Certified Medical-Surgical Registered Nurse (CMSRN) — Questions and Answers

Question 1: A patient with hemophilia A is scheduled for surgery. Which factor replacement therapy would the nurse anticipate administering?

Vitamin K injection
Fresh frozen plasma only
Factor VIII concentrate (Correct answer)
Factor IX concentrate

Correct answer: Factor VIII concentrate

Hemophilia A is caused by a deficiency of Factor VIII; replacement therapy with Factor VIII concentrate is required before and after surgical procedures.

Question 2: A patient with chronic neuropathic pain is prescribed gabapentin (Neurontin). The nurse should teach the patient that this medication:

Should be stopped abruptly if ineffective after one dose
Is an opioid analgesic that requires monitoring for respiratory depression
Is an anticonvulsant that treats neuropathic pain by stabilizing nerve membranes; causes dizziness and somnolence (Correct answer)
Provides immediate pain relief within minutes of administration

Correct answer: Is an anticonvulsant that treats neuropathic pain by stabilizing nerve membranes; causes dizziness and somnolence

Gabapentin is an anticonvulsant used for neuropathic pain that works via calcium channel modulation; it requires gradual dose titration and causes dizziness and sedation.

Question 3: After a total knee replacement, which assessment finding requires the most immediate nursing action?

Sudden onset of calf pain, redness, and warmth (Correct answer)
Mild swelling at the knee
Pain rating of 5/10 at rest
Serosanguineous drainage from the incision

Correct answer: Sudden onset of calf pain, redness, and warmth

Sudden calf pain, redness, and warmth after knee replacement are classic signs of DVT, which requires immediate assessment and provider notification.

Question 4: A patient with a surgical wound develops dehiscence (wound separation without organ protrusion). The nurse should:

Place the patient in Trendelenburg position and apply pressure
Irrigate with hydrogen peroxide and close with butterfly strips
Apply a wound closure device immediately without notifying the provider
Cover with a sterile dressing, notify the provider, and have the patient avoid Valsalva maneuver (Correct answer)

Correct answer: Cover with a sterile dressing, notify the provider, and have the patient avoid Valsalva maneuver

Wound dehiscence requires sterile wound coverage, provider notification for possible surgical re-closure, and preventing increased intra-abdominal pressure.

Question 5: A patient is receiving a blood transfusion and develops chills, fever, and back pain 15 minutes after initiation. What is the FIRST nursing action?

Slow the infusion rate and notify the provider
Stop the transfusion and keep the IV line open with normal saline (Correct answer)
Administer acetaminophen and continue the transfusion
Draw blood cultures and continue monitoring

Correct answer: Stop the transfusion and keep the IV line open with normal saline

Stopping the transfusion immediately while maintaining IV access with normal saline is the priority to prevent further exposure to incompatible blood products.

Question 6: Which patient is at HIGHEST risk for developing contrast-induced nephropathy (CIN) after IV contrast administration?

A 25-year-old with normal renal function
A 40-year-old with controlled hypertension
A 50-year-old with hyperthyroidism
A 65-year-old with CKD, diabetes, and heart failure (Correct answer)

Correct answer: A 65-year-old with CKD, diabetes, and heart failure

Pre-existing CKD, diabetes, and heart failure are the strongest risk factors for contrast-induced nephropathy following IV contrast administration.

Question 7: A patient with a spinal compression fracture related to osteoporosis reports sudden severe back pain. The nurse's priority action is to:

Assess neurological function of the lower extremities (Correct answer)
Encourage ambulation to prevent deconditioning
Administer NSAIDs without further assessment
Apply a heating pad to the area

Correct answer: Assess neurological function of the lower extremities

A spinal compression fracture can cause cord compression; assessing neurological function of the lower extremities detects potential motor or sensory deficits.

Question 8: Which laboratory value is most important to monitor following a total joint replacement due to intraoperative blood loss?

Serum creatinine
Hemoglobin and hematocrit (Correct answer)
Serum potassium
White blood cell count

Correct answer: Hemoglobin and hematocrit

Hemoglobin and hematocrit are monitored post-arthroplasty to detect significant blood loss requiring transfusion.

Question 9: In patients with Addison's disease, which hormone is deficient?

Thyroxine
Growth hormone
Cortisol (Correct answer)
Insulin

Correct answer: Cortisol

Addison's disease is a rare but serious condition characterized by the adrenal glands' inability to produce sufficient amounts of certain hormones. The most significant deficiency in Addison's disease is cortisol, a glucocorticoid vital for stress response, metabolism, and immune function. Aldosterone, a mineralocorticoid, may also be deficient, leading to electrolyte imbalances.

Question 10: When caring for a patient with pernicious anemia, which finding confirms this diagnosis over other types of anemia?

Elevated reticulocyte count and jaundice
Decreased intrinsic factor and low serum vitamin B12 (Correct answer)
Low serum iron and elevated TIBC
Microcytic hypochromic red blood cells on smear

Correct answer: Decreased intrinsic factor and low serum vitamin B12

Pernicious anemia is caused by the absence of intrinsic factor, which is required for vitamin B12 absorption, resulting in megaloblastic anemia and neurological deficits.

Question 11: A patient with CKD receives erythropoietin (EPO) therapy. The nurse should monitor for which serious adverse effect?

Severe hypoglycemia
Pulmonary fibrosis
Hypertension and thromboembolic events (Correct answer)
Bleeding complications

Correct answer: Hypertension and thromboembolic events

EPO stimulates RBC production and can elevate hematocrit rapidly, increasing blood viscosity and the risk of hypertension, thrombosis, and stroke.

Question 12: A patient receiving IV patient-controlled analgesia (PCA) morphine is found with a respiratory rate of 7 breaths/min and is difficult to arouse. The nurse's priority action is:

Increase the PCA lockout interval
Reposition the patient and reassess in 15 minutes
Stop the PCA, administer naloxone (Narcan), and call for emergency assistance (Correct answer)
Administer supplemental oxygen and monitor

Correct answer: Stop the PCA, administer naloxone (Narcan), and call for emergency assistance

Respiratory depression from opioid overdose is life-threatening and requires immediate PCA cessation, naloxone administration, and emergency response.

Question 13: A patient with gout is having an acute attack. Which dietary teaching is most appropriate?

Increase fluid intake and avoid purine-rich foods and alcohol (Correct answer)
Increase intake of organ meats and shellfish
Limit fluid intake to reduce kidney workload
Start a high-protein diet to promote healing

Correct answer: Increase fluid intake and avoid purine-rich foods and alcohol

Adequate hydration promotes uric acid excretion; avoiding purines (organ meats, shellfish) and alcohol reduces uric acid production during a gout attack.

Question 14: Which patient position is safest for a patient who had a lumbar puncture (LP) 30 minutes ago?

