Medical-Surgical Nursing — 200
Short-Answer Questions & Answers
solutions ( 2025 _2026)
Questions 1–200
1. (Ch 1) What is the primary goal of the nursing process? — To provide individualized,
goal-directed care through assessment, diagnosis, planning, implementation, and
evaluation. — Rationale: The nursing process is a systematic method that organizes
care and ensures continuity and evaluation of outcomes.
2. (Ch 1) Name two essential components of a comprehensive health history. — Chief
complaint and past medical history. — Rationale: These provide the reason for seeking
care and context for current health problems.
3. (Ch 2) What is a priority nursing action for a patient with suspected hypovolemia? —
Assess vital signs and peripheral perfusion; initiate IV fluids per order. — Rationale:
Rapid assessment identifies hemodynamic instability and IV fluids restore circulating
volume.
4. (Ch 2) List one lab test useful to evaluate hydration status. — Serum sodium. —
Rationale: Sodium concentration can indicate hyper- or hyponatremia related to fluid
balance.
5. (Ch 3) What isolation precautions are required for a patient with active pulmonary
tuberculosis? — Airborne precautions with N95 respirator and negative-pressure room.
— Rationale: TB spreads via droplet nuclei small enough to remain airborne; special
ventilation and respirators protect staff.
6. (Ch 3) How long should standard handwashing last for visible soiling? — At least 40–60
seconds with soap and water. — Rationale: Longer washing removes visible
contamination better than quick washing or hand sanitizer alone.
7. (Ch 4) Name a common side effect of opioid analgesics that nurses must monitor. —
Respiratory depression. — Rationale: Opioids depress the respiratory center; monitoring
, prevents hypoventilation and hypoxia.
8. (Ch 4) What is the antidote for opioid overdose? — Naloxone (Narcan). — Rationale:
Naloxone is an opioid antagonist that reverses respiratory depression.
9. (Ch 5) What assessment finding indicates increased intracranial pressure (ICP)? —
Decreased level of consciousness and papilledema. — Rationale: Rising ICP impairs
cerebral perfusion, causing altered mentation and optic disc swelling.
10.(Ch 5) Describe one nursing priority for a patient with suspected stroke. — Obtain CT
scan immediately to differentiate ischemic vs hemorrhagic stroke. — Rationale: Imaging
guides therapy (e.g., thrombolytics are indicated for ischemic stroke only).
11.(Ch 6) What electrolyte imbalance is most concerning with severe vomiting? —
Metabolic alkalosis with hypochloremia and possible hypokalemia. — Rationale: Loss of
gastric acid raises pH and depletes chloride and potassium.
12.(Ch 6) Name one immediate nursing action for a patient with hypokalemia. — Cardiac
monitoring and replace potassium per protocol. — Rationale: Hypokalemia predisposes
to arrhythmias; monitoring and replacement reduce risk.
13.(Ch 7) What is the normal range for fasting blood glucose in adults? — Approximately
70–99 mg/dL. — Rationale: Values above indicate impaired fasting glucose or diabetes;
used for screening and diagnosis.
14.(Ch 7) For a type 1 diabetic in DKA, what is a key nursing priority? — Administer IV
insulin and monitor potassium closely. — Rationale: Insulin shifts potassium into cells,
risking hypokalemia; potassium must be replaced as needed.
15.(Ch 8) What bedside test assesses oxygenation quickly? — Pulse oximetry. —
Rationale: Pulse oximetry provides continuous, noninvasive estimation of arterial oxygen
saturation.
16.(Ch 8) Name one sign of respiratory distress in an adult. — Use of accessory muscles
and tachypnea. — Rationale: Increased work of breathing and rapid respirations indicate
inadequate ventilation/oxygenation.
17.(Ch 9) What is a priority for wound care to prevent infection? — Maintain a clean, moist
wound environment and perform proper hand hygiene during dressing changes. —
Rationale: Moisture supports healing while asepsis reduces microbial contamination.
18.(Ch 9) What does purulent drainage from a wound usually indicate? — Infection. —
Rationale: Pus signifies white cell activity and bacterial presence needing treatment.
, 19.(Ch 10) What is the earliest sign of hypoxia in many patients? — Restlessness or
agitation. — Rationale: The brain responds to low oxygen with behavioral changes
before vital signs deteriorate.
