NURS 320 MED SURGE ACTUAL
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALE (GRADED A+) | NEW
2025
Which meal option should the nurse select for a patient on a low-sodium diet?
a. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers and
iced tea
b. Spaghetti with sausage, green salad, hard-crust bread, and diet cola
c. Baked chicken, corn on the cob, dinner roll, and milk
d. Steak, broccoli with cheese sauce, crackers and hot tea - ANSWER C
A nurse receives a phone call that patient is extremely upset, angry and learns
from the patient that he has a gun on the table. Which action is most appropriate
by the nurse?
a. Use therapeutic communication and allow the patient to vent his feelings
b. Elicit from the patient any plan for self harm
c. Remind the patient that killing himself is not the way to handle problems
d. Keep the patient talking while another nurse contacts the police - ANSWER
D
After tripping over a rug in the house, the patient arrives in the ER with a sprained
ankle along with minor swelling and foot abrasions. What rationale explains why
the nurse should apply cold therapy to the area immediately after the injury?
a. Reduce the body's temperature
b. Increase circulation to the area
,c. Aid in resorbing the edema
d. Relieve pain and control bleeding - ANSWER D
The patient reports having frequent episodes of palpitations but denies having
chest pain. Which follow-up question would be best for the nurse to ask in order
to assess the patient's condition?
a. Have you noticed shortness of breath when lying flat?
b. Do your shoes feel unusually tight?
c. Do you feel dizzy or lightheaded?
d. Does anyone in your family have a history of palpitations or heart disease? -
ANSWER C
rationale: Focus on palpitations which does circulation of the body
When caring for an immobile client, which diagnosis is priority? Risk for...
a. Fluid Volume Deficit
b. Impaired Gas Exchange
c. Impaired Skin Integrity
d. Altered Tissue Perfusion - ANSWER B
rationale: Priority! Worst for Fluid Volume Deficit is dehydration, Impaired Gas
Exchange is no being able to breathe, Impaired Skin Integrity is pressure ulcer/skin
breakdown, and Altered Tissue Perfusion is circulation which is not as important
as not being able to breathe
What should the nurse do next when a patient demonstrated labored shallow
respirations and a respiratory rate of 32/min with a pulse oximetry of 85%?
a. Assess the lung sounds
,b. Place in high fowler's position
c. Notify the physician and request a breathing treatment
d. Encourage cough and deep breathing - ANSWER B
Which action should the nurse perform first when caring for a client who begins to
experience a sudden onset of chest pain, shortness of breath, wheezing, cough
and watery eyes and the nurse suspects an allergic reaction?
a. Transfer the patient to the intensive care unit
b. Remove all allergens from the room
c. Notify the doctor
d. Administer Epinephrine
e. Assess the pulse ox - ANSWER D
rationale: If you see to administer something, you pick that answer. From now on,
you can assume you have everything. You can transfer patient to ICU if the
epinephrine doesn't work. You can remove all allergens but not first. You can
notify the doctor if there's nothing else you can do as a nurse, which is to provide
the best care for the patient. You don't need the pulse ox to know that the patient
is having an anaphylaxis reaction.
A triage nurse, working in the Emergency Room received four admissions. Which
patient should the nurse see first?
a. A 40 year old client who is diaphoretic and complains of chest pain
b. A 18 year old client who thinks he might have a broken tooth from playin
football
c. A 35 year old client who cut her finger with a knife while preparing food
d. A 60 year old client who is dyspneic and has swollen lips after being stung by a
bee - ANSWER D
, rationale: Dyspneic- not breathing or able to breath except with difficulty; ABCs =
1st priority
Which patient should the emergency room nurse list as urgent?
a. Patient A admitted to ER with chest discomfort and shortness of breath
b. Patient B admitted with slurred speech and left side weakness
c. Patient C admitted with abdominal pain and right-sided rebound tenderness
d. Patient D admitted with ear pain and sinus congestion with fever - ANSWER
C
rationale: Appendicitis: rebound tenderness -- not emergent but urgent; Patient A
is having a heart attack which is emergent
A 58 year old patient presents in the ER a BP of 210/140, vomiting and confusion.
