Med Surg Practice Exam and Solution
1. 1.ID: 310945742
Which milestone indicates to the nurse successful achievement of young adulthood?
o Demonstrates a conceptualization of death and dying.
o Completes education and becomes self-supporting. Correct
o Creates a new definition of self and roles with others. Incorrect
o Develops a strong need for parental support and approval.
Transitioning through young adulthood is characterized by establishing independence as
an adult, and includes developmental tasks such as completing education, beginning a
career, and becoming self-supporting (B). (A and C) are characteristic of adolescence.
Although strong bonds with parents are an expected finding for this age group, the need
for support and approval (D) indicates dependency, which is a developmental delay.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 310959831
The nurse working on a telemetry unit finds a client unconscious and in pulseless
ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What
action should the nurse implement?
o Prepare the client for transcutaneous pacemaker.
o Shock the client with 200 joules per hospital policy. Correct
o Use a magnet to deactivate the implanted pacemaker.
o Observe the monitor until the onset of ventricular fibrillation.
The client must be externally shocked (B) to restore an effective cardiac rhythm. The
automatic defibrillator is obviously malfunctioning. (A) will not be effective during
ventricular tachycardia, since it is used for asystole. Since the defibrillator is not
functioning, (C) is not warranted. The client should be treated immediately to restore
cardiac output (D).
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 311013679
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
o Positive polarity right shoulder, negative polarity left shoulder, ground left
chest nipple line.
o Positive polarity left shoulder, negative polarity right chest nipple line, ground
left chest nipple line.
o Positive polarity right chest nipple line, negative polarity left chest nipple
line, ground left shoulder.
o Negative polarity left shoulder, positive polarity right chest nipple line,
ground left chest nipple line. Correct
, In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the
right of the sternum, and the negative electrode is placed on the upper left part of the
chest (D). The ground may be placed anywhere, but is usually placed on the lower left
portion of the chest. (A, B, and C) describe incorrect placement of electrodes for
telemetry monitoring.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 310950770
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client
for which treatment protocol?
o Diuretic therapy.
o Pacemaker implantation.
o Anticoagulation therapy. Correct
o Cardiac catheterization.
The client is experiencing atrial fibrillation, and the nurse should prepare the client for
anticoagulation therapy (C) which should be prescribed before rhythm control therapies
to prevent cardioembolic events which result from blood pooling in the fibrillating atria.
(A, B, and D) are not indicated.
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 310959877
In preparing to administer intravenous albumin to a client following surgery, what is the
priority nursing intervention? (Select all that apply.)
o Set the infusion pump to infuse the albumin within four hours. Correct
o Compare the client's blood type with the label on the albumin.
o Assign a UAP to monitor blood pressure q15 minutes. Incorrect
o Administer through a large gauge catheter. Correct
o Monitor hemoglobin and hematocrit levels. Correct
o Assess for increased bleeding after administration. Correct
(A, D, E, and F) are the correct selections. Albumin should be infused within four hours
because it does not contain any preservatives. Any fluid remaining after four hours
should be discarded (A). Albumin administration does not require blood typing (B). Vital
signs should be monitored periodically to assess for fluid volume overload, but every 15
minutes is not necessary (C). This frequency is often used during the first hour of a blood
transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be
necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while
increased blood volume and blood pressure may cause bleeding (F).
Awarded 0.0 points out of 1.0 possible points.
6. 6.ID: 310944546
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?
, o Give 20 mEq of potassium chloride.
o Initiate continuous cardiac monitoring. Correct
o Arrange a consultation with the dietician.
o Teach about the side effects of diuretics. Incorrect
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
(B) to identify ventricular ectopy or other life-threatening dysrhythmias. Potassium
chloride (A) should be given after cardiac monitoring is initiated so that the effects
of potassium replacement on the cardiac rhythm can be monitored. (C and D) should
be implemented when the client is stable.
Awarded 0.0 points out of 1.0 possible points.
7. 7.ID: 310945798
The nurse is teaching a female client about the best time to plan sexual intercourse in
order to conceive. Which information should the nurse provide?
o Two weeks before menstruation. Correct
o Vaginal mucous discharge is thick.
o Low basal temperature. Incorrect
o First thing in the morning.
Ovulation typically occurs 14 days before menstruation begins (A), and sexual
intercourse should occur within 24 hours of ovulation for conception to occur. High
estrogen levels occur during ovulation and increase the vaginal mucous membrane
characteristics, which become more "slippery" and stretchy, not (B). A rise in basal
temperature, not (C), signals ovulation. The timing during the day is not as significant in
determining conception as the day before and after ovulation (D).
