NUR 1211 MEDICAL SURGICAL EXAM SCRIPT 2025/2026
QUESTIONS WITH ANSWERS GRADED A+
✔✔A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the physician
with which treatment? - ✔✔Perform synchronized cardioversion.
Rationale: With uncontrolled atrial fibrillation, the treatment of choice is synchronized
cardioversion to convert the cardiac rhythm back to normal sinus rhythm.
✔✔The post-operative client states to the nurse, "I hate the feeling of those
compression stockings as they inflate and deflate all the time. It keeps me awake."
What is the nurse's best response? - ✔✔"Tell me what you know about the intermittent
compression stockings."
Rationale:The purpose of the intermittent compression stockings is to decrease the risk
of blood clots forming in the legs. By assessing the client's knowledge about the devise,
the nurse can determine if the client is aware of the potential for blood clots and the
sequela that clots have.
✔✔Which condition should the nurse anticipate as a potential problem in a female client
with a neurogenic bladder? - ✔✔Infection
Rationale: Infection is the major complication resulting from stasis of urine and
subsequent catheterization.
✔✔Zolpidem tartrate, 1.75 mg PRN at bedtime, is prescribed for rest. The scored
tablets are labeled 3.5 mg per tablet. What dose should the nurse plan to
administer?____________ - ✔✔Rationale:1.75 is ordered. 3.5 is available. 1.75/3.5
time one tab equals. 0.5 or one half tablet.
✔✔The nurse is concerned about infection for a client after an esophagogastrostomy for
esophageal cancer. Which actions should the nurse include in the client's plan of care?
(Select all that apply.) - ✔✔-Frequent oral care every 2 hours while awake.
-Use incentive spirometer every 2 hours.
-Empty contents from NG tube every 8 hours.
Rationale:One hour post op is too soon to ambulate for this client. Visitors help support
the patient and are encouraged to visit. Oral care is necessary as the client will be NPO.
To decrease the risk of infection post operatively, implement routine pulmonary
exercises. The client will have an NG tube in place, likely to intermittent suction, to
decompress the stomach post surgery.
,✔✔Which data would the nurse expect to find when reviewing laboratory values of an
80-year-old who is in good health overall? - ✔✔Urinalysis reveals slight protein in the
urine and bacteriuria, with pyuria.
Rationale:In older adults, the protein found in urine slightly rises, probably as a result of
kidney changes or subclinical urinary tract infections, and clients frequently experience
asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying.
✔✔The nurse on a medical-surgical unit is receiving a client from the postanesthesia
care unit (PACU) with a Penrose drain. Before choosing a room for this client, which
information is most important for the nurse to obtain? - ✔✔If the client's wound is
infected
Rationale: The fact that the client has a Penrose drain should alert the nurse to the
possibility that the surgical wound is infected. Penrose drains provide a sinus tract or
opening and are often used to provide drainage of an abscess. To avoid contamination
of another postoperative client, it is most important to place any client with an infected
wound in a private room.
✔✔The nurse is planning care for a client with diabetes mellitus who has gangrene of
the toes to the midfoot. Which goal should be included in this client's plan of care? -
✔✔Prevent infection.
Rationale: The prevention of infection is a priority goal for this client. Gangrene is the
result of necrosis (tissue death). If infection develops, there is insufficient circulation to
fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue
death has already occurred
✔✔The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention? - ✔✔Deep
unrelenting pain in the right arm
Rationale: Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
uncontrolled by opioids and neurovascular compromise.
✔✔A client is placed on a mechanical ventilator following a cerebral hemorrhage. What
are the priority nursing actions for this client? (Select all that apply.) - ✔✔-Assess lung
sounds.
-Look for equal and bilateral expansion of the chest.
-Monitor skin color.
-Evaluate the need for suctioning.
-Make sure the ventilator alarms are set.
,Rationale:The outcome of the client is too early to relay to the family. The nurse must
not offer false reassurance. The remaining actions are correct for a client on a
ventilator.
