• NUR 6001 09/15/2026
NU 185 Medical-Surgical Nursing II Comprehensive
Exam Prep Comprehensive Study Guide
UPDATE Actual Questions & Verified Answers with
Detailed Clinical Rationales
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most
important for the nurse to implement?
a. Give 20 mEq of potassium chloride.
b. Initiate continuous cardiac monitoring.
c. Arrange a consultation with the dietician.
d. Teach about the side effects of diuretics. - Correct Answer :B
Rationale
Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is most
important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-
P 1
, • NUR 6001 09/15/2026
threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so
that the effects of potassium replacement on the cardiac rhythm can be monitored.
56. A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in
skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for
impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based
on this diagnosis statement?
a. Release the traction q4h to provide skin care.
b. Turn the client for back care while suspending traction.
c. Provide back and skin care while maintaining the traction.
d. Give back care after the client is released from traction. - Correct Answer :C
Rationale
Maintaining skin integrity and providing back care is difficult when a client is in traction, but must be performed
and is the correct intervention to maintain the client's skin integrity.
57. What is the correct procedure for performing an opthalmoscopic examination on a client's right retina?
a. Instruct the client to look at examiner's nose and not move his/her eyes during the exam.
b. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
c. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
d. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. - Correct Answer
:C
Rationale
The client should focus on a distant object behind the examiner who should stand at 12-15 inches away and to
the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against his/her face and
then direct it at the client's pupil.
P 2
, • NUR 6001 09/15/2026
58. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the
best for the nurse to provide?
a. "Check it again in one month, and if it is still there schedule an appointment."
b. "Most lumps are benign, but it is always best to come in for an examination."
c. "Try not to worry too much about it, because usually, most lumps are benign."
d. "If you are in your menstrual period it is not a good time to check for lumps." - Correct Answer :B
Rationale
The nurse advising the client to come in provides the best response because it addresses the client's anxiety
most effectively and encourages prompt and immediate action for a potential problem.
59. A 58-year-old client who has been post-menopausal for five years is concerned about the risk for
osteoporosis because her mother has the condition. Which information should the nurse offer?
a. Osteoporosis is a progressive genetic disease with no effective treatment.
b. Calcium loss from bones can be slowed by increasing calcium intake and exercise.
c. Estrogen replacement therapy should be started to prevent the progression osteoporosis.
d. Low-dose corticosteroid treatment effectively halts the course of osteoporosis. - Correct Answer :B
Rationale
Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen
including calcium, vitamin D, and weight-bearing exercise can help prevent further bone loss.
60. What types of medications should the nurse expect to administer to a client during an acute respiratory
distress episode?
a. Vasodilators and hormones.
b. Analgesics and sedatives.
P 3
, • NUR 6001 09/15/2026
c. Anticoagulants and expectorants.
d. Bronchodilators and steroids. - Correct Answer :D
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages, increase air space,
and reduce alveolar membrane inflammation, such as bronchodilators and steroids.
61. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and
warmth on the lower left calf. What intervention would be most helpful to this client?
a. Apply sequential compression devices (SCDs) bilaterally.
b. Assess for a positive Homan's sign in each leg.
c. Pad all bony prominences on the affected leg.
d. Advise the client to remain in bed with the leg elevated. - Correct Answer :D
Rationale
The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial care
includes bedrest and elevation of the extremity.
62. A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the
last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives
alone and denies problems or concerns. What action should the nurse implement?
a. Notify social services immediately of suspected elderly abuse.
b. Discuss the need for mental health counseling with the daughter.
c. Explain to the client that she needs to take better care of herself.
d. Collect further data to determine whether self-neglect is occurring. - Correct Answer :D
Rationale
P 4
NU 185 Medical-Surgical Nursing II Comprehensive
Exam Prep Comprehensive Study Guide
UPDATE Actual Questions & Verified Answers with
Detailed Clinical Rationales
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most
important for the nurse to implement?
a. Give 20 mEq of potassium chloride.
b. Initiate continuous cardiac monitoring.
c. Arrange a consultation with the dietician.
d. Teach about the side effects of diuretics. - Correct Answer :B
Rationale
Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is most
important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-
P 1
, • NUR 6001 09/15/2026
threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so
that the effects of potassium replacement on the cardiac rhythm can be monitored.
56. A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in
skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for
impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based
on this diagnosis statement?
a. Release the traction q4h to provide skin care.
b. Turn the client for back care while suspending traction.
c. Provide back and skin care while maintaining the traction.
d. Give back care after the client is released from traction. - Correct Answer :C
Rationale
Maintaining skin integrity and providing back care is difficult when a client is in traction, but must be performed
and is the correct intervention to maintain the client's skin integrity.
57. What is the correct procedure for performing an opthalmoscopic examination on a client's right retina?
a. Instruct the client to look at examiner's nose and not move his/her eyes during the exam.
b. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
c. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
d. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. - Correct Answer
:C
Rationale
The client should focus on a distant object behind the examiner who should stand at 12-15 inches away and to
the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against his/her face and
then direct it at the client's pupil.
P 2
, • NUR 6001 09/15/2026
58. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the
best for the nurse to provide?
a. "Check it again in one month, and if it is still there schedule an appointment."
b. "Most lumps are benign, but it is always best to come in for an examination."
c. "Try not to worry too much about it, because usually, most lumps are benign."
d. "If you are in your menstrual period it is not a good time to check for lumps." - Correct Answer :B
Rationale
The nurse advising the client to come in provides the best response because it addresses the client's anxiety
most effectively and encourages prompt and immediate action for a potential problem.
59. A 58-year-old client who has been post-menopausal for five years is concerned about the risk for
osteoporosis because her mother has the condition. Which information should the nurse offer?
a. Osteoporosis is a progressive genetic disease with no effective treatment.
b. Calcium loss from bones can be slowed by increasing calcium intake and exercise.
c. Estrogen replacement therapy should be started to prevent the progression osteoporosis.
d. Low-dose corticosteroid treatment effectively halts the course of osteoporosis. - Correct Answer :B
Rationale
Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen
including calcium, vitamin D, and weight-bearing exercise can help prevent further bone loss.
60. What types of medications should the nurse expect to administer to a client during an acute respiratory
distress episode?
a. Vasodilators and hormones.
b. Analgesics and sedatives.
P 3
, • NUR 6001 09/15/2026
c. Anticoagulants and expectorants.
d. Bronchodilators and steroids. - Correct Answer :D
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages, increase air space,
and reduce alveolar membrane inflammation, such as bronchodilators and steroids.
61. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and
warmth on the lower left calf. What intervention would be most helpful to this client?
a. Apply sequential compression devices (SCDs) bilaterally.
b. Assess for a positive Homan's sign in each leg.
c. Pad all bony prominences on the affected leg.
d. Advise the client to remain in bed with the leg elevated. - Correct Answer :D
Rationale
The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial care
includes bedrest and elevation of the extremity.
62. A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the
last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives
alone and denies problems or concerns. What action should the nurse implement?
a. Notify social services immediately of suspected elderly abuse.
b. Discuss the need for mental health counseling with the daughter.
c. Explain to the client that she needs to take better care of herself.
d. Collect further data to determine whether self-neglect is occurring. - Correct Answer :D
Rationale
P 4