Awarded 0.0 points out of 1.0 possible points.
8. 8.ID: 310959839
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse
why she becomes excessively diaphoretic and feels warm during nighttime. What is the
nurse’s best response?
o Explain the effect of the follicle-stimulating and luteinizing hormones.
o Discuss perimenopause and related comfort measures. Correct
o Assess lung fields and for a cough productive of blood-tinged mucous.
o Ask if a fever above 101º F has occurred in the last 24 hours. Incorrect
The perimenopausal period begins about 10 years before menopause with the cessation of
menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH
secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot
flashes, so discussions about the perimenopausal body's changes, comfort measures (B),
and treatment options should be provided. In-depth pathophysiology of the symptoms (A)
, may only confuse the client. There is no indication that the client has tuberculosis and an
infection, so (C and D) are not indicated.
Awarded 0.0 points out of 1.0 possible points.
9. 9.ID: 311023615
Which client should the nurse recognize as most likely to experience sleep apnea?
o Middle-aged female who takes a diuretic nightly.
o Obese older male client with a short, thick neck. Correct
o Adolescent female with a history of tonsillectomy.
o School-aged male with a history of hyperactivity disorder.
Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep
and is due to the loss of pharyngeal tone which allows the pharynx to collapse during
inspiration and obstructs air flow through the nose and mouth. With obstructive sleep
apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not
typically prone to sleep apnea.
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 310949492
The nurse is planning care for a client with newly diagnosed diabetes mellitus
that requires insulin. Which assessment should the nurse identify before
beginning the teaching session?
o Present knowledge related to the skill of injection.
o Intelligence and developmental level of the client.
o Willingness of the client to learn the injection sites. Correct
o Financial resources available for the equipment.
If a client is incapable or does not want to learn, it is unlikely that learning will occur, so
motivation is the first factor the nurse should assess before teaching (C). To determine
learning needs, the nurse should assess (A), but this is not the most important factor for
the nurse to assess. (B and D) are factors to consider, but not as vital as (C).
Awarded 1.0 points out of 1.0 possible points.
11. 11.ID: 310959881
The nurse is assessing a client's laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing
tumor lysis syndrome (TLS)?
o Serum PTT of 10 seconds.
o Serum calcium of 5 mg/dl. Correct
o Oxygen saturation of 90%.
o Hemoglobin of 10 g/dl.
1. 1.ID: 310945742
Which milestone indicates to the nurse successful achievement of young adulthood?
o Demonstrates a conceptualization of death and dying.
o Completes education and becomes self-supporting. Correct
o Creates a new definition of self and roles with others. Incorrect
o Develops a strong need for parental support and approval.
Transitioning through young adulthood is characterized by establishing independence as
an adult, and includes developmental tasks such as completing education, beginning a
career, and becoming self-supporting (B). (A and C) are characteristic of adolescence.
Although strong bonds with parents are an expected finding for this age group, the need
for support and approval (D) indicates dependency, which is a developmental delay.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 310959831
The nurse working on a telemetry unit finds a client unconscious and in pulseless
ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What
action should the nurse implement?
o Prepare the client for transcutaneous pacemaker.
o Shock the client with 200 joules per hospital policy. Correct
o Use a magnet to deactivate the implanted pacemaker.
o Observe the monitor until the onset of ventricular fibrillation.
The client must be externally shocked (B) to restore an effective cardiac rhythm. The
automatic defibrillator is obviously malfunctioning. (A) will not be effective during
ventricular tachycardia, since it is used for asystole. Since the defibrillator is not
functioning, (C) is not warranted. The client should be treated immediately to restore
cardiac output (D).
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 311013679
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
o Positive polarity right shoulder, negative polarity left shoulder, ground left
chest nipple line.
o Positive polarity left shoulder, negative polarity right chest nipple line, ground
left chest nipple line.
o Positive polarity right chest nipple line, negative polarity left chest nipple
line, ground left shoulder.
o Negative polarity left shoulder, positive polarity right chest nipple line,
ground left chest nipple line. Correct
, In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the
right of the sternum, and the negative electrode is placed on the upper left part of the
chest (D). The ground may be placed anywhere, but is usually placed on the lower left
portion of the chest. (A, B, and C) describe incorrect placement of electrodes for
telemetry monitoring.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 310950770
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client
for which treatment protocol?
o Diuretic therapy.
o Pacemaker implantation.
o Anticoagulation therapy. Correct
o Cardiac catheterization.
The client is experiencing atrial fibrillation, and the nurse should prepare the client for
anticoagulation therapy (C) which should be prescribed before rhythm control therapies
to prevent cardioembolic events which result from blood pooling in the fibrillating atria.