Left lateral with knees flexed
Flat or prone for 1–4 hours per facility protocol (Correct answer)
Reverse Trendelenburg
High Fowler's position

Correct answer: Flat or prone for 1–4 hours per facility protocol

Remaining flat after LP reduces the risk of post-lumbar puncture headache caused by CSF leakage through the puncture site.

Question 15: A palliative care patient declines a recommended blood transfusion, stating it conflicts with their religious beliefs. The nurse's appropriate response is:

Respect the patient's decision and document their refusal, ensuring informed consent principles are upheld (Correct answer)
Pressure the family to convince the patient to accept the transfusion
Administer the transfusion anyway because the patient needs it to survive
Contact ethics to override the patient's decision

Correct answer: Respect the patient's decision and document their refusal, ensuring informed consent principles are upheld

Competent adult patients have the right to refuse any medical treatment; the nurse's role is to ensure the decision is informed and to document it, respecting patient autonomy.

Question 16: Which intervention is most effective in preventing wound infection in a surgical patient?

Administering prophylactic IV antibiotics within 60 minutes before the surgical incision (Correct answer)
Applying antiseptic ointment to the wound daily
Shaving the surgical site the night before surgery
Administering prophylactic antibiotics for 14 days post-operatively

Correct answer: Administering prophylactic IV antibiotics within 60 minutes before the surgical incision

Evidence-based SSI prevention includes administering prophylactic antibiotics within 60 minutes of incision to achieve therapeutic tissue levels at the time of incision.

Question 17: A patient receiving a fentanyl transdermal patch for chronic pain needs to know that the patch should be:

Changed every 24 hours for consistent drug delivery
Applied to the chest over bony prominences for best absorption
Applied to clean, dry, non-irritated, non-irradiated skin on the upper arm, chest, or back and rotated sites (Correct answer)
Heated with a blanket to increase absorption

Correct answer: Applied to clean, dry, non-irritated, non-irradiated skin on the upper arm, chest, or back and rotated sites

Fentanyl patches must be applied to intact, hairless, non-irradiated skin; heating the patch (fever, heating pads) accelerates absorption and can cause fatal overdose.

Question 18: A patient receiving radiation therapy to the abdomen reports severe diarrhea and rectal bleeding. Which nursing action is the PRIORITY?

Assess the frequency, character, and volume of stool and notify the provider (Correct answer)
Reassure the patient that this is a normal, expected side effect
Encourage a high-fiber diet to bulk the stool
Administer a Fleet enema to relieve rectal pressure

Correct answer: Assess the frequency, character, and volume of stool and notify the provider

Rectal bleeding and severe diarrhea during abdominal radiation can indicate bowel injury requiring prompt provider notification and assessment before interventions are initiated.

Question 19: A post-operative craniotomy patient has a urine output of 600 mL/hour with a specific gravity of 1.001. The nurse suspects:

Acute kidney injury
Urinary tract infection
Diabetes insipidus (DI) (Correct answer)
Syndrome of inappropriate antidiuretic hormone (SIADH)

Correct answer: Diabetes insipidus (DI)

Diabetes insipidus presents with large volumes of very dilute urine (low specific gravity), common after pituitary or hypothalamic surgery.

Question 20: Fat embolism syndrome (FES) is a serious complication most commonly associated with:

Hip replacement surgery in elderly women
Vertebral compression fractures
Rotator cuff repair
Long bone fractures, particularly femur and tibia (Correct answer)

Correct answer: Long bone fractures, particularly femur and tibia

Fat embolism syndrome most commonly occurs after fractures of long bones (femur, tibia) when fat globules enter the bloodstream.

Question 21: Which finding is characteristic of disseminated intravascular coagulation (DIC)?

Prolonged PT, prolonged aPTT, and elevated D-dimer (Correct answer)
Decreased PT with elevated fibrinogen levels
Thrombocytosis and shortened bleeding time
Elevated fibrinogen and decreased D-dimer

Correct answer: Prolonged PT, prolonged aPTT, and elevated D-dimer

DIC involves consumption of clotting factors and platelets, resulting in prolonged PT and aPTT, thrombocytopenia, low fibrinogen, and elevated D-dimer from fibrinolysis.

Question 22: Which of the following is a common symptom of gastroesophageal reflux disease (GERD)?

Jaundice
Diarrhea
Chronic cough (Correct answer)
Acute lower abdominal pain

Correct answer: Chronic cough

Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently flows back into the esophagus. While heartburn and regurgitation are classic symptoms, chronic cough is also a common and often overlooked symptom of GERD. The refluxed acid can irritate the esophagus and trigger a cough reflex, or it can be aspirated into the lungs, leading to persistent coughing.

Question 23: A patient with osteoporosis is starting alendronate (Fosamax). The nurse should instruct the patient to:

Take it at bedtime for best absorption
Take it with a full glass of water and remain upright for 30 minutes (Correct answer)
Crush the tablet for easier swallowing
Take it with a full meal to prevent nausea

Correct answer: Take it with a full glass of water and remain upright for 30 minutes

Bisphosphonates like alendronate must be taken with a full glass of water, and the patient must remain upright for at least 30 minutes to prevent esophageal irritation and ulceration.

Question 24: A nurse is educating a patient about acetaminophen (Tylenol) use. The maximum recommended daily dose for a healthy adult is:

1 gram per day
6 grams per day
4 grams per day (Correct answer)
2 grams per day

Correct answer: 4 grams per day

The maximum recommended daily dose of acetaminophen for healthy adults is 4 grams (4,000 mg); doses exceeding this risk hepatotoxicity.

Question 25: Which of the following is a common symptom of hyperthyroidism?

Heat intolerance (Correct answer)
Bradycardia
Constipation
Constipation

Correct answer: Heat intolerance

Hyperthyroidism is characterized by an overproduction of thyroid hormones, which significantly increases the body's metabolic rate. This elevated metabolism generates excess heat, causing individuals to feel uncomfortably warm and experience heat intolerance. Other common symptoms include weight loss, rapid heart rate, and nervousness.

Question 26: A patient with FES develops petechiae on the chest, axillae, and conjunctivae 48 hours after a femur fracture. The nurse recognizes this as:

An allergic reaction to analgesics
Normal ecchymosis from trauma
A sign of disseminated intravascular coagulation (DIC)
A classic sign of fat embolism syndrome (Correct answer)

Correct answer: A classic sign of fat embolism syndrome

Petechiae on the chest, axillae, and conjunctivae are a classic clinical sign of fat embolism syndrome caused by fat microglobules obstructing dermal capillaries.

Question 27: A patient receiving heparin therapy has a platelet count that dropped from 240,000 to 62,000/mm³ over 5 days. What condition does the nurse suspect?

Heparin-induced thrombocytopenia (HIT) (Correct answer)
Aplastic anemia
Disseminated intravascular coagulation (DIC)
Idiopathic thrombocytopenic purpura (ITP)

Correct answer: Heparin-induced thrombocytopenia (HIT)

A significant platelet drop (>50%) occurring 5–10 days after heparin initiation is the hallmark of HIT, an immune-mediated complication requiring immediate cessation of all heparin products.

