Medical-Surgical LPN/RN
Assessment 1 Questions and
Answers} 2024
1. Question:
A 68-year-old patient with a history of chronic obstructive pulmonary disease (COPD) is
admitted with an exacerbation. What is the most appropriate nursing intervention to improve
oxygenation?
● A. Administering high-flow oxygen via a non-rebreather mask.
● B. Placing the patient in a high Fowler's position.
● C. Encouraging deep breathing and coughing exercises.
● D. Administering bronchodilators as prescribed.
Answer: B. Placing the patient in a high Fowler's position.
Rationale: High Fowler's position maximizes lung expansion, which is crucial for patients with
COPD who are experiencing an exacerbation. Administering high-flow oxygen without
monitoring can lead to CO2 retention in COPD patients, making it less favorable as the first
intervention. Encouraging deep breathing and coughing exercises and administering
bronchodilators are important but should follow after positioning.
2. Question:
A patient is admitted with acute pancreatitis. Which of the following lab values would the nurse
expect to be elevated?
● A. Serum amylase.
● B. Serum potassium.
● C. Hemoglobin.
● D. Serum calcium.
Answer: A. Serum amylase.
, Rationale: In acute pancreatitis, serum amylase and lipase levels are typically elevated due to
the inflammation of the pancreas. Serum potassium, hemoglobin, and calcium are not
specifically elevated in pancreatitis and would require different clinical conditions to be altered.
3. Question:
A patient with congestive heart failure (CHF) is prescribed furosemide (Lasix). Which of the
following is a priority assessment before administering the medication?
● A. Blood pressure.
● B. Heart rate.
● C. Respiratory rate.
● D. Serum creatinine level.
Answer: A. Blood pressure.
Rationale: Furosemide is a diuretic that can cause significant drops in blood pressure due to
volume depletion. It is critical to assess the patient's blood pressure before administration to
prevent hypotension. Monitoring heart rate, respiratory rate, and serum creatinine are also
important, but blood pressure is the priority before administering a diuretic.
4. Question:
Which of the following is the most appropriate initial nursing action for a patient who reports
chest pain radiating to the left arm and jaw?
● A. Administering aspirin.
● B. Performing an ECG.
● C. Applying oxygen.
● D. Administering nitroglycerin.
Answer: C. Applying oxygen.
Rationale: Chest pain that radiates to the arm and jaw suggests myocardial ischemia. The
initial priority is to improve oxygenation by applying oxygen to reduce myocardial demand. An
ECG should follow immediately to assess the extent of the ischemia, while medications like
aspirin and nitroglycerin are essential but should come after ensuring oxygenation.
5. Question:
A patient with diabetes mellitus presents with confusion, diaphoresis, and tachycardia. What is
the most likely cause, and what should be the initial intervention?
● A. Hyperglycemia; administer insulin.
Assessment 1 Questions and
Answers} 2024
1. Question:
A 68-year-old patient with a history of chronic obstructive pulmonary disease (COPD) is
admitted with an exacerbation. What is the most appropriate nursing intervention to improve
oxygenation?
● A. Administering high-flow oxygen via a non-rebreather mask.
● B. Placing the patient in a high Fowler's position.
● C. Encouraging deep breathing and coughing exercises.
● D. Administering bronchodilators as prescribed.
Answer: B. Placing the patient in a high Fowler's position.
Rationale: High Fowler's position maximizes lung expansion, which is crucial for patients with
COPD who are experiencing an exacerbation. Administering high-flow oxygen without
monitoring can lead to CO2 retention in COPD patients, making it less favorable as the first
intervention. Encouraging deep breathing and coughing exercises and administering
bronchodilators are important but should follow after positioning.
2. Question:
A patient is admitted with acute pancreatitis. Which of the following lab values would the nurse
expect to be elevated?
● A. Serum amylase.
● B. Serum potassium.
● C. Hemoglobin.
● D. Serum calcium.
Answer: A. Serum amylase.
, Rationale: In acute pancreatitis, serum amylase and lipase levels are typically elevated due to
the inflammation of the pancreas. Serum potassium, hemoglobin, and calcium are not
specifically elevated in pancreatitis and would require different clinical conditions to be altered.
3. Question:
A patient with congestive heart failure (CHF) is prescribed furosemide (Lasix). Which of the
following is a priority assessment before administering the medication?
● A. Blood pressure.
● B. Heart rate.
● C. Respiratory rate.
● D. Serum creatinine level.
Answer: A. Blood pressure.
Rationale: Furosemide is a diuretic that can cause significant drops in blood pressure due to
volume depletion. It is critical to assess the patient's blood pressure before administration to
prevent hypotension. Monitoring heart rate, respiratory rate, and serum creatinine are also
important, but blood pressure is the priority before administering a diuretic.
4. Question:
Which of the following is the most appropriate initial nursing action for a patient who reports
chest pain radiating to the left arm and jaw?
● A. Administering aspirin.
● B. Performing an ECG.
● C. Applying oxygen.
● D. Administering nitroglycerin.
Answer: C. Applying oxygen.
Rationale: Chest pain that radiates to the arm and jaw suggests myocardial ischemia. The
initial priority is to improve oxygenation by applying oxygen to reduce myocardial demand. An
ECG should follow immediately to assess the extent of the ischemia, while medications like
aspirin and nitroglycerin are essential but should come after ensuring oxygenation.
5. Question:
A patient with diabetes mellitus presents with confusion, diaphoresis, and tachycardia. What is
the most likely cause, and what should be the initial intervention?
● A. Hyperglycemia; administer insulin.
