Swift River- Med Surg Questions and
Answers Latest Version Already Passed
A post-op patient has a respiratory rate of 24 and is using accessory muscles to breathe. What is
the nurse's priority?
✔✔ Assess oxygen saturation and apply oxygen as needed.
A patient reports abdominal pain and has a distended abdomen with absent bowel sounds. What
should the nurse suspect?
✔✔ Possible bowel obstruction; notify the provider immediately.
A patient with a new colostomy is crying and says, “I’ll never be normal again.” What is the best
nursing response?
✔✔ Acknowledge the emotion and offer to arrange a visit from a wound ostomy nurse.
A patient receiving IV potassium reports burning at the IV site. What is the best nursing action?
✔✔ Slow the infusion rate and assess for signs of phlebitis.
A patient has a potassium level of 6.2 mEq/L. What is the first intervention?
1
,✔✔ Place the patient on cardiac monitor and notify the provider.
A patient reports calf pain and has swelling and warmth in the leg. What should the nurse do
next?
✔✔ Suspect deep vein thrombosis and keep the patient on bedrest until further evaluation.
A patient is postoperative day two after abdominal surgery and reports gas pain. What should the
nurse suggest?
✔✔ Encourage ambulation to promote intestinal motility.
A patient with pneumonia has a productive cough and oxygen saturation of 89%. What is the
next step?
✔✔ Increase oxygen delivery and encourage coughing and deep breathing.
A diabetic patient’s blood glucose is 300 mg/dL and the patient reports increased thirst. What is
the most appropriate intervention?
✔✔ Administer insulin as ordered and monitor fluid status.
A patient’s IV site is swollen and cool to touch. What is the likely issue?
2
,✔✔ Infiltration; stop the IV and elevate the limb.
A patient with heart failure gains 3 pounds overnight. What should the nurse do first?
✔✔ Assess for signs of fluid overload and notify the provider.
A patient on a diuretic reports dizziness and weakness. What lab should be reviewed?
✔✔ Sodium and potassium levels.
A patient with COPD is drowsy and has a PaCO₂ of 60 mmHg. What is the nurse’s concern?
✔✔ Carbon dioxide retention and impending respiratory failure.
A patient with a urinary catheter has cloudy urine and reports suprapubic discomfort. What
action is needed?
✔✔ Assess for UTI and notify the provider for possible urine culture.
A patient reports pain at a surgical incision site and has a temperature of 101°F. What should the
nurse do?
✔✔ Assess the incision for signs of infection and report findings.
3
, A patient on opioids has a respiratory rate of 8. What is the priority?
✔✔ Administer naloxone as ordered and monitor respiratory function.
A patient with a PEG tube has gastric residual of 250 mL. What is the appropriate action?
✔✔ Hold the feeding and reassess in 1 hour per protocol.
A patient receiving a blood transfusion reports chills and back pain. What is the nurse’s first
action?
✔✔ Stop the transfusion immediately and notify the provider.
A post-op patient is restless and has a heart rate of 120. What complication should the nurse
consider?
✔✔ Hypovolemia or bleeding.
A patient complains of severe headache after a lumbar puncture. What is the most likely cause?
✔✔ CSF leakage; instruct the patient to lie flat and increase fluids.
4
Answers Latest Version Already Passed
A post-op patient has a respiratory rate of 24 and is using accessory muscles to breathe. What is
the nurse's priority?
✔✔ Assess oxygen saturation and apply oxygen as needed.
A patient reports abdominal pain and has a distended abdomen with absent bowel sounds. What
should the nurse suspect?
✔✔ Possible bowel obstruction; notify the provider immediately.
A patient with a new colostomy is crying and says, “I’ll never be normal again.” What is the best
nursing response?
✔✔ Acknowledge the emotion and offer to arrange a visit from a wound ostomy nurse.
A patient receiving IV potassium reports burning at the IV site. What is the best nursing action?
✔✔ Slow the infusion rate and assess for signs of phlebitis.
A patient has a potassium level of 6.2 mEq/L. What is the first intervention?
1
,✔✔ Place the patient on cardiac monitor and notify the provider.
A patient reports calf pain and has swelling and warmth in the leg. What should the nurse do
next?
✔✔ Suspect deep vein thrombosis and keep the patient on bedrest until further evaluation.
A patient is postoperative day two after abdominal surgery and reports gas pain. What should the
nurse suggest?
✔✔ Encourage ambulation to promote intestinal motility.
A patient with pneumonia has a productive cough and oxygen saturation of 89%. What is the
next step?
✔✔ Increase oxygen delivery and encourage coughing and deep breathing.
A diabetic patient’s blood glucose is 300 mg/dL and the patient reports increased thirst. What is
the most appropriate intervention?
✔✔ Administer insulin as ordered and monitor fluid status.
A patient’s IV site is swollen and cool to touch. What is the likely issue?
2
,✔✔ Infiltration; stop the IV and elevate the limb.
A patient with heart failure gains 3 pounds overnight. What should the nurse do first?
✔✔ Assess for signs of fluid overload and notify the provider.
A patient on a diuretic reports dizziness and weakness. What lab should be reviewed?
✔✔ Sodium and potassium levels.
A patient with COPD is drowsy and has a PaCO₂ of 60 mmHg. What is the nurse’s concern?
✔✔ Carbon dioxide retention and impending respiratory failure.
A patient with a urinary catheter has cloudy urine and reports suprapubic discomfort. What
action is needed?
✔✔ Assess for UTI and notify the provider for possible urine culture.
A patient reports pain at a surgical incision site and has a temperature of 101°F. What should the
nurse do?
✔✔ Assess the incision for signs of infection and report findings.
3
, A patient on opioids has a respiratory rate of 8. What is the priority?
✔✔ Administer naloxone as ordered and monitor respiratory function.
A patient with a PEG tube has gastric residual of 250 mL. What is the appropriate action?
✔✔ Hold the feeding and reassess in 1 hour per protocol.
A patient receiving a blood transfusion reports chills and back pain. What is the nurse’s first
action?
✔✔ Stop the transfusion immediately and notify the provider.
A post-op patient is restless and has a heart rate of 120. What complication should the nurse
consider?
✔✔ Hypovolemia or bleeding.
A patient complains of severe headache after a lumbar puncture. What is the most likely cause?
✔✔ CSF leakage; instruct the patient to lie flat and increase fluids.
4