Question 28: What is the primary purpose of administering bronchodilators to patients with asthma?

To treat bacterial infections
To increase mucus production
To reduce inflammation
To dilate the airways and improve airflow (Correct answer)

Correct answer: To dilate the airways and improve airflow

Bronchodilators are a class of medications specifically designed to relax the smooth muscles surrounding the airways in the lungs. In patients with asthma, these airways can constrict, making breathing difficult. By dilating the airways, bronchodilators help to open them up, reduce airflow obstruction, and improve the patient's ability to breathe more easily.

Question 29: A patient taking carbamazepine (Tegretol) for seizure management requires monitoring for which serious adverse effect?

Hypertension
Nephrolithiasis
Aplastic anemia and agranulocytosis (Correct answer)
Pulmonary fibrosis

Correct answer: Aplastic anemia and agranulocytosis

Carbamazepine can cause potentially fatal hematologic reactions including aplastic anemia, requiring routine CBC monitoring.

Question 30: A patient diagnosed with Guillain-Barré syndrome (GBS) is most at risk for which life-threatening complication?

Diabetic ketoacidosis
Renal failure
Hepatic encephalopathy
Respiratory failure (Correct answer)

Correct answer: Respiratory failure

GBS causes ascending paralysis that can involve the respiratory muscles, leading to respiratory failure requiring mechanical ventilation.

Question 31: Which dietary restriction is essential for a patient with end-stage renal disease (ESRD) on hemodialysis?

Restrict all fruits and vegetables permanently
Increase protein to compensate for dialysis losses
Restrict potassium, phosphorus, sodium, and fluid intake (Correct answer)
Restrict calcium and vitamin C only

Correct answer: Restrict potassium, phosphorus, sodium, and fluid intake

ESRD patients on hemodialysis must restrict potassium (arrhythmia risk), phosphorus (bone disease), sodium (fluid retention), and fluids (pulmonary edema risk).

Question 32: Which diagnostic test is most commonly used to confirm the presence of a myocardial infarction?

Chest X-ray
Electrocardiogram (ECG) (Correct answer)
Complete blood count (CBC)
Echocardiogram

Correct answer: Electrocardiogram (ECG)

An electrocardiogram (ECG or EKG) is the most commonly used and initial diagnostic test to confirm the presence of a myocardial infarction. It records the electrical activity of the heart and can reveal characteristic changes, such as ST-segment elevation or T-wave inversions, indicative of heart muscle damage or ischemia. The ECG provides immediate, vital information for guiding treatment decisions.

Question 33: A patient in skeletal traction requires nursing care. Which action is correct?

Tape the traction ropes to prevent slipping
Reposition the patient to the lateral position every 2 hours
Ensure weights hang freely and do not rest on the floor (Correct answer)
Remove weights briefly during patient repositioning

Correct answer: Ensure weights hang freely and do not rest on the floor

Traction weights must hang freely at all times to maintain proper traction force; resting weights on the floor negates the therapeutic effect.

Question 34: Which intervention is the priority when a patient with a C6 spinal cord injury develops severe hypertension (BP 210/115 mmHg), pounding headache, and diaphoresis above the level of injury?

Administer antihypertensive medication immediately
Sit the patient upright and identify/remove the noxious stimulus (Correct answer)
Insert a urinary catheter only after obtaining a physician order
Apply a warming blanket

Correct answer: Sit the patient upright and identify/remove the noxious stimulus

Autonomic dysreflexia requires immediate upright positioning and identification/removal of the triggering noxious stimulus (usually a distended bladder or bowel) as the first intervention.

Question 35: A patient is to receive ketorolac (Toradol) IV for post-operative pain. The nurse knows that ketorolac should not be administered for more than:

5 days (Correct answer)
10 days
30 days
24 hours

Correct answer: 5 days

Ketorolac is limited to 5 days maximum (IV or IM) due to cumulative risk of GI bleeding, renal impairment, and platelet dysfunction with prolonged use.

Question 36: A patient with a urinary tract infection (UTI) is prescribed trimethoprim-sulfamethoxazole (TMP-SMX). The nurse should instruct the patient to:

Avoid drinking water to concentrate the medication
Stop taking the medication once symptoms resolve to prevent resistance
Take the medication only at bedtime
Take the full course of antibiotics even if symptoms resolve (Correct answer)

Correct answer: Take the full course of antibiotics even if symptoms resolve

Completing the full antibiotic course eradicates the infection completely and prevents recurrence and antibiotic resistance.

Question 37: A patient on loop diuretic therapy for fluid overload should be monitored for:

Polycythemia and hypercalcemia
Hyperkalemia and metabolic acidosis
Hypernatremia and respiratory acidosis
Hypokalemia, hyponatremia, and metabolic alkalosis (Correct answer)

Correct answer: Hypokalemia, hyponatremia, and metabolic alkalosis

Loop diuretics cause loss of potassium, sodium, and chloride; chloride loss leads to metabolic alkalosis and hypokalemia increases arrhythmia risk.

Question 38: What is the most common cause of primary hypothyroidism?

Excessive iodine intake
Autoimmune thyroiditis (Hashimoto's disease) (Correct answer)
Pituitary adenoma
Thyroid cancer

Correct answer: Autoimmune thyroiditis (Hashimoto's disease)

Autoimmune thyroiditis, commonly known as Hashimoto's disease, is the most prevalent cause of primary hypothyroidism. In this condition, the body's immune system mistakenly attacks and gradually destroys the thyroid gland's cells. This chronic autoimmune assault impairs the thyroid's ability to produce sufficient thyroid hormones, leading to an underactive thyroid state.

Question 39: Which of the following is a hallmark symptom of chronic obstructive pulmonary disease (COPD)?

Sudden onset of chest pain
Intermittent fever
Progressive shortness of breath (Correct answer)
Acute abdominal pain

Correct answer: Progressive shortness of breath

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease characterized by persistent airflow obstruction. The hallmark symptom is progressive shortness of breath (dyspnea), which worsens over time and with exertion. This debilitating symptom significantly impacts a patient's quality of life and is a defining feature of the condition.

Question 40: The nurse is caring for a patient with Paget's disease of bone. Which laboratory finding is expected?

Markedly elevated alkaline phosphatase (ALP) (Correct answer)
Decreased serum uric acid
Elevated serum calcium and phosphorus
Low parathyroid hormone (PTH)

Correct answer: Markedly elevated alkaline phosphatase (ALP)

Markedly elevated alkaline phosphatase reflects the high rate of abnormal bone remodeling (osteoblastic activity) characteristic of Paget's disease.

