address while providing client care?
(Select all that apply.) - ✔✔Physiological: Comfort
Physiological: Gas Exchange
Physiological: Perfusion
Physiological: Infection
Health Promotion: Client Education
✔✔Charlie Raymond
The assistive personnel (AP) informs the nurse that the client's current vital signs are
blood pressure 125/78 mmHg, heart rate 102/min, respirations 30/min and labored,
temperature 101.3°F (38.5°C), and oxygen saturation 91% on 2L via nasal cannula.
When reviewing the client's recent ABG results, the nurse identifies these findings to be
consistent with respiratory distress and is preparing to enter the client's room.
Which of the following actions should the nurse take? (Select all that apply.) -
✔✔Review the client's chest x-ray results.
Assess the client for bronchial breath sounds.
Reposition the client every 2 hours.
✔✔Charlie Raymond
PAPER QUESTIONS AND ANSWERS SURE A+
✔✔Arthur Thomason
The nurse administered morphine 4 mg IV for anxiety to the client. Respiratory therapist
placed the client on oxygen 7 L/min via simple face mask and SpO2 is now 94%. The
client is alert and oriented x 3 and appears calm. The client has prescriptions for
acetaminophen 650 mg PO every 4 hours PRN temperature greater than 38° C (100.4°
F) and furosemide (Lasix) 40 mg BID as diuretic. The nurse has administered
acetaminophen 650 mg PO for the client's fever and is preparing to administer
furosemide 40 mg IV to the client.
Which of the following nursing actions should the nurse take for the administration of
furosemide? (Select all that apply.) - ✔✔Assess client's blood pressure before
administration of furosemide
Ask client if they have allergies to sulfonamides.
Instruct client to change positions slowly.
✔✔Arthur Thomason
The nurse returns to the client's room one hour later to assess the client's status. When
the nurse walks in the client's room, the client is sitting up in bed with simple face mask
hanging off their face and reports sharp chest pain on inspiration rated as 10 on a scale
,of 0 to 10. The nurse observes the client sweating, several tissues with blood-tinged
sputum, and the client appears apprehensive and states "feels like I am not going to
make it". Lung sounds with crackles, increased respirations at 34/min, heart rate
112/min with S4 heart sounds auscultated.
The nurse suspects the client is experiencing a pulmonary embolism. Which of the
following actions should the nurse take? (Select all that apply.) - ✔✔Place the simple
face mask back on the client.
Prepare the client for transfer to the intensive care unit (ICU).
Remain with client and reassure them.
Assess capillary refill
✔✔Arthur Thomason
The nurse preparing a plan of care for the client who has just returned from the
intensive care unit (ICU) after six days following a pulmonary embolism. The client is
awake, alert, and oriented x 3. Breath sounds clear, respirations even and unlabored.
Abdomen soft with active bowel sounds x 4 quadrants. Active range of motion to all
extremities. No swelling or edema in lower extremities. The client reports they feel so
much better and cannot wait to be discharged home. The client's prescription for
heparin has been discontinued, but the prescription for warfarin (Coumadin) 5 mg PO
daily remains active.
Which of the following nursing interventions should the nurse include in the plan of care
for the client recovering from a pulmonary embolism? (Select all that apply.) -
✔✔Monitor the client's PTT.
Inform the client to report bleeding mouth or gums.
Assess vital signs frequently.
Monitor the client's platelet count.
✔✔Charlie Raymond, a 65-year-old client, was admitted to a negative pressure room on
COVID-19 precautions. Charlie is a retired postal worker who lives at home with their
partner. Charlie has a history of COPD, hypertension, type II diabetes, smoking, and a
recent myocardial infarction. Wheezing auscultated in bilateral lower lobes. Current
prescriptions include cefotaxime 2 g IV every 4 hours and insulin glargine 24 units at
bedtime. The client reports no pain but states they have some shortness of breath on
exertion. Vital Signs are blood pressure 145/78 mmHg, heart rate 89/min, respirations
24/min and slightly labored, temperature 100.2°F (37.9°C), and oxygen saturation 94%
on 2L nasal cannula. The client reports feeling very anxious about their diagnosis.
After receiving handoff report, the nurse should determine the client's priority needs.
Indicate if the client is a high priority or low priority using each of t - ✔✔Maslow's
Hierarchy of Needs- high
, Airway, Breathing, Circulation- high
Safety and Risk Reduction- high
Urgent vs Nonurgent- high
Chronic vs Acute/Stable vs Unstable- low
✔✔Charlie Raymond
Initial Nursing Assessment
The nurse reviews the information received in the report and enters the client's room to
perform a physical assessment. Upon assessment, the client is alert and oriented to
person, place, time, and event. Pupils are equal, round, reactive to light, and
accommodation. IV to left hand is heparin locked. Lung sounds reveal crackles and
wheezes in bilateral lower lobes. Shortness of breath on exertion noted with dry non-
productive cough. ABG results are pending. Client reports fatigue, headache rated as a
6 on a 0 to 10 pain scale, and loss of taste and smell. S1S2 heart tones noted. All
pulses palpable. Abdomen is soft and non-tender. Bowel sounds active in all 4
quadrants. Client is lying in semi-Fowler's position. Call light is within reach.
Which of the following concerns should the nurse address while providing client care?
(Select all that apply.) - ✔✔Physiological: Comfort
Physiological: Gas Exchange
Physiological: Perfusion
Physiological: Infection
Health Promotion: Client Education
✔✔Charlie Raymond
The assistive personnel (AP) informs the nurse that the client's current vital signs are
blood pressure 125/78 mmHg, heart rate 102/min, respirations 30/min and labored,
temperature 101.3°F (38.5°C), and oxygen saturation 91% on 2L via nasal cannula.
When reviewing the client's recent ABG results, the nurse identifies these findings to be
consistent with respiratory distress and is preparing to enter the client's room.
Which of the following actions should the nurse take? (Select all that apply.) -
✔✔Review the client's chest x-ray results.
Assess the client for bronchial breath sounds.
Reposition the client every 2 hours.
✔✔Charlie Raymond