Which category should the nurse assign to this patient?
a. Urgent
b. Non-urgent
c. Emergent
d. Semi-urgent - ANSWER C
The registered nurse (RN) requests the unlicensed assistive personnel (UAP)
ambulate a patient with orthostatic hypotension and weakness, up and down the
hall after breakfast and lunch for 10 minutes and to report back when task
completed. Which right of delegation did the RN violate?
a. Right task
b. Right circumstance
c. Right direction
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALE (GRADED A+) | NEW
2025
Which meal option should the nurse select for a patient on a low-sodium diet?
a. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers and
iced tea
b. Spaghetti with sausage, green salad, hard-crust bread, and diet cola
c. Baked chicken, corn on the cob, dinner roll, and milk
d. Steak, broccoli with cheese sauce, crackers and hot tea - ANSWER C
A nurse receives a phone call that patient is extremely upset, angry and learns
from the patient that he has a gun on the table. Which action is most appropriate
by the nurse?
a. Use therapeutic communication and allow the patient to vent his feelings
b. Elicit from the patient any plan for self harm
c. Remind the patient that killing himself is not the way to handle problems
d. Keep the patient talking while another nurse contacts the police - ANSWER
D
After tripping over a rug in the house, the patient arrives in the ER with a sprained
ankle along with minor swelling and foot abrasions. What rationale explains why
the nurse should apply cold therapy to the area immediately after the injury?
a. Reduce the body's temperature
b. Increase circulation to the area
,c. Aid in resorbing the edema
d. Relieve pain and control bleeding - ANSWER D
The patient reports having frequent episodes of palpitations but denies having
chest pain. Which follow-up question would be best for the nurse to ask in order
to assess the patient's condition?
a. Have you noticed shortness of breath when lying flat?
b. Do your shoes feel unusually tight?
c. Do you feel dizzy or lightheaded?
d. Does anyone in your family have a history of palpitations or heart disease? -
ANSWER C
rationale: Focus on palpitations which does circulation of the body
When caring for an immobile client, which diagnosis is priority? Risk for...
a. Fluid Volume Deficit
b. Impaired Gas Exchange
c. Impaired Skin Integrity
d. Altered Tissue Perfusion - ANSWER B
rationale: Priority! Worst for Fluid Volume Deficit is dehydration, Impaired Gas
Exchange is no being able to breathe, Impaired Skin Integrity is pressure ulcer/skin
breakdown, and Altered Tissue Perfusion is circulation which is not as important
as not being able to breathe
What should the nurse do next when a patient demonstrated labored shallow
respirations and a respiratory rate of 32/min with a pulse oximetry of 85%?
a. Assess the lung sounds
,b. Place in high fowler's position
c. Notify the physician and request a breathing treatment
d. Encourage cough and deep breathing - ANSWER B
Which action should the nurse perform first when caring for a client who begins to
experience a sudden onset of chest pain, shortness of breath, wheezing, cough
and watery eyes and the nurse suspects an allergic reaction?
a. Transfer the patient to the intensive care unit
b. Remove all allergens from the room
c. Notify the doctor
d. Administer Epinephrine
e. Assess the pulse ox - ANSWER D
rationale: If you see to administer something, you pick that answer. From now on,
you can assume you have everything. You can transfer patient to ICU if the
epinephrine doesn't work. You can remove all allergens but not first. You can
notify the doctor if there's nothing else you can do as a nurse, which is to provide
the best care for the patient. You don't need the pulse ox to know that the patient
is having an anaphylaxis reaction.
A triage nurse, working in the Emergency Room received four admissions. Which
patient should the nurse see first?
a. A 40 year old client who is diaphoretic and complains of chest pain
b. A 18 year old client who thinks he might have a broken tooth from playin
football
c. A 35 year old client who cut her finger with a knife while preparing food
d. A 60 year old client who is dyspneic and has swollen lips after being stung by a
bee - ANSWER D
, rationale: Dyspneic- not breathing or able to breath except with difficulty; ABCs =
1st priority
Which patient should the emergency room nurse list as urgent?
a. Patient A admitted to ER with chest discomfort and shortness of breath
b. Patient B admitted with slurred speech and left side weakness
c. Patient C admitted with abdominal pain and right-sided rebound tenderness
d. Patient D admitted with ear pain and sinus congestion with fever - ANSWER
C
rationale: Appendicitis: rebound tenderness -- not emergent but urgent; Patient A
is having a heart attack which is emergent
A 58 year old patient presents in the ER a BP of 210/140, vomiting and confusion.
Which category should the nurse assign to this patient?
a. Urgent
b. Non-urgent
c. Emergent
d. Semi-urgent - ANSWER C
The registered nurse (RN) requests the unlicensed assistive personnel (UAP)
ambulate a patient with orthostatic hypotension and weakness, up and down the
hall after breakfast and lunch for 10 minutes and to report back when task
completed. Which right of delegation did the RN violate?
a. Right task
b. Right circumstance
c. Right direction