Question 41: A family member asks the nurse to 'not tell my mother she has terminal cancer' to protect her feelings. The nurse should:

Avoid the topic and hope the patient doesn't ask
Explain that the patient has the right to know her diagnosis and discuss goals of care; involve the palliative care team (Correct answer)
Tell the patient immediately without family present
Agree and withhold the diagnosis from the patient

Correct answer: Explain that the patient has the right to know her diagnosis and discuss goals of care; involve the palliative care team

Patient autonomy requires truthful disclosure of the diagnosis; the nurse should involve the multidisciplinary palliative care team to facilitate sensitive family-patient communication.

Question 42: A patient with urinary incontinence is started on oxybutynin (Ditropan). The nurse should teach the patient to anticipate which common side effects?

Increased salivation and bradycardia
Increased urination and diarrhea
Dry mouth, constipation, and urinary retention (Correct answer)
Hypertension and tachycardia

Correct answer: Dry mouth, constipation, and urinary retention

Oxybutynin is an anticholinergic medication; classic side effects include dry mouth, constipation, blurred vision, and urinary retention.

Question 43: A patient has a wound with red, moist, granulating tissue filling the wound bed. The nurse correctly identifies this as:

Healthy granulation tissue indicating the wound is healing (Correct answer)
A sign of wound infection requiring cultures
Eschar that should be monitored
Necrotic tissue requiring debridement

Correct answer: Healthy granulation tissue indicating the wound is healing

Bright red, moist, granulating tissue is healthy new tissue forming during the proliferative phase of wound healing.

Question 44: A nurse is debriding a wound using wet-to-dry dressing changes. The nurse understands this method works by:

Applying enzymatic agents to break down necrosis
Mechanically removing necrotic tissue as the gauze dries and adheres to the wound (Correct answer)
Providing a moist wound environment for healing
Promoting autolysis through moisture balance

Correct answer: Mechanically removing necrotic tissue as the gauze dries and adheres to the wound

Wet-to-dry debridement works mechanically — the moist gauze dries and adheres to necrotic tissue, which is removed when the dressing is changed.

Question 45: A patient with ankylosing spondylitis requires which nursing intervention to maintain optimal function?

Apply cervical traction daily
Encourage upright posture and spinal extension exercises (Correct answer)
Restrict all physical activity during flares
Bed rest with soft mattress to minimize pain

Correct answer: Encourage upright posture and spinal extension exercises

Maintaining upright posture and performing spinal extension exercises helps prevent the progressive kyphotic spinal deformity of ankylosing spondylitis.

Question 46: When performing a neurological assessment, the nurse asks the patient to identify a familiar object placed in their hand without looking. This test evaluates:

Proprioception
Two-point discrimination
Stereognosis (Correct answer)
Graphesthesia

Correct answer: Stereognosis

Stereognosis is the ability to identify objects by touch alone, testing sensory cortex and parietal lobe integration.

Question 47: To prevent pressure injury development, the nurse should reposition an immobile patient at minimum every:

2 hours on a standard mattress, or every 4 hours on a high-specification foam mattress (Correct answer)
1 hour if on a standard mattress
4 hours regardless of mattress type
6 hours during nighttime hours

Correct answer: 2 hours on a standard mattress, or every 4 hours on a high-specification foam mattress

NPIAP guidelines recommend repositioning every 2 hours on standard mattresses, or every 4 hours on high-specification foam mattresses to relieve pressure.

Question 48: A patient with multiple sclerosis (MS) reports worsening symptoms after a hot shower. The nurse recognizes this as:

Uhthoff's phenomenon — temporary worsening with heat (Correct answer)
An MS relapse requiring IV steroids
A hypertensive crisis
A sign of medication toxicity

Correct answer: Uhthoff's phenomenon — temporary worsening with heat

Uhthoff's phenomenon is the temporary worsening of MS symptoms with heat exposure due to impaired nerve conduction in demyelinated fibers.

Question 49: A medical-surgical nurse is inserting an indwelling urinary catheter in a female patient. To prevent catheter-associated UTI (CAUTI), which action is MOST important?

Routinely irrigate the catheter with antibiotic solution
Use strict aseptic technique during catheter insertion (Correct answer)
Change the catheter every 48 hours
Secure the catheter to the bed rail

Correct answer: Use strict aseptic technique during catheter insertion

Strict aseptic technique during insertion is the single most important intervention to prevent CAUTI by preventing bacterial introduction.

Question 50: A patient with nephrotic syndrome has 4+ pitting edema and serum albumin of 1.8 g/dL. The edema is primarily caused by:

Loss of albumin in urine reducing plasma oncotic pressure (Correct answer)
Excessive sodium intake
Increased aldosterone secretion
Right-sided heart failure

Correct answer: Loss of albumin in urine reducing plasma oncotic pressure

Massive protein (albumin) loss in urine lowers plasma oncotic pressure, allowing fluid to shift into the interstitium, causing profound edema.

Question 51: Which symptom is characteristic of Parkinson's disease that the medical-surgical nurse should assess for?

Intention tremor at rest that worsens with movement
Resting tremor, rigidity, and bradykinesia (Correct answer)
Sudden onset paralysis and aphasia
Ascending muscle weakness

Correct answer: Resting tremor, rigidity, and bradykinesia

The classic triad of Parkinson's disease is resting tremor, muscle rigidity, and bradykinesia (slowness of movement).

Question 52: A patient is receiving IV phenytoin for seizure management. The nurse should monitor for which priority adverse effect?

Cardiac dysrhythmias (Correct answer)
Hyperglycemia
Hypokalemia
Constipation

Correct answer: Cardiac dysrhythmias

IV phenytoin administered too rapidly can cause severe cardiac dysrhythmias, including bradycardia and heart block.

Question 53: Which assessment finding is MOST consistent with a patient experiencing sickle cell crisis?

Petechiae and prolonged bleeding
Severe localized bone pain and fever (Correct answer)
Jaundice and elevated platelet count
Bradycardia and hypotension

Correct answer: Severe localized bone pain and fever

Vaso-occlusive (painful) sickle cell crisis causes severe bone and joint pain due to microvascular obstruction, often accompanied by fever.

Question 54: A patient with CKD has a serum bicarbonate of 16 mEq/L. The nurse recognizes this as:

Metabolic alkalosis from vomiting
Respiratory alkalosis from hyperventilation
Metabolic acidosis from impaired acid excretion (Correct answer)
Normal finding in CKD

Correct answer: Metabolic acidosis from impaired acid excretion

The failing kidney cannot adequately excrete hydrogen ions or reabsorb bicarbonate, causing metabolic acidosis (low bicarbonate) in CKD.

Question 55: A patient with a cervical spinal cord injury at C4 suddenly develops bradycardia and hypotension with warm, flushed skin below the injury. The nurse should recognize this as:

Autonomic dysreflexia
Neurogenic shock (Correct answer)
Septic shock
Hypovolemic shock

Correct answer: Neurogenic shock

Neurogenic shock following high spinal cord injury causes loss of sympathetic tone, resulting in bradycardia, hypotension, and vasodilation below the injury.

