Med-Surg Nightingale

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Sample questions from Med-Surg Nightingale

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A client admitted with acute chest pain has new ST-segment elevation and reports worsening pressure despite resting. Which action should the nurse take first?

   • A.Ask the client to walk to determine whether activity worsens the pain
   • B.Obtain a 12-lead electrocardiogram and activate the facility's urgent chest-pain response
   • C.Give the client's scheduled oral antihypertensive medication
   • D.Reassess the pain in 30 minutes

   Rationale: New ST-segment elevation with ongoing chest pressure suggests acute myocardial injury and requires immediate evaluation and escalation. Walking can increase myocardial oxygen demand, and waiting to reassess risks delaying reperfusion. A scheduled oral antihypertensive does not address the time-critical concern.

2. 2.A client with heart failure reports sleeping upright and has crackles in both lung bases. Which assessment finding best indicates worsening fluid overload?

   • A.Warm, dry skin
   • B.A heart rate of 78 beats/min
   • C.Urine output of 45 mL/hr
   • D.A 1.5-kg weight gain over 2 days

   Rationale: A rapid weight gain is a sensitive indicator of retained fluid and can precede more severe heart-failure symptoms. A heart rate of 78 beats/min and urine output of 45 mL/hr may be within expected ranges, while warm, dry skin does not indicate worsening congestion. Daily weights under consistent conditions help detect fluid changes early.

3. 3.The nurse is teaching a client with heart failure how to monitor the condition at home. Which instructions should the nurse include? Select all that apply.

   • A.Follow the sodium and fluid limits prescribed for you
   • B.Stop taking your diuretic when your ankle swelling improves
   • C.Use an extra dose of potassium whenever you feel short of breath
   • D.Weigh yourself every morning after urinating and before eating
   • E.Report a gain of 2 lb (0.9 kg) in a day or 5 lb (2.3 kg) in a week, or follow your clinician's specific threshold

   Rationale: Daily weights taken at the same time and under similar conditions help identify fluid retention, and a rapid gain should be reported according to the client's care plan. Prescribed sodium and fluid limits can reduce congestion. Stopping a diuretic or taking unprescribed potassium is unsafe because either action can worsen symptoms or cause electrolyte and rhythm problems.

4. 4.A client taking digoxin reports nausea and yellow-green halos around lights. The apical pulse is 54 beats/min. What should the nurse do?

   • A.Hold the digoxin and notify the health care provider
   • B.Encourage the client to increase dietary sodium
   • C.Give the next dose and document the visual changes
   • D.Administer the digoxin with food

   Answer and rationale are in the full material.

5. 5.A client with peripheral arterial disease reports calf pain after walking two blocks that resolves with rest. Which teaching is appropriate?

   • A.Keep the legs crossed while sitting to reduce discomfort
   • B.Apply a heating pad to the feet each evening
   • C.Walk regularly, stopping to rest when claudication occurs
   • D.Elevate the legs above the heart whenever resting

   Answer and rationale are in the full material.