med surg 2 exam 2 latest updates!!!
2026-2027 | correct solutions with
practice questions & answers |
verified | highly graded a+
A nurse is conducting a physical assessment on a 68-year-old client with a long history
of tobacco use and sedentary lifestyle. The client reports that their feet often feel cold
and look "pale" when sitting in a recliner with their legs up, but turn a "dark reddish-
purple" when they stand up to walk. The nurse should document this finding as:
a) Venous stasis dermatitis and peripheral edema.
b) Dependent rubor and elevation pallor associated with PAD.
c) Raynaud's phenomenon triggered by postural changes. d) Normal age-related
changes in skin perfusion. - CORRECT ANSWERS-b) Dependent rubor and elevation
pallor associated with PAD.
dependent rubor (redness when down) and elevation pallor (paleness when up) are
classic assessment findings for PAD.
A 54-year-old client is being evaluated in the clinic for a routine wellness check. The
nurse obtains an initial blood pressure reading of 134/84 mm Hg. Following a 5-minute
rest period, a second reading is 132/82 mm Hg. According to the ACC/AHA guidelines,
how should the nurse categorize this client's blood pressure?
a) Elevated blood pressure
b) Normal blood pressure
c) Stage 1 Hypertension
d) Stage 2 Hypertension - CORRECT ANSWERS-c) Stage 1 Hypertension
Stage 1 is 130-139 SBP OR 80-89 DBP. The client's readings (134 and 132) fall in this
range.
A nurse is assessing a client who presented to the urgent care clinic with a severe sore
throat and difficulty opening their mouth (trismus). The nurse notes that the client's
uvula is displaced to the left and the right tonsillar area is markedly swollen and red.
What is the priority nursing action?
a) Administer a prescribed dose of oral penicillin.
b) Obtain a throat culture for Group A Streptococcus.
c) Assess airway patency and monitor for signs of respiratory distress.
d) Provide the client with warm saline gargles for pain relief. - CORRECT ANSWERS-c)
Assess airway patency and monitor for signs of respiratory distress.
,uvular deviation and trismus are red flags for peritonsillar abscess, which can rapidly
obstruct the airway.
A client with hypertension is reviewing the DASH (Dietary Approaches to Stop
Hypertension) diet with the nurse. The client's typical daily intake includes 2 servings of
vegetables, 1 serving of fruit, and 4 servings of whole grains. Which dietary adjustment
should the nurse recommend to align with DASH goals?
a) Increase vegetable intake to 4 to 5 servings and fruits to 4 to 5 servings.
b) Decrease whole grain intake to 2 servings to reduce carbohydrate load.
c) Supplement the diet with full-fat dairy to increase calcium absorption.
d) Focus on increasing red meat intake for protein while limiting legumes. - CORRECT
ANSWERS-a) Increase vegetable intake to 4 to 5 servings and fruits to 4 to 5 servings.
DASH goals for a 2,000 calorie diet include 4-5 servings of fruit and 4-5 servings of
vegetables.
A client diagnosed with a deep vein thrombosis (DVT) in the left femoral vein has been
started on a continuous heparin infusion. The nurse receives the following laboratory
results: Platelets 160,000/mm³, PTT 85 seconds (Control: 30 seconds). Based on the
PTT result, which action by the nurse is most appropriate?
a) Increase the heparin infusion rate per the hospital's titration protocol.
b) Maintain the current infusion rate as the PTT is within the therapeutic range.
c) Stop the infusion and prepare to administer protamine sulfate.
d) Decrease the infusion rate or hold the dose per the titration protocol. - CORRECT
ANSWERS-d) Decrease the infusion rate or hold the dose per the titration protocol.
the PTT is above the therapeutic range, necessitating a decrease in the infusion rate.
A nurse is caring for a client who is 12 hours postoperative following a total
laryngectomy for laryngeal cancer. The nurse notes that the client has become
increasingly restless, has a respiratory rate of 28 breaths/min, and is using accessory
muscles to breathe. What is the nurse's first action?
a) Administer a prescribed dose of lorazepam for anxiety. b) Suction the laryngectomy
tube to ensure it is not occluded by mucus.
c) Document the findings and reassess the client in 30 minutes.
d) Encourage the client to use an incentive spirometer. - CORRECT ANSWERS-b)
Suction the laryngectomy tube to ensure it is not occluded by mucus.
mucus plugging is the most common cause of respiratory distress in a new
laryngectomy; suctioning clears the airway.
A nurse is preparing to admit a client with a confirmed diagnosis of active pulmonary
tuberculosis (TB). Which room assignment and set of precautions are most appropriate
for this client?
a) A semi-private room with a client who has pneumonia; Droplet precautions.
b) A private room with positive-pressure airflow; Contact precautions.