Question 56: A patient with non-Hodgkin's lymphoma is starting rituximab infusion. Which adverse effect should the nurse monitor for MOST closely during the infusion?

Infusion-related reaction including fever, chills, and hypotension (Correct answer)
Severe constipation and ileus
Hypoglycemia and diaphoresis
Pulmonary edema and decreased urine output

Correct answer: Infusion-related reaction including fever, chills, and hypotension

Rituximab commonly causes infusion-related reactions (fever, chills, rigors, hypotension) especially during the first infusion, requiring close monitoring and slowing or stopping the infusion if reactions occur.

Question 57: Which of the following laboratory tests is the best indicator of long-term glycemic control in diabetic patients?

Hemoglobin A1c (Correct answer)
Random blood glucose
Fasting blood glucose
Postprandial blood glucose

Correct answer: Hemoglobin A1c

Hemoglobin A1c (HbA1c) is the best indicator of long-term glycemic control because it measures the average blood glucose levels over the preceding 2 to 3 months. This test reflects the amount of glucose attached to hemoglobin in red blood cells, which have a lifespan of approximately 120 days. Unlike fasting or random blood glucose tests, HbA1c provides a comprehensive picture of glucose management, making it crucial for monitoring diabetes treatment effectiveness.

Question 58: Which of the following dietary recommendations is most appropriate for a patient with irritable bowel syndrome (IBS)?

High-fat diet
Low-fiber diet
Low-FODMAP diet (Correct answer)
High-sugar diet

Correct answer: Low-FODMAP diet

For patients with irritable bowel syndrome (IBS), a low-FODMAP (Fermentable Oligo-, Di-, Mono-saccharides And Polyols) diet is often recommended and has strong evidence for symptom relief. FODMAPs are types of carbohydrates that can be poorly absorbed and fermented in the gut, leading to gas, bloating, and abdominal pain in sensitive individuals. Reducing their intake can significantly alleviate IBS symptoms.

Question 59: A patient in hospice care becomes increasingly confused, restless, and distressed in the final days of life. The nurse recognizes this as:

Severe medication overdose
Normal sleep pattern changes
Terminal restlessness (terminal delirium), a common end-of-life phenomenon (Correct answer)
A sign of undertreated pain requiring dose escalation

Correct answer: Terminal restlessness (terminal delirium), a common end-of-life phenomenon

Terminal restlessness is a common end-of-life syndrome characterized by agitation, confusion, and distress that often responds to low-dose haloperidol or benzodiazepines.

Question 60: Which assessment finding in a post-stroke patient indicates a deteriorating neurological status requiring immediate notification of the provider?

Mild headache rated 3/10
Muscle weakness on the affected side
Blood pressure of 148/90 mmHg
New onset confusion and unequal pupils (Correct answer)

Correct answer: New onset confusion and unequal pupils

New onset confusion combined with unequal pupils (anisocoria) signals herniation or expanding hemorrhage and is a neurological emergency.

Question 61: A patient's sacral wound has a foul smell, green exudate, and surrounding erythema. The nurse identifies this as:

Normal serosanguineous drainage
Signs of wound infection requiring provider notification (Correct answer)
Granulation tissue formation — a sign of healing
Epithelization of the wound bed

Correct answer: Signs of wound infection requiring provider notification

Foul odor, purulent (green/yellow) exudate, and periwound erythema are classic signs of wound infection requiring medical evaluation and possible antibiotic therapy.

Question 62: A patient with leukemia is being discharged after chemotherapy. Which statement by the patient indicates a need for FURTHER teaching?

'I will wash my hands frequently throughout the day.'
'I will avoid fresh fruits and salads until my counts recover.'
'I will take my temperature daily and report a reading above 100.4°F.'
'I can visit my grandchildren even if they have a cold; they need me.' (Correct answer)

Correct answer: 'I can visit my grandchildren even if they have a cold; they need me.'

Immunocompromised patients must avoid contact with individuals who have infections, including minor colds, as these can be life-threatening when neutropenic.

Question 63: A patient with rheumatoid arthritis (RA) is prescribed methotrexate. The nurse should teach the patient to avoid:

Alcohol and NSAIDs (Correct answer)
Weight-bearing exercise
Vitamin D supplements
Calcium-rich foods

Correct answer: Alcohol and NSAIDs

Alcohol combined with methotrexate greatly increases hepatotoxicity risk; NSAIDs increase methotrexate toxicity by reducing renal clearance.

Question 64: A patient rates their post-operative pain as 8/10 and reports their current analgesic regimen is ineffective. The nurse's first action is:

Apply ice to the surgical site only
Wait until the next scheduled medication time
Assess the pain fully using location, quality, onset, and aggravating factors, then contact the provider for orders if needed (Correct answer)
Administer the next scheduled dose early

Correct answer: Assess the pain fully using location, quality, onset, and aggravating factors, then contact the provider for orders if needed

Comprehensive pain reassessment is necessary before escalating treatment to ensure the appropriate analgesic approach is selected for the type of pain.

Question 65: A patient with suspected increased intracranial pressure (ICP) is admitted to the medical-surgical unit. Which nursing intervention is the priority?

Elevate the head of bed to 30–45 degrees (Correct answer)
Apply a heating pad to the neck
Place the patient in Trendelenburg position
Encourage vigorous coughing to clear secretions

Correct answer: Elevate the head of bed to 30–45 degrees

Elevating the head of bed to 30–45 degrees promotes venous drainage and helps reduce intracranial pressure.

Question 66: A patient with advanced heart failure is transitioned to comfort-focused care. Which order would the nurse anticipate discontinuing?

Oral opioids for pain management
Morphine sulfate PRN for dyspnea
Daily lipid-lowering statin therapy (Correct answer)
Mouth care and skin care

Correct answer: Daily lipid-lowering statin therapy

Preventive medications like statins that serve no immediate comfort purpose are typically discontinued in comfort-focused care to reduce the pill burden and focus on symptom management.

Question 67: A patient with chronic kidney disease (CKD) stage 4 asks why they need to restrict dietary phosphorus. The best response is:

'Low phosphorus diets prevent kidney stones.'
'Phosphorus restriction prevents potassium from rising.'
'Your kidneys cannot excrete phosphorus well, which causes it to build up and leach calcium from bones.' (Correct answer)
'High phosphorus increases your blood pressure.'

Correct answer: 'Your kidneys cannot excrete phosphorus well, which causes it to build up and leach calcium from bones.'

In CKD, impaired phosphorus excretion leads to hyperphosphatemia, which stimulates PTH release and causes calcium to be pulled from bone (renal osteodystrophy).

Question 68: What is the most common cause of acute pancreatitis?

