A STUDY GUIDE FOR CLINICAL JUDGMENT
AND COLLABORATIVE CARE IN MED-SURG
NURSING WITH QUESTIONS AND CORRRECT
ANSWERS 2026
[1] A nurse is assessing a patient with hypovolemic shock. Which assessment finding requires
immediate intervention?
A. Heart rate of 112 beats/min
B. Urine output of 20 mL/hr
C. Blood pressure of 78/40 mmHg
D. Cool, clammy skin
Correct Answer: C
Explanation: Severe hypotension indicates inadequate tissue perfusion and is a life-threatening
sign of progressing shock. Tachycardia, decreased urine output, and cool skin are expected
findings but are less immediately critical than profound hypotension.
[2] A patient with heart failure is prescribed furosemide. Which laboratory value should the
nurse monitor most closely?
A. Hemoglobin
B. Potassium
C. Platelet count
D. Calcium
Correct Answer: B
Explanation: Furosemide is a loop diuretic that can cause significant potassium loss, increasing
the risk for dysrhythmias. Monitoring potassium is essential during therapy.
[3] A nurse is caring for a patient experiencing an acute myocardial infarction. Which
intervention should be implemented first?
A. Obtain a 12-lead ECG
B. Administer prescribed morphine
,C. Assess oxygen saturation
D. Initiate cardiac rehabilitation teaching
Correct Answer: C
Explanation: Assessment of oxygenation is a priority because myocardial tissue requires
adequate oxygen delivery. Immediate evaluation of oxygen status guides urgent interventions.
[4] Which finding is most characteristic of left-sided heart failure?
A. Peripheral edema
B. Jugular venous distention
C. Pulmonary crackles
D. Hepatomegaly
Correct Answer: C
Explanation: Left-sided heart failure causes pulmonary congestion, resulting in crackles,
dyspnea, and orthopnea. The other findings are more common with right-sided heart failure.
[5] A patient develops sudden shortness of breath after surgery. Which condition should the
nurse suspect first?
A. Asthma
B. Pulmonary embolism
C. Pneumonia
D. Tuberculosis
Correct Answer: B
Explanation: Sudden dyspnea after surgery is a classic sign of pulmonary embolism, particularly
in patients with risk factors for venous thromboembolism.
[6] Which assessment finding is most indicative of dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Decreased skin turgor
D. Increased urine output
,Correct Answer: C
Explanation: Decreased skin turgor is a common sign of dehydration. Bounding pulse and
increased urine output are inconsistent with fluid volume deficit.
[7] A patient with chronic kidney disease has a serum potassium level of 6.5 mEq/L. Which
complication is the greatest concern?
A. Infection
B. Dysrhythmias
C. Fractures
D. Hyperglycemia
Correct Answer: B
Explanation: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias and requires
immediate treatment.
[8] Which assessment finding suggests worsening respiratory distress?
A. Respiratory rate of 18 breaths/min
B. Oxygen saturation of 98%
C. Use of accessory muscles
D. Clear breath sounds
Correct Answer: C
Explanation: Accessory muscle use indicates increased work of breathing and respiratory
compromise.
[9] A nurse is teaching a patient with hypertension. Which statement indicates understanding?
A. "I will stop taking my medication when I feel better."
B. "I should limit sodium intake."
C. "Exercise increases my blood pressure permanently."
D. "Hypertension always causes symptoms."
Correct Answer: B
, Explanation: Sodium restriction helps manage hypertension. Medications should not be stopped
without provider guidance, and hypertension is often asymptomatic.
[10] Which patient is at highest risk for developing pressure injuries?
A. Ambulatory patient
B. Patient with frequent repositioning
C. Immobile patient with poor nutrition
D. Patient receiving physical therapy
Correct Answer: C
Explanation: Immobility and malnutrition significantly increase pressure injury risk due to
prolonged tissue pressure and impaired healing.
[11] A patient with diabetes mellitus reports shakiness and sweating. Which action should the
nurse take first?
A. Administer insulin
B. Check blood glucose level
C. Restrict fluids
D. Encourage exercise
Correct Answer: B
Explanation: Shakiness and sweating suggest hypoglycemia. Blood glucose should be assessed
immediately before interventions.
[12] Which laboratory value confirms effective anticoagulant therapy with warfarin?
A. INR within therapeutic range
B. Elevated hemoglobin
C. Increased sodium
D. Normal potassium
Correct Answer: A
Explanation: INR is the primary laboratory test used to evaluate warfarin effectiveness.