,c) A private room with negative-pressure airflow; Airborne precautions.
d) A standard private room with the door kept open; Protective environment -
CORRECT ANSWERS-c) A private room with negative-pressure airflow; Airborne
precautions.
Airborne precautions and a negative-pressure room are mandatory for active TB.
A nurse is monitoring a client with a chest tube placed for a spontaneous
pneumothorax. While checking the pleur-evac system, the nurse observes that the
water-seal chamber has vigorous, continuous bubbling. There is no bubbling in the
suction control chamber. How should the nurse proceed?
a) Document this as a normal finding for a client with a pneumothorax.
b) Check the chest tube insertion site and all connections for an air leak.
c) Decrease the suction wall regulator to stop the bubbling. d) Clamp the chest tube
close to the patient's chest to see if it stops. - CORRECT ANSWERS-b) Check the
chest tube insertion site and all connections for an air leak.
the nurse must find the source of the leak (patient, tubing, or system)
A client presents with a warm, edematous, and painful area on the right lower leg that
has doubled in size over the last 24 hours. The borders are ill-defined. The nurse
identifies this as cellulitis. Which intervention should the nurse implement first?
a) Apply a heating pad to the area to increase blood flow. b) Administer the first dose of
IV vancomycin.
c) Elevate the affected leg 3 to 6 inches above the level of the heart.
d) Apply graduated compression stockings to both legs. - CORRECT ANSWERS-c)
Elevate the affected leg 3 to 6 inches above the level of the heart.
elevation (3-6 inches above heart level) is the primary nursing intervention to reduce the
edema associated with cellulitis.
A 12-year-old client with a history of asthma is brought to the school nurse's office
during recess. The client is wheezing and reports chest tightness. The client's peak flow
meter reading is 180 L/min (Personal Best: 360 L/min). Which action is the priority?
a) Give the client 8 oz of water and have them rest for 15 minutes.
b) Administer the client's prescribed rescue inhaler (albuterol) immediately.
c) Call the parents to pick the child up from school.
d) Perform a full head-to-toe physical assessment. - CORRECT ANSWERS-b)
Administer the client's prescribed rescue inhaler (albuterol) immediately.
the client is in the "Yellow/Red" transition (50% of best); immediate rescue
bronchodilation is the priority.
A nurse is caring for a client with community-acquired pneumonia. The client's vital
signs are: Temp 102.1°F (38.9°C), HR 112, RR 26, BP 102/64. Which of the following
, clinical findings are directly related to the body's compensatory response to the fever?
Select all that apply. a) Tachycardia
b) Tachypnea
c) Hypotension
d) Diaphoresis
e) Sputum production - CORRECT ANSWERS-a) Tachycardia
b) Tachypnea
d) Diaphoresis
A nurse is providing discharge education to an 82-year-old client who lives alone and
has been newly prescribed three different medications for Stage 2 Hypertension. Which
assessment finding should the nurse prioritize as the greatest risk for medication non-
adherence?
a) The client's spouse passed away five years ago.
b) The client expresses concern about the monthly cost of the prescriptions.
c) The client has a history of mild osteoarthritis in the hands.
d) The client reports walking for 20 minutes every morning. - CORRECT ANSWERS-b)
The client expresses concern about the monthly cost of the prescriptions.
expense of medications is a significant barrier to adherence for older adults.
A client with Peripheral Arterial Disease (PAD) tells the nurse, "I can walk about half a
block before my calves start cramping and hurting really bad, but as soon as I sit down
for a minute, the pain goes away." The nurse recognizes this as intermittent claudication
and understands the pathophysiology is:
a) Inadequate venous return causing blood to pool in the lower legs.
b) Nerve compression in the lumbar spine during physical activity.
c) Inability of the damaged arteries to provide enough oxygen to the muscles during
exercise.
d) A sudden vasospasm of the small cutaneous arteries in the feet. - CORRECT
ANSWERS-c) Inability of the damaged arteries to provide enough oxygen to the
muscles during exercise.
claudication is "angina of the legs"; the oxygen supply cannot meet the metabolic
demand of the exercising muscle.
A nurse on a busy medical unit is planning care for a client with a stable, long-term
tracheostomy. Which task is appropriate for the nurse to delegate to a trained
unlicensed assistive personnel (UAP)?
a) Performing tracheostomy care, including changing the ties and cleaning the stoma.
b) Suctioning the oropharyngeal cavity using a Yankauer suction tip.
c) Assessing the client's lung sounds before and after suctioning.
d) Adjusting the pressure on the tracheostomy cuff to prevent aspiration. - CORRECT
ANSWERS-b) Suctioning the oropharyngeal cavity using a Yankauer suction tip.
UAPs can perform oral/oropharyngeal suctioning in stable patients.