Gallstones (Correct answer)
Appendicitis
Chronic constipation
Ulcerative colitis

Correct answer: Gallstones

Gallstones are the most common cause of acute pancreatitis because they can obstruct the common bile duct, which shares an opening with the pancreatic duct. This blockage prevents pancreatic enzymes from flowing into the small intestine, causing them to back up and prematurely activate within the pancreas itself. This auto-digestion leads to inflammation and damage of the pancreatic tissue, resulting in acute pancreatitis.

Question 69: A patient with a draining wound has periwound skin breakdown from moisture. The nurse should apply which product to protect the surrounding skin?

Wet-to-dry dressings to the entire wound and periwound area
Dry gauze taped over the area
Moisture barrier ointment or liquid skin protectant to the periwound area (Correct answer)
Adhesive film dressing directly over the macerated skin

Correct answer: Moisture barrier ointment or liquid skin protectant to the periwound area

Moisture barrier ointments or liquid skin protectants create a waterproof barrier over the periwound skin, preventing further maceration from wound exudate.

Question 70: A patient with acute kidney injury (AKI) has a serum potassium of 6.8 mEq/L and peaked T waves on ECG. The nurse's priority action is:

Prepare to administer calcium gluconate and notify the provider immediately (Correct answer)
Administer a potassium supplement
Encourage increased fluid intake
Restrict dietary potassium intake only

Correct answer: Prepare to administer calcium gluconate and notify the provider immediately

Hyperkalemia with ECG changes is a cardiac emergency; calcium gluconate is administered first to stabilize the myocardium while definitive treatment is arranged.

Question 71: A patient with a diabetic foot ulcer has a wound covered with a black, hard, leathery crust. The nurse recognizes this as:

Necrotic eschar that typically requires debridement to assess wound base (Correct answer)
A scab indicating normal wound healing
Healthy eschar that should be left intact
Granulation tissue forming under the crust

Correct answer: Necrotic eschar that typically requires debridement to assess wound base

Black, hard eschar is necrotic tissue that prevents wound assessment and healing; debridement is generally required unless the wound is on a heel with good perfusion.

Question 72: Which medication is commonly prescribed to manage chronic heart failure by reducing fluid overload?

Diuretics (Correct answer)
Beta-blockers
ACE inhibitors
Statins

Correct answer: Diuretics

Diuretics are commonly prescribed medications for patients with chronic heart failure because they help reduce fluid overload. These drugs promote the elimination of excess fluid and sodium through increased urine output, thereby decreasing congestion and symptoms like swelling and shortness of breath. This action helps to reduce the workload on the failing heart.

Question 73: A patient with a urinary catheter develops a fever, flank pain, and costovertebral angle (CVA) tenderness. The nurse suspects:

Nephrolithiasis
Urethritis
Pyelonephritis (upper UTI) (Correct answer)
Lower UTI (cystitis)

Correct answer: Pyelonephritis (upper UTI)

Fever, flank pain, and CVA tenderness indicate pyelonephritis (kidney infection), which can progress to sepsis if not treated promptly.

Question 74: Which Braden Scale score indicates the HIGHEST risk for pressure injury development?

18
6 (Correct answer)
13
23

Correct answer: 6

The Braden Scale scores from 6 (lowest possible) to 23 (no risk); a score of 6 indicates the most severe risk for pressure injury across all subscales.

Question 75: What is the primary goal of administering thrombolytic therapy in patients with acute coronary syndrome?

To reduce hypertension
To lower cholesterol levels
To prevent arrhythmias
To dissolve the blood clot obstructing the coronary artery (Correct answer)

Correct answer: To dissolve the blood clot obstructing the coronary artery

Thrombolytic therapy, often referred to as 'clot-busting' drugs, is administered in acute coronary syndrome to dissolve the blood clot obstructing a coronary artery. By breaking down the clot, this therapy aims to restore blood flow to the heart muscle. This crucial intervention helps limit the extent of myocardial damage and improve patient outcomes, especially when administered promptly.

Question 76: A patient with a history of opioid use disorder requires post-operative pain management. The nurse understands that:

Opioids must never be used in this patient under any circumstances
Patients with opioid use disorder have the right to effective pain management; coordinate with pain/addiction specialists (Correct answer)
Lower than standard opioid doses should be used since the patient is drug-seeking
Only NSAIDs should be used regardless of pain severity

Correct answer: Patients with opioid use disorder have the right to effective pain management; coordinate with pain/addiction specialists

Patients with opioid use disorder are entitled to effective pain management; undertreating pain is unethical, and coordination with addiction medicine optimizes both comfort and safety.

Question 77: A nurse is caring for a patient with thrombocytopenia (platelet count 18,000/mm³). Which action should the nurse AVOID?

Applying firm pressure after venipuncture
Using a soft-bristled toothbrush
Administering stool softeners
Administering aspirin for headache (Correct answer)

Correct answer: Administering aspirin for headache

Aspirin inhibits platelet aggregation and is contraindicated in thrombocytopenia because it further increases the risk of serious bleeding.

Question 78: A patient with iron-deficiency anemia is prescribed ferrous sulfate. Which instruction should the nurse include?

Take the medication with orange juice on an empty stomach (Correct answer)
Take the medication with milk to reduce GI upset
Take the medication with antacids to improve absorption
Take the medication at bedtime to avoid daytime nausea

Correct answer: Take the medication with orange juice on an empty stomach

Vitamin C (ascorbic acid) in orange juice enhances iron absorption, and taking ferrous sulfate on an empty stomach maximizes uptake despite potential GI discomfort.

Question 79: A patient with a fractured hip is placed in Buck's traction pre-operatively. The PRIMARY purpose is to:

Heal the fracture without surgery
Strengthen the leg muscles before surgery
Prevent DVT
Reduce muscle spasm and pain while maintaining alignment (Correct answer)

Correct answer: Reduce muscle spasm and pain while maintaining alignment

Buck's traction is applied pre-operatively to reduce painful muscle spasms and maintain alignment of the fractured hip until surgical repair.

Question 80: A patient with a venous stasis ulcer on the lower leg is prescribed compression therapy. The nurse should apply compression wraps:

With the greatest pressure at the knee and decreasing distally
After assessing for arterial insufficiency — do not apply if ABIs are below 0.5 (Correct answer)
Only during sleep to reduce discomfort
With the greatest pressure at the ankle and decreasing toward the knee (graduated compression)

Correct answer: After assessing for arterial insufficiency — do not apply if ABIs are below 0.5

Compression is contraindicated in severe arterial disease (ABI <0.5); assessing ankle-brachial index (ABI) before applying compression prevents dangerous ischemia.

Question 81: A patient with a hip replacement is being repositioned by the nurse. Which action should be AVOIDED to prevent hip dislocation?

