Medical Surgical Nursing Exam 2
with Q&A 100% Verified
(Guarantee A+) 2025/2026
1. After a cerebrovascular accident, a 75 yr old client is admitted to the
health care facility. The client has left-sided weakness and an absent gag
reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50
mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority
for this client?
A. checking stools for occult blood
B. performing range-of-motion exercises to the left side
C. keeping skin clean and dry
D. elevating the head of the bed to 30 degrees
2. The nurse is caring for a client with a colostomy. The client tells the
nurse that he makes small pin holes in the drainage bag to help relieve gas.
The nurse should teach him that this action:
A. destroys the odor-proof seal
B. wont affect the colostomy system
, C. is appropriate for relieving the gas in a colostomy system
D. destroys the moisture barrier seal
3. When assessing the client with celiac disease, the nurse can expect to
find which of the following?
A. steatorrhea
B. jaundiced sclerae
C. clay-colored stools
D. widened pulse pressure
4. A client is hospitalized with a diagnosis of chronic glomerulonephritis.
The client mentions that she likes salty foods. The nurse should warn her
to avoid foods containing sodium because:
A. reducing sodium promotes urea nitrogen excretion
B. reducing sodium improves her glomerular filtration rate
C. reducing sodium increases potassium absorption
D. reducing sodium decreases edema
5. The nurse is caring for a client with a cerebral injury that impaired his
speech and hearing. Most likely, the client has experienced damage to the:
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
6. The nurse is assessing a postcraniotomy client and finds the urine
output from a catheter is 1500 ml for the 1st hour and the same for the
2nd hour. The nurse should suspect:
A. Cushing’s syndrome
B. Diabetes mellitus
C. Adrenal crisis
, D. Diabetes insipidus
7. The nurse is providing postprocedure care for a client who underwent
percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted
through a nephrostomy tube into the renal pelvis generates ultra-high-
frequency sound waves to shatter renal calculi. The nurse should instruct
the client to:
A. limit oral fluid intake for 1 to 2 weeks
B. report the presence of fine, sandlike particles through the
nephrostomy tube.
C. Notify the physician about cloudy or foul smelling urine
D. Report bright pink urine within 24 hours after the procedure
8. A client with a serum glucose level of 618 mg/dl is admitted to the
facility. He’s awake and oriented, has hot dry skin, and has the following
vital signs: temperature of 100.6º F (38.1º C), heart rate of 116
beats/minute, and blood pressure of 108/70 mm Hg. Based on these
assessment findings, which nursing diagnosis takes the highest priority?
A. deficient fluid volume related to osmotic diuresis
B. decreased cardiac output related to elevated heart rate
C. imbalanced nutrition: Less than body requirements related to
insulin deficiency
D. ineffective thermoregulation related to dehydration
9. Capillary glucose monitoring is being performed every 4 hours for a
client diagnosed with diabetic ketoacidosis. Insulin is administered using
a scale of regular insulin according to glucose results. At 2 p.m., the client
has a capillary glucose level of 250 mg/dl for which he receives 8 U of
regular insulin. The
nurse should expect the dose’s:
, A. onset to be at 2 p.m. and its peak at 3 p.m.
B. onset to be at 2:15 p.m. and its peak at 3 p.m.
C. onset to be at 2:30 p.m. and its peak at 4 p.m.
D. onset to be at 4 p.m. and its peak at 6 p.m.
10. A client with a head injury is being monitored for increased
intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the
ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg
11. A 52 yr-old female tells the nurse that she has found a painless lump
in her right breast during her monthly self-examination. Which
assessment finding would strongly suggest that this client’s lump is
cancerous?
A. eversion of the right nipple and a mobile mass
B. nonmobile mass with irregular edges
C. mobile mass that is oft and easily delineated
D. nonpalpable right axillary lymph nodes
12. A Client is scheduled to have a descending colostomy. He’s very
anxious and has many questions regarding the surgical procedure, care of
stoma, and lifestyle changes. It would be most appropriate for the nurse
to make a referral to which member of the health care team?