2026-2027 | correct solutions with
practice questions & answers |
verified | highly graded a+
A nurse is conducting a physical assessment on a 68-year-old client with a long history
of tobacco use and sedentary lifestyle. The client reports that their feet often feel cold
and look "pale" when sitting in a recliner with their legs up, but turn a "dark reddish-
purple" when they stand up to walk. The nurse should document this finding as:
a) Venous stasis dermatitis and peripheral edema.
b) Dependent rubor and elevation pallor associated with PAD.
c) Raynaud's phenomenon triggered by postural changes. d) Normal age-related
changes in skin perfusion. - CORRECT ANSWERS-b) Dependent rubor and elevation
pallor associated with PAD.
dependent rubor (redness when down) and elevation pallor (paleness when up) are
classic assessment findings for PAD.
A 54-year-old client is being evaluated in the clinic for a routine wellness check. The
nurse obtains an initial blood pressure reading of 134/84 mm Hg. Following a 5-minute
rest period, a second reading is 132/82 mm Hg. According to the ACC/AHA guidelines,
how should the nurse categorize this client's blood pressure?
a) Elevated blood pressure
b) Normal blood pressure
c) Stage 1 Hypertension
d) Stage 2 Hypertension - CORRECT ANSWERS-c) Stage 1 Hypertension
Stage 1 is 130-139 SBP OR 80-89 DBP. The client's readings (134 and 132) fall in this
range.
A nurse is assessing a client who presented to the urgent care clinic with a severe sore
throat and difficulty opening their mouth (trismus). The nurse notes that the client's
uvula is displaced to the left and the right tonsillar area is markedly swollen and red.
What is the priority nursing action?
a) Administer a prescribed dose of oral penicillin.
b) Obtain a throat culture for Group A Streptococcus.
c) Assess airway patency and monitor for signs of respiratory distress.
d) Provide the client with warm saline gargles for pain relief. - CORRECT ANSWERS-c)
Assess airway patency and monitor for signs of respiratory distress.
,uvular deviation and trismus are red flags for peritonsillar abscess, which can rapidly
obstruct the airway.
A client with hypertension is reviewing the DASH (Dietary Approaches to Stop
Hypertension) diet with the nurse. The client's typical daily intake includes 2 servings of
vegetables, 1 serving of fruit, and 4 servings of whole grains. Which dietary adjustment
should the nurse recommend to align with DASH goals?
a) Increase vegetable intake to 4 to 5 servings and fruits to 4 to 5 servings.
b) Decrease whole grain intake to 2 servings to reduce carbohydrate load.
c) Supplement the diet with full-fat dairy to increase calcium absorption.
d) Focus on increasing red meat intake for protein while limiting legumes. - CORRECT
ANSWERS-a) Increase vegetable intake to 4 to 5 servings and fruits to 4 to 5 servings.
DASH goals for a 2,000 calorie diet include 4-5 servings of fruit and 4-5 servings of
vegetables.
A client diagnosed with a deep vein thrombosis (DVT) in the left femoral vein has been
started on a continuous heparin infusion. The nurse receives the following laboratory
results: Platelets 160,000/mm³, PTT 85 seconds (Control: 30 seconds). Based on the
PTT result, which action by the nurse is most appropriate?
a) Increase the heparin infusion rate per the hospital's titration protocol.
b) Maintain the current infusion rate as the PTT is within the therapeutic range.
c) Stop the infusion and prepare to administer protamine sulfate.
d) Decrease the infusion rate or hold the dose per the titration protocol. - CORRECT
ANSWERS-d) Decrease the infusion rate or hold the dose per the titration protocol.
the PTT is above the therapeutic range, necessitating a decrease in the infusion rate.
A nurse is caring for a client who is 12 hours postoperative following a total
laryngectomy for laryngeal cancer. The nurse notes that the client has become
increasingly restless, has a respiratory rate of 28 breaths/min, and is using accessory
muscles to breathe. What is the nurse's first action?
a) Administer a prescribed dose of lorazepam for anxiety. b) Suction the laryngectomy
tube to ensure it is not occluded by mucus.
c) Document the findings and reassess the client in 30 minutes.
d) Encourage the client to use an incentive spirometer. - CORRECT ANSWERS-b)
Suction the laryngectomy tube to ensure it is not occluded by mucus.
mucus plugging is the most common cause of respiratory distress in a new
laryngectomy; suctioning clears the airway.
A nurse is preparing to admit a client with a confirmed diagnosis of active pulmonary
tuberculosis (TB). Which room assignment and set of precautions are most appropriate
for this client?
a) A semi-private room with a client who has pneumonia; Droplet precautions.
b) A private room with positive-pressure airflow; Contact precautions.
