Medsur 2

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Sample questions from Medsur 2

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

1. 1.A 68-year-old client is admitted to the medical-surgical unit with pneumonia. The client is newly confused, has a temperature of 39.2 C (102.6 F), heart rate of 124/min, blood pressure of 86/50 mm Hg, and oxygen saturation of 91% on room air. Which action should the nurse take first?

   • A.Obtain a clean-catch urine specimen
   • B.Activate the rapid response system and support airway and circulation
   • C.Administer the prescribed oral antipyretic
   • D.Teach the client how to use an incentive spirometer

   Rationale: Hypotension, tachycardia, fever, and acute confusion suggest sepsis with impaired perfusion, requiring immediate escalation and stabilization. A urine specimen may be useful but must not delay care; an oral antipyretic and teaching are lower priorities while the client is unstable. The exam takeaway is to recognize deterioration and address airway, breathing, and circulation before routine tasks.

2. 2.A 74-year-old client with heart failure is admitted to a medical-surgical unit with worsening dyspnea. The client has crackles, oxygen saturation of 88% on room air, and is sitting upright. Which action should the nurse take first?

   • A.Place the client in high-Fowler position and apply prescribed oxygen
   • B.Obtain the client's daily weight
   • C.Restrict oral fluids to the prescribed amount
   • D.Administer the scheduled oral potassium supplement

   Rationale: Hypoxemia and respiratory distress make positioning and oxygenation the immediate priorities. Daily weight and fluid restriction help manage heart failure but do not rapidly address the current breathing problem; potassium is not the first action in an unstable client. The exam takeaway is to stabilize breathing before implementing ongoing fluid-management measures.

3. 3.A 63-year-old client with type 1 diabetes is admitted to the emergency department with nausea, abdominal pain, and deep rapid respirations. Glucose is 540 mg/dL, pH is 7.18, and potassium is 5.6 mEq/L. Which prescribed intervention should the nurse implement first?

   • A.Begin an infusion of regular insulin
   • B.Start isotonic intravenous fluids
   • C.Administer intravenous sodium bicarbonate
   • D.Give oral potassium replacement

   Rationale: The client has diabetic ketoacidosis with likely severe volume depletion, so isotonic fluid resuscitation is the initial priority. Insulin is essential but is generally started after initial fluid therapy and confirmation that potassium can be safely managed; bicarbonate is not routinely indicated at this pH, and potassium is already elevated. The exam takeaway is to restore circulating volume before initiating insulin in diabetic ketoacidosis.

4. 4.A 57-year-old client arrives on the medical-surgical unit 2 hours after a thyroidectomy. The client is restless, has inspiratory stridor, and has an oxygen saturation of 89%. Which action should the nurse take first?

   • A.Inspect the surgical dressing for drainage
   • B.Prepare to administer prescribed calcium gluconate
   • C.Call for emergency assistance and prepare to support the airway
   • D.Offer sips of water to assess swallowing

   Answer and rationale are in the full material.

5. 5.A 71-year-old client is admitted to the medical-surgical unit with a suspected ischemic stroke. The client has right-sided weakness, facial droop, and slurred speech that began 1 hour ago. Blood pressure is 182/98 mm Hg and glucose is 126 mg/dL. Which action is most important before giving anything by mouth?

   • A.Perform a swallow screening
   • B.Give aspirin with a sip of water
   • C.Offer a soft diet
   • D.Administer oral antihypertensive medication

   Answer and rationale are in the full material.