HA2 CJE Exam – Complete
Medical-Surgical Review Guide
(Latest 2025/2026 Edition
TESTED QUESTIONS AND 100%
SOLVED VERIFIED ANSWERS
GRADED A+
Question 1
A client with COPD is receiving oxygen therapy at 4 L/min via nasal
cannula. Which finding requires immediate intervention?
A. Respiratory rate of 20/min
B. SpO₂ of 90%
C. Increasing drowsiness
D. Use of accessory muscles
Correct Answer: C. Increasing drowsiness
Rationale
• Clients with COPD retain CO₂ due to impaired ventilation.
• Giving too much oxygen can suppress the hypoxic respiratory
drive, leading to CO₂ narcosis, which presents as drowsiness,
confusion, headache, and reduced LOC.
• SpO₂ 88-92% is targeted in COPD.
, • Accessory muscle use indicates work of breathing, but drowsiness
= respiratory failure risk.
Question 2
A nurse is caring for a postoperative abdominal surgery patient. Which
action helps prevent deep vein thrombosis (DVT)?
A. Restricting fluids
B. Applying compression stockings
C. Encouraging bed rest
D. Keeping legs elevated above the head
Correct Answer: B. Applying compression stockings
Rationale
• DVT prevention requires venous return promotion: compression
stockings, leg exercises, ambulation, hydration.
• Bed rest increases clot risk.
• Elevation above the head is not useful and may impair circulation.
Question 3
A client with heart failure has crackles and dyspnea. Which intervention
should the nurse do first?
A. Give prescribed furosemide
B. Place the client in high Fowler’s position
C. Notify the provider
D. Restrict sodium intake
Correct Answer: B. High Fowler’s position
, Rationale
• When prioritizing: Airway → Breathing → Circulation.
• Placing upright immediately improves ventilation, reduces
preload, and increases lung expansion.
• Diuretics are appropriate, but position change is faster.
Question 4
Which lab value is most critical in a client with chronic kidney disease?
A. Potassium 6.2 mEq/L
B. Hemoglobin 10 g/dL
C. BUN 35 mg/dL
D. Creatinine 2.2 mg/dL
Correct Answer: A. Potassium 6.2 mEq/L
Rationale
• Hyperkalemia in CKD can cause lethal arrhythmias.
• Elevated BUN/Cr is expected in CKD.
• Hgb 10 is common due to low erythropoietin.
Question 5
The nurse prepares to administer blood. Which action is mandatory?
A. Match blood type with client wristband
B. Verify blood with another licensed nurse
C. Administer through 24-gauge IV
D. Infuse over 1 hour
, Correct Answer: B. Verify with another licensed nurse
Rationale
• Two-nurse verification reduces fatal transfusion errors.
• Must check against blood label, transfusion record, and ID band.
• Blood needs at least 18-20 gauge.
• PRBCs are infused over 2–4 hours.
Question 6
A patient with pneumonia has fever and productive cough. What is the
priority assessment?
A. Frequency of cough
B. Color of sputum
C. Oxygen saturation
D. Breath sounds
Correct Answer: C. Oxygen saturation
Rationale
• Airway and oxygenation first.
• SpO₂ determines severity and need for oxygen.
• Sputum and breath sounds are important, but secondary.
Question 7
Which client is at highest risk for postoperative infection?
A. 32-year-old with appendectomy
B. 60-year-old with diabetes
Medical-Surgical Review Guide
(Latest 2025/2026 Edition
TESTED QUESTIONS AND 100%
SOLVED VERIFIED ANSWERS
GRADED A+
Question 1
A client with COPD is receiving oxygen therapy at 4 L/min via nasal
cannula. Which finding requires immediate intervention?
A. Respiratory rate of 20/min
B. SpO₂ of 90%
C. Increasing drowsiness
D. Use of accessory muscles
Correct Answer: C. Increasing drowsiness
Rationale
• Clients with COPD retain CO₂ due to impaired ventilation.
• Giving too much oxygen can suppress the hypoxic respiratory
drive, leading to CO₂ narcosis, which presents as drowsiness,
confusion, headache, and reduced LOC.
• SpO₂ 88-92% is targeted in COPD.
, • Accessory muscle use indicates work of breathing, but drowsiness
= respiratory failure risk.
Question 2
A nurse is caring for a postoperative abdominal surgery patient. Which
action helps prevent deep vein thrombosis (DVT)?
A. Restricting fluids
B. Applying compression stockings
C. Encouraging bed rest
D. Keeping legs elevated above the head
Correct Answer: B. Applying compression stockings
Rationale
• DVT prevention requires venous return promotion: compression
stockings, leg exercises, ambulation, hydration.
• Bed rest increases clot risk.
• Elevation above the head is not useful and may impair circulation.
Question 3
A client with heart failure has crackles and dyspnea. Which intervention
should the nurse do first?
A. Give prescribed furosemide
B. Place the client in high Fowler’s position
C. Notify the provider
D. Restrict sodium intake
Correct Answer: B. High Fowler’s position
, Rationale
• When prioritizing: Airway → Breathing → Circulation.
• Placing upright immediately improves ventilation, reduces
preload, and increases lung expansion.
• Diuretics are appropriate, but position change is faster.
Question 4
Which lab value is most critical in a client with chronic kidney disease?
A. Potassium 6.2 mEq/L
B. Hemoglobin 10 g/dL
C. BUN 35 mg/dL
D. Creatinine 2.2 mg/dL
Correct Answer: A. Potassium 6.2 mEq/L
Rationale
• Hyperkalemia in CKD can cause lethal arrhythmias.
• Elevated BUN/Cr is expected in CKD.
• Hgb 10 is common due to low erythropoietin.
Question 5
The nurse prepares to administer blood. Which action is mandatory?
A. Match blood type with client wristband
B. Verify blood with another licensed nurse
C. Administer through 24-gauge IV
D. Infuse over 1 hour
, Correct Answer: B. Verify with another licensed nurse
Rationale
• Two-nurse verification reduces fatal transfusion errors.
• Must check against blood label, transfusion record, and ID band.
• Blood needs at least 18-20 gauge.
• PRBCs are infused over 2–4 hours.
Question 6
A patient with pneumonia has fever and productive cough. What is the
priority assessment?
A. Frequency of cough
B. Color of sputum
C. Oxygen saturation
D. Breath sounds
Correct Answer: C. Oxygen saturation
Rationale
• Airway and oxygenation first.
• SpO₂ determines severity and need for oxygen.
• Sputum and breath sounds are important, but secondary.
Question 7
Which client is at highest risk for postoperative infection?
A. 32-year-old with appendectomy
B. 60-year-old with diabetes