✔✔During the change of shift report, the charge nurse reviews the infusions being
received by clients on the oncology unit. The client receiving which infusion should be
assessed first? - ✔✔Continuous epidural infusion of morphine
Rationale: The client with the morphine epidural infusion is at highest risk for respiratory
depression and should be assessed first.
✔✔The nurse is caring for a client who is one day post-acute myocardial infarction. The
client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock.
The nurse notes that the client is having eight premature ventricular contractions
(PVCs) per minute. Which action should the nurse take first? - ✔✔Increase the client's
oxygen flow rate.
Rationale: Increasing the oxygen flow rate provides more oxygen to the client's
myocardium and may decrease myocardial irritability as manifested by the frequent
PVCs.
✔✔The nurse in the emergency room assesses a client with a head trauma and notes a
Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the
client's safety? (Select all that apply.) - ✔✔-Assess airway and suction secretions as
needed.
-Change the client's position every 2 hours.
-Monitor for drainage from the ears.
Rationale:The client should be at least sitting at a 45 degree angle to avoid aspiration
and increased intracranial pressure. Provide frequent mouth care as the client is unable
to do so at this time. The remaining actions are appropriate for the client with a GCS
score of 5.
✔✔While at a home game, the mother of a 6-year-old is heard screaming, "My child is
having an asthma attack! Can anyone help?" The nurse arrives and finds the child
gasping for breath with circumoral cyanosis. What are the nurse's next actions? (Select
all that apply.) - ✔✔-Yell, "Call 911."
-Ask the mother if she has the child's bronchodilator.
-Stay with the child and mother until the ambulance arrives.
-Sit the child straight up in Fowler's position.
Rationale:CPR is not needed at this time as the child is still moving air. An allergy to
bee stings is related to anaphylactic shock, which is not the situation here. The
remaining actions are correct for asthma.
, ✔✔A 77-year-old client is admitted to the hospital with confusion and anorexia of
several days' duration. Additional symptoms reported are nausea and vomiting, and
current complaints of a headache. The client's pulse rate is 43 beats/min. The nurse is
most concerned about the client's history related to which medication? - ✔✔Digoxin
Rationale: Older persons are particularly susceptible to the buildup of cardiac
glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic
level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea,
headache, and fatigue.
✔✔A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an
ulcer on the heel of the left foot that has not healed with wound care. The nurse
observes that the entire left foot is darker in color than the right foot. Which additional
symptom should the nurse expect to find? - ✔✔Pedal pulses will be weak or absent in
the left foot.
Rationale: Symptoms associated with decreased blood supply are weak or absent pedal
and tibial pulses. The client with diabetes experiences vascular scarring as a result of
atherosclerotic changes in the peripheral vessels. This results in compromised
perfusion to the dependent extremities, which further delays wound healing in the
affected foot.
✔✔A central venous catheter has been inserted via a jugular vein, and a radiograph has
confirmed placement of the catheter. A prescription has been received for a medication
STAT, but IV fluids have not yet been started. Which action should the nurse take prior
to administering the prescribed medication? - ✔✔Flush the line with normal saline.
Rationale: Medication can be administered via a central line without additional IV fluids.
The line should first be flushed with a normal saline solution to ensure patency.
Insufficient evidence exists on the effectiveness of flushing catheters with heparin.
✔✔What is the correct location for placement of the hands for manual chest
compressions during cardiopulmonary resuscitation (CPR) on the adult client? - ✔✔Just
above the xiphoid process, on the lower third of the sternum
Rationale:The correct placement of the hands for chest compressions in CPR is just
above the notch where the ribs meet the sternum on the lower part of the sternum.
✔✔The nurse is observing an unlicensed assistive personnel (UAP) performing care for
a bedridden client with advanced Huntington disease. Which care measures are most
important for the nurse to supervise? (Select all that apply.) - ✔✔-Oral care
-Enteral feeding
QUESTIONS WITH ANSWERS GRADED A+
✔✔A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the physician
with which treatment? - ✔✔Perform synchronized cardioversion.
