1
Medical-Surgical RN A Prophecy
Relias Exam (2025) – Latest Verified
Questions and Correct Answers |
Guaranteed Nursing Pass
1. A client with heart failure reports a 3 kg weight gain in 2 days. What should the
nurse prioritize?
a) Encourage fluid intake
b) Notify the healthcare provider
c) Restrict potassium
d) Administer analgesics
Rationale: Rapid weight gain (2–3 kg in days) indicates fluid retention in heart failure,
requiring immediate provider notification for diuretic adjustment, per Prophecy Relias
case management standards.
2. A client with a stage III pressure ulcer requires a dressing change. What should the
nurse prioritize?
a) Apply a dry gauze dressing
b) Use a moist wound dressing
c) Clean with alcohol
d) Leave the wound open to air
Rationale: Stage III pressure ulcers require moist dressings to promote healing and
prevent infection, per Prophecy Relias wound care standards.
3. Which vital sign finding requires immediate action in a post-operative client?
a) BP 120/80 mmHg
b) Pulse 110 bpm
c) Respiratory rate 16 breaths/min
d) Temperature 98.6°F
Rationale: A pulse of 110 bpm suggests tachycardia, possibly indicating hypovolemia or
pain, requiring immediate assessment, per Prophecy Relias vital signs standards.
4. A client reports severe chest pain after a myocardial infarction. What should the
nurse do first?
a) Encourage ambulation
b) Administer nitroglycerin as prescribed
c) Restrict fluids
d) Monitor temperature
Rationale: Nitroglycerin relieves angina by dilating coronary arteries, a priority in chest
pain, per Prophecy Relias pain management standards.
5. A client with COPD has an oxygen saturation of 86%. What is the priority action?
a) Restrict oxygen therapy
, 2
b) Increase oxygen as prescribed
c) Encourage coughing
d) Position supine
Rationale: An SpO2 of 86% indicates hypoxia, requiring oxygen adjustment to maintain
88–92% in COPD, per Prophecy Relias prioritization standards.
6. A client with a new colostomy asks about skin care. What should the nurse teach?
a) Use alcohol-based cleansers
b) Keep peristomal skin clean and dry
c) Avoid skin barriers
d) Restrict fluid intake
Rationale: Clean, dry peristomal skin prevents irritation and breakdown, per Prophecy
Relias patient education standards.
7. Which client should the nurse assess first?
a) A client with diabetes requesting a snack
b) A client with a BP of 180/100 mmHg
c) A client awaiting discharge instructions
d) A client with a temperature of 99°F
Rationale: Severe hypertension (180/100 mmHg) poses an immediate risk of stroke,
requiring urgent assessment, per Prophecy Relias prioritization standards.
8. A client with a surgical wound shows signs of dehiscence. What should the nurse do
first?
a) Apply a pressure dressing
b) Notify the healthcare provider
c) Clean with saline
d) Encourage ambulation
Rationale: Wound dehiscence is a surgical emergency, requiring immediate provider
notification, per Prophecy Relias wound care standards.
9. A client with pneumonia reports pain on inspiration. What should the nurse do?
a) Restrict fluids
b) Assess pain level and administer analgesics
c) Limit oxygen therapy
d) Position supine
Rationale: Pain on inspiration may indicate pleuritis; assessing and treating pain
improves comfort and breathing, per Prophecy Relias pain management standards.
10. A client’s telemetry shows ventricular tachycardia. What is the priority action?
a) Administer oxygen
b) Prepare for defibrillation
c) Monitor blood pressure
d) Encourage deep breathing
Rationale: Ventricular tachycardia is life-threatening, requiring immediate defibrillation,
per Prophecy Relias prioritization standards.