A. Social worker
B. registered dietician
C. occupational therapist
D. enterostomal nurse therapist
with Q&A 100% Verified
(Guarantee A+) 2025/2026
1. After a cerebrovascular accident, a 75 yr old client is admitted to the
health care facility. The client has left-sided weakness and an absent gag
reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50
mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority
for this client?
A. checking stools for occult blood
B. performing range-of-motion exercises to the left side
C. keeping skin clean and dry
D. elevating the head of the bed to 30 degrees
2. The nurse is caring for a client with a colostomy. The client tells the
nurse that he makes small pin holes in the drainage bag to help relieve gas.
The nurse should teach him that this action:
A. destroys the odor-proof seal
B. wont affect the colostomy system
, C. is appropriate for relieving the gas in a colostomy system
D. destroys the moisture barrier seal
3. When assessing the client with celiac disease, the nurse can expect to
find which of the following?
A. steatorrhea
B. jaundiced sclerae
C. clay-colored stools
D. widened pulse pressure
4. A client is hospitalized with a diagnosis of chronic glomerulonephritis.
The client mentions that she likes salty foods. The nurse should warn her
to avoid foods containing sodium because:
A. reducing sodium promotes urea nitrogen excretion
B. reducing sodium improves her glomerular filtration rate
C. reducing sodium increases potassium absorption
D. reducing sodium decreases edema
5. The nurse is caring for a client with a cerebral injury that impaired his
speech and hearing. Most likely, the client has experienced damage to the:
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
6. The nurse is assessing a postcraniotomy client and finds the urine
output from a catheter is 1500 ml for the 1st hour and the same for the
2nd hour. The nurse should suspect:
A. Cushing’s syndrome
B. Diabetes mellitus
C. Adrenal crisis
, D. Diabetes insipidus
7. The nurse is providing postprocedure care for a client who underwent
percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted
through a nephrostomy tube into the renal pelvis generates ultra-high-
frequency sound waves to shatter renal calculi. The nurse should instruct
the client to:
A. limit oral fluid intake for 1 to 2 weeks
B. report the presence of fine, sandlike particles through the
nephrostomy tube.
C. Notify the physician about cloudy or foul smelling urine
D. Report bright pink urine within 24 hours after the procedure
8. A client with a serum glucose level of 618 mg/dl is admitted to the
facility. He’s awake and oriented, has hot dry skin, and has the following
vital signs: temperature of 100.6º F (38.1º C), heart rate of 116
beats/minute, and blood pressure of 108/70 mm Hg. Based on these
assessment findings, which nursing diagnosis takes the highest priority?
A. deficient fluid volume related to osmotic diuresis
B. decreased cardiac output related to elevated heart rate
C. imbalanced nutrition: Less than body requirements related to
insulin deficiency
D. ineffective thermoregulation related to dehydration
9. Capillary glucose monitoring is being performed every 4 hours for a
client diagnosed with diabetic ketoacidosis. Insulin is administered using
a scale of regular insulin according to glucose results. At 2 p.m., the client
has a capillary glucose level of 250 mg/dl for which he receives 8 U of
regular insulin. The
nurse should expect the dose’s:
, A. onset to be at 2 p.m. and its peak at 3 p.m.
B. onset to be at 2:15 p.m. and its peak at 3 p.m.
C. onset to be at 2:30 p.m. and its peak at 4 p.m.
D. onset to be at 4 p.m. and its peak at 6 p.m.
10. A client with a head injury is being monitored for increased
intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the
ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg
11. A 52 yr-old female tells the nurse that she has found a painless lump
in her right breast during her monthly self-examination. Which
assessment finding would strongly suggest that this client’s lump is
cancerous?
A. eversion of the right nipple and a mobile mass
B. nonmobile mass with irregular edges
C. mobile mass that is oft and easily delineated
D. nonpalpable right axillary lymph nodes
12. A Client is scheduled to have a descending colostomy. He’s very
anxious and has many questions regarding the surgical procedure, care of
stoma, and lifestyle changes. It would be most appropriate for the nurse
to make a referral to which member of the health care team?
A. Social worker
B. registered dietician
C. occupational therapist
D. enterostomal nurse therapist