(A, B, and D) are not indicated.
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 310959877
In preparing to administer intravenous albumin to a client following surgery, what is the
priority nursing intervention? (Select all that apply.)
o Set the infusion pump to infuse the albumin within four hours. Correct
o Compare the client's blood type with the label on the albumin.
o Assign a UAP to monitor blood pressure q15 minutes. Incorrect
o Administer through a large gauge catheter. Correct
o Monitor hemoglobin and hematocrit levels. Correct
o Assess for increased bleeding after administration. Correct
(A, D, E, and F) are the correct selections. Albumin should be infused within four hours
because it does not contain any preservatives. Any fluid remaining after four hours
should be discarded (A). Albumin administration does not require blood typing (B). Vital
signs should be monitored periodically to assess for fluid volume overload, but every 15
minutes is not necessary (C). This frequency is often used during the first hour of a blood
transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be
necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while
increased blood volume and blood pressure may cause bleeding (F).
Awarded 0.0 points out of 1.0 possible points.
6. 6.ID: 310944546
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?
, o Give 20 mEq of potassium chloride.
o Initiate continuous cardiac monitoring. Correct
o Arrange a consultation with the dietician.
o Teach about the side effects of diuretics. Incorrect
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
(B) to identify ventricular ectopy or other life-threatening dysrhythmias. Potassium
chloride (A) should be given after cardiac monitoring is initiated so that the effects
of potassium replacement on the cardiac rhythm can be monitored. (C and D) should
be implemented when the client is stable.
Awarded 0.0 points out of 1.0 possible points.
7. 7.ID: 310945798
The nurse is teaching a female client about the best time to plan sexual intercourse in
order to conceive. Which information should the nurse provide?
o Two weeks before menstruation. Correct
o Vaginal mucous discharge is thick.
o Low basal temperature. Incorrect
o First thing in the morning.
Ovulation typically occurs 14 days before menstruation begins (A), and sexual
intercourse should occur within 24 hours of ovulation for conception to occur. High
estrogen levels occur during ovulation and increase the vaginal mucous membrane
characteristics, which become more "slippery" and stretchy, not (B). A rise in basal
temperature, not (C), signals ovulation. The timing during the day is not as significant in
determining conception as the day before and after ovulation (D).
Awarded 0.0 points out of 1.0 possible points.
8. 8.ID: 310959839
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse
why she becomes excessively diaphoretic and feels warm during nighttime. What is the
nurse’s best response?
o Explain the effect of the follicle-stimulating and luteinizing hormones.
o Discuss perimenopause and related comfort measures. Correct
o Assess lung fields and for a cough productive of blood-tinged mucous.
o Ask if a fever above 101º F has occurred in the last 24 hours. Incorrect
The perimenopausal period begins about 10 years before menopause with the cessation of
menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH
secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot
flashes, so discussions about the perimenopausal body's changes, comfort measures (B),
and treatment options should be provided. In-depth pathophysiology of the symptoms (A)
, may only confuse the client. There is no indication that the client has tuberculosis and an
infection, so (C and D) are not indicated.
Awarded 0.0 points out of 1.0 possible points.
9. 9.ID: 311023615
Which client should the nurse recognize as most likely to experience sleep apnea?
o Middle-aged female who takes a diuretic nightly.
o Obese older male client with a short, thick neck. Correct
o Adolescent female with a history of tonsillectomy.
o School-aged male with a history of hyperactivity disorder.
Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep
and is due to the loss of pharyngeal tone which allows the pharynx to collapse during
inspiration and obstructs air flow through the nose and mouth. With obstructive sleep
apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not
typically prone to sleep apnea.
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 310949492
The nurse is planning care for a client with newly diagnosed diabetes mellitus
that requires insulin. Which assessment should the nurse identify before
beginning the teaching session?
o Present knowledge related to the skill of injection.
o Intelligence and developmental level of the client.
o Willingness of the client to learn the injection sites. Correct
o Financial resources available for the equipment.
If a client is incapable or does not want to learn, it is unlikely that learning will occur, so
motivation is the first factor the nurse should assess before teaching (C). To determine
learning needs, the nurse should assess (A), but this is not the most important factor for
the nurse to assess. (B and D) are factors to consider, but not as vital as (C).
Awarded 1.0 points out of 1.0 possible points.
11. 11.ID: 310959881
The nurse is assessing a client's laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing
tumor lysis syndrome (TLS)?
o Serum PTT of 10 seconds.
o Serum calcium of 5 mg/dl. Correct
o Oxygen saturation of 90%.
o Hemoglobin of 10 g/dl.
