Swift River Med Surg Clinical Questions
and Answers Latest Version Already
Passed
A patient recovering from abdominal surgery reports feeling faint when sitting up. What is the
best first action?
✔✔ Assist the patient to lie back down and assess for orthostatic hypotension.
A patient newly diagnosed with Type 2 Diabetes is unsure how to check their blood glucose.
What is the nurse's priority?
✔✔ Demonstrate proper technique and allow the patient to perform a return demonstration.
A post-op patient has a respiratory rate of 10 breaths per minute after morphine administration.
What should the nurse do?
✔✔ Stop the opioid and assess oxygenation; notify the provider.
A patient reports redness and warmth around their IV site. What should the nurse do first?
✔✔ Discontinue the IV and initiate a new line in a different site.
1
,A patient with COPD is using accessory muscles to breathe and has oxygen saturation of 88%.
What is the next best nursing intervention?
✔✔ Administer prescribed bronchodilator and elevate the head of the bed.
A patient who had surgery 4 hours ago has not voided. What is the nurse’s best next step?
✔✔ Perform a bladder scan to assess for urinary retention.
A patient is experiencing new confusion and restlessness post-op. What should the nurse assess
first?
✔✔ Check oxygen saturation and rule out hypoxia.
A patient is receiving IV vancomycin and reports itching and flushing of the neck and chest.
What is the appropriate response?
✔✔ Stop the infusion and assess for Red Man Syndrome.
A patient with a new tracheostomy has thick secretions and audible gurgling. What should the
nurse do?
✔✔ Suction the tracheostomy using sterile technique.
2
,A patient with heart failure has gained 2.5 kg in three days. What should the nurse anticipate?
✔✔ Administration of a loop diuretic to remove excess fluid.
A post-surgical patient has not had a bowel movement in 4 days. What should the nurse suggest
first?
✔✔ Encourage increased fluid intake and ambulation.
A patient with pneumonia is receiving antibiotics but continues to spike a fever. What is the next
best nursing action?
✔✔ Obtain a new set of vital signs and notify the provider of persistent fever.
A patient with chronic renal failure reports metallic taste and itching. What lab should the nurse
check?
✔✔ Elevated BUN and creatinine.
A patient with a central line develops a fever and chills. What action should the nurse take
immediately?
✔✔ Stop infusions, draw blood cultures, and monitor for infection.
3
, A diabetic patient has a blood sugar reading of 42 mg/dL and is drowsy. What is the first nursing
intervention?
✔✔ Administer glucose per protocol and reassess glucose level in 15 minutes.
A patient reports dizziness after receiving furosemide. What is the most likely cause?
✔✔ Fluid volume depletion or hypotension; check blood pressure.
A patient newly started on warfarin asks how to monitor its effect. What should the nurse teach?
✔✔ Regular INR blood tests are needed to monitor therapeutic level.
A patient who received contrast dye for a CT scan reports difficulty urinating. What is the nurse's
priority assessment?
✔✔ Monitor kidney function through BUN and creatinine levels.
A patient is receiving blood and begins to complain of chest tightness and chills. What is the
nurse’s first action?
✔✔ Stop the transfusion and notify the provider immediately.
4
and Answers Latest Version Already
Passed
A patient recovering from abdominal surgery reports feeling faint when sitting up. What is the
best first action?
✔✔ Assist the patient to lie back down and assess for orthostatic hypotension.
A patient newly diagnosed with Type 2 Diabetes is unsure how to check their blood glucose.
What is the nurse's priority?
✔✔ Demonstrate proper technique and allow the patient to perform a return demonstration.
A post-op patient has a respiratory rate of 10 breaths per minute after morphine administration.
What should the nurse do?
✔✔ Stop the opioid and assess oxygenation; notify the provider.
A patient reports redness and warmth around their IV site. What should the nurse do first?
✔✔ Discontinue the IV and initiate a new line in a different site.
1
,A patient with COPD is using accessory muscles to breathe and has oxygen saturation of 88%.
What is the next best nursing intervention?
✔✔ Administer prescribed bronchodilator and elevate the head of the bed.
A patient who had surgery 4 hours ago has not voided. What is the nurse’s best next step?
✔✔ Perform a bladder scan to assess for urinary retention.
A patient is experiencing new confusion and restlessness post-op. What should the nurse assess
first?
✔✔ Check oxygen saturation and rule out hypoxia.
A patient is receiving IV vancomycin and reports itching and flushing of the neck and chest.
What is the appropriate response?
✔✔ Stop the infusion and assess for Red Man Syndrome.
A patient with a new tracheostomy has thick secretions and audible gurgling. What should the
nurse do?
✔✔ Suction the tracheostomy using sterile technique.
2
,A patient with heart failure has gained 2.5 kg in three days. What should the nurse anticipate?
✔✔ Administration of a loop diuretic to remove excess fluid.
A post-surgical patient has not had a bowel movement in 4 days. What should the nurse suggest
first?
✔✔ Encourage increased fluid intake and ambulation.
A patient with pneumonia is receiving antibiotics but continues to spike a fever. What is the next
best nursing action?
✔✔ Obtain a new set of vital signs and notify the provider of persistent fever.
A patient with chronic renal failure reports metallic taste and itching. What lab should the nurse
check?
✔✔ Elevated BUN and creatinine.
A patient with a central line develops a fever and chills. What action should the nurse take
immediately?
✔✔ Stop infusions, draw blood cultures, and monitor for infection.
3
, A diabetic patient has a blood sugar reading of 42 mg/dL and is drowsy. What is the first nursing
intervention?
✔✔ Administer glucose per protocol and reassess glucose level in 15 minutes.
A patient reports dizziness after receiving furosemide. What is the most likely cause?
✔✔ Fluid volume depletion or hypotension; check blood pressure.
A patient newly started on warfarin asks how to monitor its effect. What should the nurse teach?
✔✔ Regular INR blood tests are needed to monitor therapeutic level.
A patient who received contrast dye for a CT scan reports difficulty urinating. What is the nurse's
priority assessment?
✔✔ Monitor kidney function through BUN and creatinine levels.
A patient is receiving blood and begins to complain of chest tightness and chills. What is the
nurse’s first action?
✔✔ Stop the transfusion and notify the provider immediately.
4
