medsurg
A patient with COPD is receiving oxygen at 6 L/min via nasal cannula. Which assessment finding is most concerning?
A. Oxygen saturation of 91%
B. Respiratory rate of 18/min
C. Increasing drowsiness
D. Productive cough
Answer: C. Increasing drowsiness
Rationale: COPD patients can retain carbon dioxide. Excess oxygen may suppress respiratory drive, leading to CO2 retention and decreased level of consciousness.
A patient with major depressive disorder says, “Everyone would be better off without me.” What is the nurse’s priority response?
A. “Why would you say that?”
B. “You shouldn’t feel that way.”
C. “Are you thinking about hurting yourself?”
D. “Things will get better soon.”
Answer: C. “Are you thinking about hurting yourself?”
Rationale: The priority is to assess for suicide risk directly and clearly. Asking about suicidal thoughts does not increase suicide risk.
Which intervention is priority for a patient experiencing hypoglycemia?
A. Administer long-acting insulin
B. Encourage exercise
C. Give 15 g of rapid-acting carbohydrates
D. Restrict oral intake
Answer: C. Give 15 g of rapid-acting carbohydrates
Rationale: Immediate treatment for hypoglycemia is rapid glucose replacement such as juice, glucose tablets, or regular soda to quickly raise blood sugar levels.
A nurse is teaching a patient about warfarin therapy. Which statement by the patient indicates understanding?
A. “I should avoid all green vegetables.”
B. “I will use a soft toothbrush.”
C. “I can stop taking the medication if I feel better.”
D. “I should take aspirin for headaches.”
Answer: B. “I will use a soft toothbrush.”
Rationale: Warfarin increases bleeding risk, so patients should use soft toothbrushes and electric razors. Green vegetables do not need to be avoided completely, but vitamin K intake should remain consistent.
A nurse is teaching a patient about levothyroxine therapy for hypothyroidism. Which statement indicates understanding?
A. “I will take this medication at bedtime with food.”
B. “I should stop taking it once I feel better.”
C. “I will take this medication in the morning on an empty stomach.”
D. “This medication works immediately.”
Answer: C. “I will take this medication in the morning on an empty stomach.”
Rationale: Levothyroxine is best absorbed on an empty stomach and is usually taken in the morning before eating.
A postoperative patient suddenly develops shortness of breath, chest pain, and tachycardia. Which complication should the nurse suspect first?
A. Pneumonia
B. Pulmonary embolism
C. Atelectasis
D. Heart failure
Answer: B. Pulmonary embolism
Rationale: Sudden chest pain, dyspnea, and tachycardia after surgery are classic signs of pulmonary embolism caused by a blood clot traveling to the lungs.
A patient experiencing a panic attack is hyperventilating and trembling. What is the nurse’s best action?
A. Leave the patient alone
B. Speak calmly and stay with the patient
C. Encourage group activities immediately
D. Ask multiple questions quickly
Answer: B. Speak calmly and stay with the patient
Rationale: Calm communication and staying with the patient help reduce anxiety and provide reassurance during a panic attack.
A nurse is caring for a patient with sepsis. Which finding indicates worsening condition?
A. Urine output 15 mL/hr
B. Warm flushed skin
C. Heart rate 102 bpm
D. Temperature 100.4°F
Answer: A. Urine output 15 mL/hr
Rationale: Decreased urine output indicates poor organ perfusion and possible progression toward septic shock.
Which patient is at highest risk for developing pressure injuries?
A. Ambulatory patient with hypertension
B. Patient on bed rest with incontinence
C. Patient with seasonal allergies
D. Patient recovering from cataract surgery
Answer: B. Patient on bed rest with incontinence
Rationale: Immobility and moisture from incontinence significantly increase risk for skin breakdown and pressure injuries.
A patient taking lithium reports diarrhea, tremors, and muscle weakness. What should the nurse do first?
A. Give the next dose with food
B. Hold the medication and notify the provider
C. Encourage caffeine intake
D. Tell the patient this is expected
Answer: B. Hold the medication and notify the provider
Rationale: These are signs of lithium toxicity, which can become severe and requires immediate evaluation.
Which finding is expected in a patient with metabolic acidosis?
A. Slow shallow respirations
B. Bradycardia
C. Kussmaul respirations
D. Decreased respiratory rate
Answer: C. Kussmaul respirations
Rationale: The body compensates for metabolic acidosis by increasing respirations to blow off carbon dioxide.
Which patient is at highest risk for suicide?
A. Patient with anxiety who has family support
B. Patient with depression who suddenly appears cheerful after severe hopelessness
C. Patient with OCD performing rituals
D. Patient with insomnia
Answer: B. Patient with depression who suddenly appears cheerful after severe hopelessness
Rationale: Sudden mood improvement may indicate the patient has decided to act on a suicide plan.
A patient with anorexia nervosa has a BMI of 15. Which assessment finding is most concerning?