Using a wedge pillow between the legs
Keeping the head of the bed below 90 degrees
Keeping the operative leg abducted
Adducting the leg across the midline (Correct answer)

Correct answer: Adducting the leg across the midline

After total hip arthroplasty, adduction beyond midline, extreme flexion >90°, and internal rotation are the three movements most likely to cause dislocation.

Question 82: A patient receiving high-dose opioids for cancer pain is concerned about addiction. The nurse's best response is:

'Your concern is valid — opioids always lead to addiction.'
'Addiction doesn't apply to cancer patients so don't worry about it.'
'You should be worried — we will start weaning your dose immediately.'
'Physical dependence is expected with long-term opioids, but addiction (compulsive misuse despite harm) is rare in cancer pain patients taking opioids as prescribed.' (Correct answer)

Correct answer: 'Physical dependence is expected with long-term opioids, but addiction (compulsive misuse despite harm) is rare in cancer pain patients taking opioids as prescribed.'

Distinguishing physical dependence (expected physiological adaptation) from addiction (psychological disorder with compulsive misuse) is essential patient education in pain management.

Question 83: Which Glasgow Coma Scale (GCS) score indicates a severe traumatic brain injury?

3–8 (Correct answer)
1–2
9–12
13–15

Correct answer: 3–8

A GCS score of 3–8 is classified as severe traumatic brain injury, indicating significant neurological compromise.

Question 84: A patient with benign prostatic hyperplasia (BPH) is unable to void and has a distended bladder. After catheterization, 900 mL of urine is drained. The nurse should:

Clamp the catheter after 400–600 mL and monitor for hematuria or hypotension (Correct answer)
Irrigate the bladder with normal saline
Remove the catheter after draining 200 mL
Continue draining until the bladder is completely empty immediately

Correct answer: Clamp the catheter after 400–600 mL and monitor for hematuria or hypotension

Rapid decompression of a severely distended bladder can cause decompression hematuria and vasovagal hypotension; clamping after 400–600 mL allows gradual decompression.

Question 85: A medical-surgical nurse is using non-pharmacological pain management. Which intervention has the strongest evidence for acute post-operative pain?

Multimodal approach combining ice/heat, positioning, relaxation techniques, and analgesics (Correct answer)
Distraction with television only
Guided imagery as the sole intervention
Therapeutic touch alone

Correct answer: Multimodal approach combining ice/heat, positioning, relaxation techniques, and analgesics

A multimodal approach combining non-pharmacological techniques with analgesics provides superior pain control by targeting multiple pain pathways.

Question 86: Which hormone is responsible for lowering blood glucose levels?

Insulin (Correct answer)
Epinephrine
Glucagon
Cortisol

Correct answer: Insulin

Insulin is a hormone produced by the beta cells of the pancreas, and its primary role is to lower blood glucose levels. After a meal, when blood glucose rises, insulin is released to facilitate the uptake of glucose from the bloodstream into cells for energy or storage. It acts as a key, allowing glucose to enter cells, thereby reducing its concentration in the blood.

Question 87: A patient with chronic lymphocytic leukemia (CLL) is prescribed oral chlorambucil. What priority teaching should the nurse provide?

Avoid all sunlight exposure for 6 months after therapy
Increase sodium intake to prevent electrolyte imbalance
Take the medication on a full stomach to maximize absorption
Monitor for signs of infection due to immunosuppression (Correct answer)

Correct answer: Monitor for signs of infection due to immunosuppression

Chlorambucil is an alkylating agent that suppresses bone marrow, causing leukopenia; patients must recognize infection signs promptly as they are immunocompromised.

Question 88: The nurse is educating a patient newly diagnosed with polycythemia vera. Which statement reflects accurate understanding of the condition?

'I should avoid all physical activity to prevent bleeding.'
'This condition means I am at lower risk for blood clots.'
'My bone marrow is producing too few red blood cells.'
'I need to drink more fluids and may need phlebotomy to reduce my blood thickness.' (Correct answer)

Correct answer: 'I need to drink more fluids and may need phlebotomy to reduce my blood thickness.'

Polycythemia vera involves overproduction of RBCs, increasing blood viscosity and clot risk; phlebotomy and hydration are key management strategies.

Question 89: Which of the following interventions is essential for a patient with pneumonia?

Restricting fluid intake
Administering antihypertensive medications
Encouraging deep breathing and coughing exercises (Correct answer)
Limiting physical activity

Correct answer: Encouraging deep breathing and coughing exercises

For a patient with pneumonia, encouraging deep breathing and coughing exercises is an essential intervention. These exercises help to clear secretions from the lungs, promote lung expansion, and prevent atelectasis (lung collapse). This facilitates improved oxygenation, aids in recovery, and reduces the risk of complications associated with retained secretions.

Question 90: A patient on hemodialysis reports shortness of breath and a 4 kg weight gain since the last dialysis session. The nurse's priority assessment is:

Skin turgor
Lung sounds and oxygen saturation (Correct answer)
Neurological status
Blood glucose level

Correct answer: Lung sounds and oxygen saturation

Rapid weight gain between dialysis sessions indicates fluid overload; dyspnea and crackles on auscultation suggest pulmonary edema requiring urgent assessment.

Question 91: A patient asks the nurse why ice packs are applied to a sprained ankle in the first 48 hours. The best response is:

'Ice numbs the nerves to completely eliminate pain.'
'Ice prevents infection at the injury site.'
'Cold reduces blood flow and decreases inflammation and swelling.' (Correct answer)
'Cold promotes circulation to speed healing.'

Correct answer: 'Cold reduces blood flow and decreases inflammation and swelling.'

Cold therapy reduces blood flow via vasoconstriction, decreasing local inflammation, edema, and pain in the acute phase of injury.

Question 92: A nurse is caring for a patient with Hodgkin's lymphoma after staging reveals Stage IIA disease. What does this staging PRIMARILY indicate?

Involvement of a single lymph node region without symptoms
Involvement of two or more lymph node regions on the same side of the diaphragm without B symptoms (Correct answer)
Disseminated disease involving multiple organs
Involvement of lymph nodes on both sides of the diaphragm

Correct answer: Involvement of two or more lymph node regions on the same side of the diaphragm without B symptoms

Stage II in Hodgkin's lymphoma indicates two or more lymph node regions on the same side of the diaphragm; 'A' denotes the absence of B symptoms (fever, night sweats, weight loss).

Question 93: A patient with osteoarthritis is prescribed celecoxib (Celebrex). The nurse should monitor for which serious adverse effect?

Cardiovascular events and GI bleeding (Correct answer)
Hypoglycemia
Nephrotoxicity from daily vitamin use
Pulmonary hypertension

Correct answer: Cardiovascular events and GI bleeding

COX-2 inhibitors like celecoxib carry a black box warning for increased risk of cardiovascular events (MI, stroke) and GI bleeding.

Question 94: Which assessment finding is an EARLY sign of tumor lysis syndrome (TLS)?