Rationale: With uncontrolled atrial fibrillation, the treatment of choice is synchronized
cardioversion to convert the cardiac rhythm back to normal sinus rhythm.
✔✔The post-operative client states to the nurse, "I hate the feeling of those
compression stockings as they inflate and deflate all the time. It keeps me awake."
What is the nurse's best response? - ✔✔"Tell me what you know about the intermittent
compression stockings."
Rationale:The purpose of the intermittent compression stockings is to decrease the risk
of blood clots forming in the legs. By assessing the client's knowledge about the devise,
the nurse can determine if the client is aware of the potential for blood clots and the
sequela that clots have.
✔✔Which condition should the nurse anticipate as a potential problem in a female client
with a neurogenic bladder? - ✔✔Infection
Rationale: Infection is the major complication resulting from stasis of urine and
subsequent catheterization.
✔✔Zolpidem tartrate, 1.75 mg PRN at bedtime, is prescribed for rest. The scored
tablets are labeled 3.5 mg per tablet. What dose should the nurse plan to
administer?____________ - ✔✔Rationale:1.75 is ordered. 3.5 is available. 1.75/3.5
time one tab equals. 0.5 or one half tablet.
✔✔The nurse is concerned about infection for a client after an esophagogastrostomy for
esophageal cancer. Which actions should the nurse include in the client's plan of care?
(Select all that apply.) - ✔✔-Frequent oral care every 2 hours while awake.
-Use incentive spirometer every 2 hours.
-Empty contents from NG tube every 8 hours.
Rationale:One hour post op is too soon to ambulate for this client. Visitors help support
the patient and are encouraged to visit. Oral care is necessary as the client will be NPO.
To decrease the risk of infection post operatively, implement routine pulmonary
exercises. The client will have an NG tube in place, likely to intermittent suction, to
decompress the stomach post surgery.
,✔✔Which data would the nurse expect to find when reviewing laboratory values of an
80-year-old who is in good health overall? - ✔✔Urinalysis reveals slight protein in the
urine and bacteriuria, with pyuria.
Rationale:In older adults, the protein found in urine slightly rises, probably as a result of
kidney changes or subclinical urinary tract infections, and clients frequently experience
asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying.
✔✔The nurse on a medical-surgical unit is receiving a client from the postanesthesia
care unit (PACU) with a Penrose drain. Before choosing a room for this client, which
information is most important for the nurse to obtain? - ✔✔If the client's wound is
infected
Rationale: The fact that the client has a Penrose drain should alert the nurse to the
possibility that the surgical wound is infected. Penrose drains provide a sinus tract or
opening and are often used to provide drainage of an abscess. To avoid contamination
of another postoperative client, it is most important to place any client with an infected
wound in a private room.
✔✔The nurse is planning care for a client with diabetes mellitus who has gangrene of
the toes to the midfoot. Which goal should be included in this client's plan of care? -
✔✔Prevent infection.
Rationale: The prevention of infection is a priority goal for this client. Gangrene is the
result of necrosis (tissue death). If infection develops, there is insufficient circulation to
fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue
death has already occurred
✔✔The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention? - ✔✔Deep
unrelenting pain in the right arm
Rationale: Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
uncontrolled by opioids and neurovascular compromise.
✔✔A client is placed on a mechanical ventilator following a cerebral hemorrhage. What
are the priority nursing actions for this client? (Select all that apply.) - ✔✔-Assess lung
sounds.
-Look for equal and bilateral expansion of the chest.
-Monitor skin color.
-Evaluate the need for suctioning.
-Make sure the ventilator alarms are set.
,Rationale:The outcome of the client is too early to relay to the family. The nurse must
not offer false reassurance. The remaining actions are correct for a client on a
ventilator.