AND COLLABORATIVE CARE IN MED-SURG
NURSING WITH QUESTIONS AND CORRRECT
ANSWERS 2026
[1] A nurse is assessing a patient with hypovolemic shock. Which assessment finding requires
immediate intervention?
A. Heart rate of 112 beats/min
B. Urine output of 20 mL/hr
C. Blood pressure of 78/40 mmHg
D. Cool, clammy skin
Correct Answer: C
Explanation: Severe hypotension indicates inadequate tissue perfusion and is a life-threatening
sign of progressing shock. Tachycardia, decreased urine output, and cool skin are expected
findings but are less immediately critical than profound hypotension.
[2] A patient with heart failure is prescribed furosemide. Which laboratory value should the
nurse monitor most closely?
A. Hemoglobin
B. Potassium
C. Platelet count
D. Calcium
Correct Answer: B
Explanation: Furosemide is a loop diuretic that can cause significant potassium loss, increasing
the risk for dysrhythmias. Monitoring potassium is essential during therapy.
[3] A nurse is caring for a patient experiencing an acute myocardial infarction. Which
intervention should be implemented first?
A. Obtain a 12-lead ECG
B. Administer prescribed morphine
,C. Assess oxygen saturation
D. Initiate cardiac rehabilitation teaching
Correct Answer: C
Explanation: Assessment of oxygenation is a priority because myocardial tissue requires
adequate oxygen delivery. Immediate evaluation of oxygen status guides urgent interventions.
[4] Which finding is most characteristic of left-sided heart failure?
A. Peripheral edema
B. Jugular venous distention
C. Pulmonary crackles
D. Hepatomegaly
Correct Answer: C
Explanation: Left-sided heart failure causes pulmonary congestion, resulting in crackles,
dyspnea, and orthopnea. The other findings are more common with right-sided heart failure.
[5] A patient develops sudden shortness of breath after surgery. Which condition should the
nurse suspect first?
A. Asthma
B. Pulmonary embolism
C. Pneumonia
D. Tuberculosis
Correct Answer: B
Explanation: Sudden dyspnea after surgery is a classic sign of pulmonary embolism, particularly
in patients with risk factors for venous thromboembolism.
[6] Which assessment finding is most indicative of dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Decreased skin turgor
D. Increased urine output
,Correct Answer: C
Explanation: Decreased skin turgor is a common sign of dehydration. Bounding pulse and
increased urine output are inconsistent with fluid volume deficit.
[7] A patient with chronic kidney disease has a serum potassium level of 6.5 mEq/L. Which
complication is the greatest concern?
A. Infection
B. Dysrhythmias
C. Fractures
D. Hyperglycemia
Correct Answer: B
Explanation: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias and requires
immediate treatment.
[8] Which assessment finding suggests worsening respiratory distress?
A. Respiratory rate of 18 breaths/min
B. Oxygen saturation of 98%
C. Use of accessory muscles
D. Clear breath sounds
Correct Answer: C
Explanation: Accessory muscle use indicates increased work of breathing and respiratory
compromise.
[9] A nurse is teaching a patient with hypertension. Which statement indicates understanding?
A. "I will stop taking my medication when I feel better."
B. "I should limit sodium intake."
C. "Exercise increases my blood pressure permanently."
D. "Hypertension always causes symptoms."
Correct Answer: B
, Explanation: Sodium restriction helps manage hypertension. Medications should not be stopped
without provider guidance, and hypertension is often asymptomatic.
[10] Which patient is at highest risk for developing pressure injuries?
A. Ambulatory patient
B. Patient with frequent repositioning
C. Immobile patient with poor nutrition
D. Patient receiving physical therapy
Correct Answer: C
Explanation: Immobility and malnutrition significantly increase pressure injury risk due to
prolonged tissue pressure and impaired healing.
[11] A patient with diabetes mellitus reports shakiness and sweating. Which action should the
nurse take first?
A. Administer insulin
B. Check blood glucose level
C. Restrict fluids
D. Encourage exercise
Correct Answer: B
Explanation: Shakiness and sweating suggest hypoglycemia. Blood glucose should be assessed
immediately before interventions.
[12] Which laboratory value confirms effective anticoagulant therapy with warfarin?
A. INR within therapeutic range
B. Elevated hemoglobin
C. Increased sodium
D. Normal potassium
Correct Answer: A
Explanation: INR is the primary laboratory test used to evaluate warfarin effectiveness.