11. What should the nurse do to ensure patient safety during a blood transfusion?
a) Infuse over 6 hours
b) Verify client identity and blood type
c) Use a 22-gauge needle
d) Store blood at room temperature
Medical-Surgical RN A Prophecy
Relias Exam (2025) – Latest Verified
Questions and Correct Answers |
Guaranteed Nursing Pass
1. A client with heart failure reports a 3 kg weight gain in 2 days. What should the
nurse prioritize?
a) Encourage fluid intake
b) Notify the healthcare provider
c) Restrict potassium
d) Administer analgesics
Rationale: Rapid weight gain (2–3 kg in days) indicates fluid retention in heart failure,
requiring immediate provider notification for diuretic adjustment, per Prophecy Relias
case management standards.
2. A client with a stage III pressure ulcer requires a dressing change. What should the
nurse prioritize?
a) Apply a dry gauze dressing
b) Use a moist wound dressing
c) Clean with alcohol
d) Leave the wound open to air
Rationale: Stage III pressure ulcers require moist dressings to promote healing and
prevent infection, per Prophecy Relias wound care standards.
3. Which vital sign finding requires immediate action in a post-operative client?
a) BP 120/80 mmHg
b) Pulse 110 bpm
c) Respiratory rate 16 breaths/min
d) Temperature 98.6°F
Rationale: A pulse of 110 bpm suggests tachycardia, possibly indicating hypovolemia or
pain, requiring immediate assessment, per Prophecy Relias vital signs standards.
4. A client reports severe chest pain after a myocardial infarction. What should the
nurse do first?
a) Encourage ambulation
b) Administer nitroglycerin as prescribed
c) Restrict fluids
d) Monitor temperature
Rationale: Nitroglycerin relieves angina by dilating coronary arteries, a priority in chest
pain, per Prophecy Relias pain management standards.
5. A client with COPD has an oxygen saturation of 86%. What is the priority action?
a) Restrict oxygen therapy
, 2
b) Increase oxygen as prescribed
c) Encourage coughing
d) Position supine
Rationale: An SpO2 of 86% indicates hypoxia, requiring oxygen adjustment to maintain
88–92% in COPD, per Prophecy Relias prioritization standards.
6. A client with a new colostomy asks about skin care. What should the nurse teach?
a) Use alcohol-based cleansers
b) Keep peristomal skin clean and dry
c) Avoid skin barriers
d) Restrict fluid intake
Rationale: Clean, dry peristomal skin prevents irritation and breakdown, per Prophecy
Relias patient education standards.
7. Which client should the nurse assess first?
a) A client with diabetes requesting a snack
b) A client with a BP of 180/100 mmHg
c) A client awaiting discharge instructions
d) A client with a temperature of 99°F
Rationale: Severe hypertension (180/100 mmHg) poses an immediate risk of stroke,
requiring urgent assessment, per Prophecy Relias prioritization standards.
8. A client with a surgical wound shows signs of dehiscence. What should the nurse do
first?
a) Apply a pressure dressing
b) Notify the healthcare provider
c) Clean with saline
d) Encourage ambulation
Rationale: Wound dehiscence is a surgical emergency, requiring immediate provider
notification, per Prophecy Relias wound care standards.
9. A client with pneumonia reports pain on inspiration. What should the nurse do?
a) Restrict fluids
b) Assess pain level and administer analgesics
c) Limit oxygen therapy
d) Position supine
Rationale: Pain on inspiration may indicate pleuritis; assessing and treating pain
improves comfort and breathing, per Prophecy Relias pain management standards.
10. A client’s telemetry shows ventricular tachycardia. What is the priority action?
a) Administer oxygen
b) Prepare for defibrillation
c) Monitor blood pressure
d) Encourage deep breathing
Rationale: Ventricular tachycardia is life-threatening, requiring immediate defibrillation,
per Prophecy Relias prioritization standards.
11. What should the nurse do to ensure patient safety during a blood transfusion?
a) Infuse over 6 hours
b) Verify client identity and blood type
c) Use a 22-gauge needle
d) Store blood at room temperature