20.(Ch 10) How often should neurovascular checks be performed on a limb after cast
application? — Frequently during first 24 hours (e.g., q1h initially), then per protocol. —
Rationale: Early checks detect compartment syndrome or circulatory compromise.
21.(Ch 11) What laboratory value is most specific for myocardial infarction? — Troponin I or
T elevation. — Rationale: Cardiac troponins are highly specific markers of myocardial
injury.
22.(Ch 11) Name a nursing intervention when a patient reports chest pain. — Assess pain
characteristics, vital signs, obtain ECG, and give oxygen and nitroglycerin as ordered. —
Rationale: Rapid assessment and treatment limit myocardial damage and detect
life-threatening arrhythmias.
23.(Ch 12) What is the priority nursing action for a patient with atrial fibrillation and rapid
ventricular response? — Assess hemodynamic stability and prepare for rate control
medication or cardioversion if unstable. — Rationale: Rapid rates compromise cardiac
output; immediate control may be required.
24.(Ch 12) Which medication reduces clot formation risk in atrial fibrillation? —
Anticoagulants (e.g., warfarin, DOACs). — Rationale: Atrial fibrillation increases embolic
stroke risk; anticoagulation reduces clot formation.
25.(Ch 13) What is the expected finding in left-sided heart failure? — Pulmonary congestion
and dyspnea. — Rationale: Left ventricular failure causes blood to back up into the
lungs, producing respiratory symptoms.
26.(Ch 13) Name a nursing priority for acute pulmonary edema. — High-flow oxygen,
diuretics (IV), and morphine as ordered; place upright with legs down. — Rationale:
These actions improve oxygenation, reduce preload, and relieve anxiety and dyspnea.
27.(Ch 14) What lab value indicates renal impairment? — Elevated serum creatinine. —
Rationale: Creatinine reflects glomerular filtration; rising levels indicate reduced kidney
function.
28.(Ch 14) For a patient receiving hemodialysis, which electrolyte requires close
monitoring? — Potassium. — Rationale: Dialysis rapidly alters potassium; hyper- or
hypokalemia can cause arrhythmias.
29.(Ch 15) What is a sign of deep vein thrombosis (DVT)? — Unilateral calf swelling and
tenderness. — Rationale: Local venous thrombosis produces inflammation and edema in
Short-Answer Questions & Answers
solutions ( 2025 _2026)
Questions 1–200
1. (Ch 1) What is the primary goal of the nursing process? — To provide individualized,
goal-directed care through assessment, diagnosis, planning, implementation, and
evaluation. — Rationale: The nursing process is a systematic method that organizes
care and ensures continuity and evaluation of outcomes.
2. (Ch 1) Name two essential components of a comprehensive health history. — Chief
complaint and past medical history. — Rationale: These provide the reason for seeking
care and context for current health problems.
3. (Ch 2) What is a priority nursing action for a patient with suspected hypovolemia? —
Assess vital signs and peripheral perfusion; initiate IV fluids per order. — Rationale:
Rapid assessment identifies hemodynamic instability and IV fluids restore circulating
volume.
4. (Ch 2) List one lab test useful to evaluate hydration status. — Serum sodium. —
Rationale: Sodium concentration can indicate hyper- or hyponatremia related to fluid
balance.
5. (Ch 3) What isolation precautions are required for a patient with active pulmonary
tuberculosis? — Airborne precautions with N95 respirator and negative-pressure room.
— Rationale: TB spreads via droplet nuclei small enough to remain airborne; special
ventilation and respirators protect staff.
6. (Ch 3) How long should standard handwashing last for visible soiling? — At least 40–60
seconds with soap and water. — Rationale: Longer washing removes visible
contamination better than quick washing or hand sanitizer alone.
7. (Ch 4) Name a common side effect of opioid analgesics that nurses must monitor. —
Respiratory depression. — Rationale: Opioids depress the respiratory center; monitoring
, prevents hypoventilation and hypoxia.
8. (Ch 4) What is the antidote for opioid overdose? — Naloxone (Narcan). — Rationale:
Naloxone is an opioid antagonist that reverses respiratory depression.
9. (Ch 5) What assessment finding indicates increased intracranial pressure (ICP)? —
Decreased level of consciousness and papilledema. — Rationale: Rising ICP impairs
cerebral perfusion, causing altered mentation and optic disc swelling.