A. Dry skin
B. Lanugo hair
C. Irregular heart rhythm
D. Fear of weight gain
Answer: C. Irregular heart rhythm
Rationale: Severe malnutrition can lead to electrolyte imbalances and life-threatening cardiac dysrhythmias.
A nurse is caring for a patient with hypercalcemia. Which symptom should the nurse expect?
A. Muscle spasms
B. Tetany
C. Constipation
D. Hyperactive reflexes
Answer: C. Constipation
Rationale: Hypercalcemia slows neuromuscular activity, causing constipation, weakness, lethargy, and decreased reflexes.
A patient taking Clozapine reports a sore throat and fever. What is the nurse’s priority action?
A. Encourage fluids
B. Administer acetaminophen
C. Notify the provider immediately
D. Tell the patient this is expected
Answer: C. Notify the provider immediately
Rationale: Clozapine can cause agranulocytosis, a dangerous decrease in white blood cells that increases infection risk.
Which laboratory finding is commonly associated with lupus?
A. Positive antinuclear antibody (ANA) test
B. Elevated potassium level only
C. Increased platelet count
D. Low blood glucose
Answer: A. Positive antinuclear antibody (ANA) test
Rationale: A positive ANA test is commonly seen in patients with lupus and helps support the diagnosis.
A patient prescribed Amitriptyline reports dry mouth and constipation. What should the nurse teach?
A. “These are common side effects.”
B. “Stop the medication immediately.”
C. “Restrict fluid intake.”
D. “These symptoms indicate toxicity.”
Answer: A. “These are common side effects.”
Rationale: Tricyclic antidepressants commonly cause anticholinergic effects such as dry mouth, constipation, and blurred vision.
A nurse is caring for a patient receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
A. Temperature increase from 98.6°F to 101°F
B. Blood pressure of 124/76 mmHg
C. Respiratory rate of 18/min
D. Mild fatigue
Answer: A. Temperature increase from 98.6°F to 101°F
Rationale: Fever and chills during a blood transfusion may indicate a transfusion reaction. The transfusion should be stopped immediately and the provider notified.
A patient with heart failure is prescribed Furosemide. Which finding indicates the medication is working?
A. Weight gain of 2 lb in 24 hours
B. Decreased crackles in lungs
C. Increased blood pressure
D. Elevated potassium level
Answer: B. Decreased crackles in lungs
Rationale: Loop diuretics remove excess fluid, so improvement in lung sounds (less crackles, less fluid overload) indicates effectiveness.
A 72-year-old patient with COPD is admitted for worsening shortness of breath. The provider prescribes:
Current assessment:
Which patient symptom is a common expected side effect of albuterol?
A. Bradycardia
B. Tremors
C. Severe hypotension
D. Constipation
Answer: B. Tremors
Rationale: Albuterol stimulates beta receptors, commonly causing tremors, tachycardia, and nervousness.
A patient with hypothyroidism is difficult to arouse and has a low temperature and bradycardia. Which condition should the nurse suspect?
A. Thyroid storm
B. Myxedema coma
C. Pulmonary embolism
D. Cushing syndrome
Answer: B. Myxedema coma
Rationale: Myxedema coma is a severe complication of hypothyroidism characterized by decreased mental status, hypothermia, and bradycardia.
A patient who is anxious about an upcoming surgery begins cleaning the house excessively. Which defense mechanism is being used?
A. Reaction formation
B. Sublimation
C. Projection
D. Dissociation
Answer: B. Sublimation
Rationale: Sublimation is a healthy defense mechanism where unacceptable feelings are redirected into socially acceptable activities.
A patient with borderline personality disorder tells one nurse, “You’re the only nurse who cares about me,” and tells another nurse, “You’re terrible.” Which behavior is the patient demonstrating?
A. Projection
B. Splitting
C. Regression
D. Sublimation
Answer: B. Splitting
Rationale: Splitting involves viewing people as “all good” or “all bad” and is common in borderline personality disorder.
A 68-year-old patient is admitted with worsening heart failure. The provider orders:
The nurse reviews the following assessment data:
Which assessment finding requires immediate intervention?
A. HR 54 bpm
B. Crackles in lungs
C. BP 92/58 mmHg
D. Urine output 20 mL/hr
Answer: D. Urine output 20 mL/hr
Rationale: Very low urine output indicates poor renal perfusion and worsening fluid overload, which can progress to kidney failure.
A patient with breast cancer is prescribed Cyclophosphamide. Which assessment finding should the nurse recognize as the most serious adverse effect?
A. Hair loss
B. Mild nausea
C. Burning with urination and blood in urine
D. Fatigue after treatment
Answer: C. Burning with urination and blood in urine
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, a potentially serious complication due to toxic metabolites irritating the bladder lining. Patients may develop dysuria and hematuria, which require prompt intervention and increased hydration (and sometimes protective agents like mesna).