✔✔During the change of shift report, the charge nurse reviews the infusions being
received by clients on the oncology unit. The client receiving which infusion should be
assessed first? - ✔✔Continuous epidural infusion of morphine
Rationale: The client with the morphine epidural infusion is at highest risk for respiratory
depression and should be assessed first.
✔✔The nurse is caring for a client who is one day post-acute myocardial infarction. The
client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock.
The nurse notes that the client is having eight premature ventricular contractions
(PVCs) per minute. Which action should the nurse take first? - ✔✔Increase the client's
oxygen flow rate.
Rationale: Increasing the oxygen flow rate provides more oxygen to the client's
myocardium and may decrease myocardial irritability as manifested by the frequent
PVCs.
✔✔The nurse in the emergency room assesses a client with a head trauma and notes a
Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the
client's safety? (Select all that apply.) - ✔✔-Assess airway and suction secretions as
needed.
-Change the client's position every 2 hours.
-Monitor for drainage from the ears.
Rationale:The client should be at least sitting at a 45 degree angle to avoid aspiration
and increased intracranial pressure. Provide frequent mouth care as the client is unable
to do so at this time. The remaining actions are appropriate for the client with a GCS
score of 5.
✔✔While at a home game, the mother of a 6-year-old is heard screaming, "My child is
having an asthma attack! Can anyone help?" The nurse arrives and finds the child
gasping for breath with circumoral cyanosis. What are the nurse's next actions? (Select
all that apply.) - ✔✔-Yell, "Call 911."
-Ask the mother if she has the child's bronchodilator.
-Stay with the child and mother until the ambulance arrives.
-Sit the child straight up in Fowler's position.
Rationale:CPR is not needed at this time as the child is still moving air. An allergy to
bee stings is related to anaphylactic shock, which is not the situation here. The
remaining actions are correct for asthma.
, ✔✔A 77-year-old client is admitted to the hospital with confusion and anorexia of
several days' duration. Additional symptoms reported are nausea and vomiting, and
current complaints of a headache. The client's pulse rate is 43 beats/min. The nurse is
most concerned about the client's history related to which medication? - ✔✔Digoxin
Rationale: Older persons are particularly susceptible to the buildup of cardiac
glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic
level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea,
headache, and fatigue.
✔✔A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an
ulcer on the heel of the left foot that has not healed with wound care. The nurse
observes that the entire left foot is darker in color than the right foot. Which additional
symptom should the nurse expect to find? - ✔✔Pedal pulses will be weak or absent in
the left foot.
Rationale: Symptoms associated with decreased blood supply are weak or absent pedal
and tibial pulses. The client with diabetes experiences vascular scarring as a result of
atherosclerotic changes in the peripheral vessels. This results in compromised
perfusion to the dependent extremities, which further delays wound healing in the
affected foot.
✔✔A central venous catheter has been inserted via a jugular vein, and a radiograph has
confirmed placement of the catheter. A prescription has been received for a medication
STAT, but IV fluids have not yet been started. Which action should the nurse take prior
to administering the prescribed medication? - ✔✔Flush the line with normal saline.
Rationale: Medication can be administered via a central line without additional IV fluids.
The line should first be flushed with a normal saline solution to ensure patency.
Insufficient evidence exists on the effectiveness of flushing catheters with heparin.
✔✔What is the correct location for placement of the hands for manual chest
compressions during cardiopulmonary resuscitation (CPR) on the adult client? - ✔✔Just
above the xiphoid process, on the lower third of the sternum
Rationale:The correct placement of the hands for chest compressions in CPR is just
above the notch where the ribs meet the sternum on the lower part of the sternum.
✔✔The nurse is observing an unlicensed assistive personnel (UAP) performing care for
a bedridden client with advanced Huntington disease. Which care measures are most
important for the nurse to supervise? (Select all that apply.) - ✔✔-Oral care
-Enteral feeding