10.(Ch 5) Describe one nursing priority for a patient with suspected stroke. — Obtain CT
scan immediately to differentiate ischemic vs hemorrhagic stroke. — Rationale: Imaging
guides therapy (e.g., thrombolytics are indicated for ischemic stroke only).
11.(Ch 6) What electrolyte imbalance is most concerning with severe vomiting? —
Metabolic alkalosis with hypochloremia and possible hypokalemia. — Rationale: Loss of
gastric acid raises pH and depletes chloride and potassium.
12.(Ch 6) Name one immediate nursing action for a patient with hypokalemia. — Cardiac
monitoring and replace potassium per protocol. — Rationale: Hypokalemia predisposes
to arrhythmias; monitoring and replacement reduce risk.
13.(Ch 7) What is the normal range for fasting blood glucose in adults? — Approximately
70–99 mg/dL. — Rationale: Values above indicate impaired fasting glucose or diabetes;
used for screening and diagnosis.
14.(Ch 7) For a type 1 diabetic in DKA, what is a key nursing priority? — Administer IV
insulin and monitor potassium closely. — Rationale: Insulin shifts potassium into cells,
risking hypokalemia; potassium must be replaced as needed.
15.(Ch 8) What bedside test assesses oxygenation quickly? — Pulse oximetry. —
Rationale: Pulse oximetry provides continuous, noninvasive estimation of arterial oxygen
saturation.
16.(Ch 8) Name one sign of respiratory distress in an adult. — Use of accessory muscles
and tachypnea. — Rationale: Increased work of breathing and rapid respirations indicate
inadequate ventilation/oxygenation.
17.(Ch 9) What is a priority for wound care to prevent infection? — Maintain a clean, moist
wound environment and perform proper hand hygiene during dressing changes. —
Rationale: Moisture supports healing while asepsis reduces microbial contamination.
18.(Ch 9) What does purulent drainage from a wound usually indicate? — Infection. —
Rationale: Pus signifies white cell activity and bacterial presence needing treatment.
, 19.(Ch 10) What is the earliest sign of hypoxia in many patients? — Restlessness or
agitation. — Rationale: The brain responds to low oxygen with behavioral changes
before vital signs deteriorate.
20.(Ch 10) How often should neurovascular checks be performed on a limb after cast
application? — Frequently during first 24 hours (e.g., q1h initially), then per protocol. —
Rationale: Early checks detect compartment syndrome or circulatory compromise.
21.(Ch 11) What laboratory value is most specific for myocardial infarction? — Troponin I or
T elevation. — Rationale: Cardiac troponins are highly specific markers of myocardial
injury.
22.(Ch 11) Name a nursing intervention when a patient reports chest pain. — Assess pain
characteristics, vital signs, obtain ECG, and give oxygen and nitroglycerin as ordered. —
Rationale: Rapid assessment and treatment limit myocardial damage and detect
life-threatening arrhythmias.
23.(Ch 12) What is the priority nursing action for a patient with atrial fibrillation and rapid
ventricular response? — Assess hemodynamic stability and prepare for rate control
medication or cardioversion if unstable. — Rationale: Rapid rates compromise cardiac
output; immediate control may be required.
24.(Ch 12) Which medication reduces clot formation risk in atrial fibrillation? —
Anticoagulants (e.g., warfarin, DOACs). — Rationale: Atrial fibrillation increases embolic
stroke risk; anticoagulation reduces clot formation.
25.(Ch 13) What is the expected finding in left-sided heart failure? — Pulmonary congestion
and dyspnea. — Rationale: Left ventricular failure causes blood to back up into the
lungs, producing respiratory symptoms.
26.(Ch 13) Name a nursing priority for acute pulmonary edema. — High-flow oxygen,
diuretics (IV), and morphine as ordered; place upright with legs down. — Rationale:
These actions improve oxygenation, reduce preload, and relieve anxiety and dyspnea.
27.(Ch 14) What lab value indicates renal impairment? — Elevated serum creatinine. —
Rationale: Creatinine reflects glomerular filtration; rising levels indicate reduced kidney
function.
28.(Ch 14) For a patient receiving hemodialysis, which electrolyte requires close
monitoring? — Potassium. — Rationale: Dialysis rapidly alters potassium; hyper- or
hypokalemia can cause arrhythmias.
29.(Ch 15) What is a sign of deep vein thrombosis (DVT)? — Unilateral calf swelling and
tenderness. — Rationale: Local venous thrombosis produces inflammation and edema in