,c) A private room with negative-pressure airflow; Airborne precautions.
d) A standard private room with the door kept open; Protective environment -
CORRECT ANSWERS-c) A private room with negative-pressure airflow; Airborne
precautions.
Airborne precautions and a negative-pressure room are mandatory for active TB.
A nurse is monitoring a client with a chest tube placed for a spontaneous
pneumothorax. While checking the pleur-evac system, the nurse observes that the
water-seal chamber has vigorous, continuous bubbling. There is no bubbling in the
suction control chamber. How should the nurse proceed?
a) Document this as a normal finding for a client with a pneumothorax.
b) Check the chest tube insertion site and all connections for an air leak.
c) Decrease the suction wall regulator to stop the bubbling. d) Clamp the chest tube
close to the patient's chest to see if it stops. - CORRECT ANSWERS-b) Check the
chest tube insertion site and all connections for an air leak.
the nurse must find the source of the leak (patient, tubing, or system)
A client presents with a warm, edematous, and painful area on the right lower leg that
has doubled in size over the last 24 hours. The borders are ill-defined. The nurse
identifies this as cellulitis. Which intervention should the nurse implement first?
a) Apply a heating pad to the area to increase blood flow. b) Administer the first dose of
IV vancomycin.
c) Elevate the affected leg 3 to 6 inches above the level of the heart.
d) Apply graduated compression stockings to both legs. - CORRECT ANSWERS-c)
Elevate the affected leg 3 to 6 inches above the level of the heart.
elevation (3-6 inches above heart level) is the primary nursing intervention to reduce the
edema associated with cellulitis.
A 12-year-old client with a history of asthma is brought to the school nurse's office
during recess. The client is wheezing and reports chest tightness. The client's peak flow
meter reading is 180 L/min (Personal Best: 360 L/min). Which action is the priority?
a) Give the client 8 oz of water and have them rest for 15 minutes.
b) Administer the client's prescribed rescue inhaler (albuterol) immediately.
c) Call the parents to pick the child up from school.
d) Perform a full head-to-toe physical assessment. - CORRECT ANSWERS-b)
Administer the client's prescribed rescue inhaler (albuterol) immediately.
the client is in the "Yellow/Red" transition (50% of best); immediate rescue
bronchodilation is the priority.
A nurse is caring for a client with community-acquired pneumonia. The client's vital
signs are: Temp 102.1°F (38.9°C), HR 112, RR 26, BP 102/64. Which of the following
, clinical findings are directly related to the body's compensatory response to the fever?
Select all that apply. a) Tachycardia
b) Tachypnea
c) Hypotension
d) Diaphoresis
e) Sputum production - CORRECT ANSWERS-a) Tachycardia
b) Tachypnea
d) Diaphoresis
A nurse is providing discharge education to an 82-year-old client who lives alone and
has been newly prescribed three different medications for Stage 2 Hypertension. Which
assessment finding should the nurse prioritize as the greatest risk for medication non-
adherence?
a) The client's spouse passed away five years ago.
b) The client expresses concern about the monthly cost of the prescriptions.
c) The client has a history of mild osteoarthritis in the hands.
d) The client reports walking for 20 minutes every morning. - CORRECT ANSWERS-b)
The client expresses concern about the monthly cost of the prescriptions.
expense of medications is a significant barrier to adherence for older adults.
A client with Peripheral Arterial Disease (PAD) tells the nurse, "I can walk about half a
block before my calves start cramping and hurting really bad, but as soon as I sit down
for a minute, the pain goes away." The nurse recognizes this as intermittent claudication
and understands the pathophysiology is:
a) Inadequate venous return causing blood to pool in the lower legs.
b) Nerve compression in the lumbar spine during physical activity.
c) Inability of the damaged arteries to provide enough oxygen to the muscles during
exercise.
d) A sudden vasospasm of the small cutaneous arteries in the feet. - CORRECT
ANSWERS-c) Inability of the damaged arteries to provide enough oxygen to the
muscles during exercise.
claudication is "angina of the legs"; the oxygen supply cannot meet the metabolic
demand of the exercising muscle.
A nurse on a busy medical unit is planning care for a client with a stable, long-term
tracheostomy. Which task is appropriate for the nurse to delegate to a trained
unlicensed assistive personnel (UAP)?
a) Performing tracheostomy care, including changing the ties and cleaning the stoma.
b) Suctioning the oropharyngeal cavity using a Yankauer suction tip.
c) Assessing the client's lung sounds before and after suctioning.
d) Adjusting the pressure on the tracheostomy cuff to prevent aspiration. - CORRECT
ANSWERS-b) Suctioning the oropharyngeal cavity using a Yankauer suction tip.
UAPs can perform oral/oropharyngeal suctioning in stable patients.