Hypercalcemia and hypokalemia
Hypoglycemia and metabolic alkalosis
Hyponatremia and hypochloremia
Hyperkalemia, hyperphosphatemia, and hyperuricemia (Correct answer)

Correct answer: Hyperkalemia, hyperphosphatemia, and hyperuricemia

TLS occurs when tumor cells rapidly lyse and release intracellular contents, causing hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia.

Question 95: A patient with acute myeloid leukemia (AML) asks why they need a bone marrow biopsy. What is the BEST nursing response?

'It helps confirm the diagnosis and identify the specific leukemia cell type to guide treatment.' (Correct answer)
'It will determine how well your kidneys are functioning.'
'It replaces the need for a CT scan in your case.'
'It is a routine screening test used in all cancer patients.'

Correct answer: 'It helps confirm the diagnosis and identify the specific leukemia cell type to guide treatment.'

Bone marrow biopsy is essential to confirm AML, classify the disease subtype, and guide treatment planning with chemotherapy regimens.

Question 96: A palliative care patient with advanced cancer has uncontrolled pain despite scheduled opioids. The nurse should advocate for the addition of:

A benzodiazepine as the primary analgesic
An antibiotic to reduce pain
A lower dose of the current opioid
A breakthrough (rescue) dose of a short-acting opioid for episodic pain (Correct answer)

Correct answer: A breakthrough (rescue) dose of a short-acting opioid for episodic pain

Breakthrough (rescue) doses of short-acting opioids are prescribed for episodic or incident pain that exceeds the relief provided by scheduled long-acting medications.

Question 97: Which diagnostic test is most commonly used to evaluate lung function in patients with respiratory conditions?

Pulmonary function tests (PFTs) (Correct answer)
Complete blood count (CBC)
Chest X-ray
Electrocardiogram (ECG)

Correct answer: Pulmonary function tests (PFTs)

Pulmonary function tests (PFTs) are a group of non-invasive diagnostic tests that measure how well the lungs are working. They assess lung volume, capacity, rates of flow, and gas exchange, providing crucial information about the severity and type of respiratory impairment. PFTs are essential for diagnosing and monitoring conditions like asthma, COPD, and restrictive lung diseases.

Question 98: What is the primary diagnostic test used to confirm the presence of peptic ulcer disease?

Abdominal ultrasound
Colonoscopy
Upper endoscopy (esophagogastroduodenoscopy) (Correct answer)
Barium swallow

Correct answer: Upper endoscopy (esophagogastroduodenoscopy)

Upper endoscopy, also known as esophagogastroduodenoscopy (EGD), is the primary diagnostic test used to confirm the presence of peptic ulcer disease. During an EGD, a thin, flexible tube with a camera is inserted to directly visualize the lining of the esophagus, stomach, and duodenum. This allows for definitive diagnosis, assessment of ulcer characteristics, and biopsies if necessary.

Question 99: In the WHO analgesic ladder, which step represents the use of strong opioids for severe pain?

Step 2 — weak opioids such as codeine
Step 1 — non-opioids (acetaminophen, NSAIDs)
Step 4 — interventional procedures
Step 3 — strong opioids such as morphine or oxycodone (Correct answer)

Correct answer: Step 3 — strong opioids such as morphine or oxycodone

WHO Step 3 recommends strong opioids (morphine, oxycodone, hydromorphone) for severe pain (NRS 7–10) when Step 1 and Step 2 analgesics are inadequate.

Question 100: Which finding requires the nurse to hold a scheduled dose of phenobarbital and contact the provider?

Mild drowsiness after the first dose
Blood pressure 130/80 mmHg
Mild nausea reported by the patient
Respiratory rate of 8 breaths/min and decreased LOC (Correct answer)

Correct answer: Respiratory rate of 8 breaths/min and decreased LOC

Phenobarbital causes CNS and respiratory depression; a respiratory rate of 8/min with decreased LOC indicates dangerous toxicity.

Question 101: A patient has a Stage II pressure injury on the sacrum. Which wound characteristic best describes a Stage II pressure injury?

Full-thickness tissue loss with exposed bone, tendon, or muscle
Intact skin with non-blanchable redness
Full-thickness tissue loss with visible subcutaneous fat
Partial-thickness skin loss presenting as a shallow open ulcer or intact/ruptured blister (Correct answer)

Correct answer: Partial-thickness skin loss presenting as a shallow open ulcer or intact/ruptured blister

Stage II pressure injury involves partial-thickness skin loss (epidermis and/or dermis), presenting as a shallow pink/red wound or intact or ruptured serum-filled blister.

Question 102: A patient returns from surgery for an open reduction and internal fixation (ORIF) of the femur. The nurse assesses the 5 Ps of neurovascular status. Which finding requires immediate intervention?

Bruising around the incision site
Pulselessness and pallor of the affected extremity (Correct answer)
Mild swelling at the operative site
Pain rated 6/10 managed with opioids

Correct answer: Pulselessness and pallor of the affected extremity

Pulselessness and pallor indicate arterial compromise or compartment syndrome, which are surgical emergencies requiring immediate action.

Question 103: A patient is receiving negative pressure wound therapy (NPWT/VAC). The nurse notes the therapy has lost suction. The priority action is:

Inspect the dressing for air leaks, reinforce with foam and drape to restore seal (Correct answer)
Remove the dressing and apply a dry gauze dressing
Discontinue therapy and notify provider immediately
Increase the prescribed negative pressure setting

Correct answer: Inspect the dressing for air leaks, reinforce with foam and drape to restore seal

Loss of suction in NPWT is most commonly due to a dressing air leak; inspecting and reinforcing the seal restores therapeutic function without discontinuing treatment.

Question 104: A patient with a sacral pressure injury has yellow, soft, stringy tissue in the wound bed. The nurse identifies this as:

Slough — non-viable tissue that impedes healing and may require debridement (Correct answer)
Normal epithelizing tissue
Granulation tissue — a positive healing sign
Necrotic eschar requiring immediate surgical debridement

Correct answer: Slough — non-viable tissue that impedes healing and may require debridement

Slough is yellow, tan, or green moist necrotic tissue that adheres to the wound bed; it must be debrided as it harbors bacteria and impedes healing.

Question 105: A nurse is providing discharge teaching to a patient using crutches after a lower extremity fracture. Which instruction is correct for three-point non-weight-bearing gait?

Bear equal weight on both legs and crutches simultaneously
Move both crutches and the affected leg forward together, then swing the unaffected leg through (Correct answer)
Step with the unaffected leg first, then advance crutches
Move both crutches forward, then step with the good leg, then the affected leg

Correct answer: Move both crutches and the affected leg forward together, then swing the unaffected leg through

In three-point gait, both crutches and the injured extremity advance together, followed by the unaffected leg, keeping all weight off the injured limb.

Question 106: A patient with aplastic anemia is receiving immunosuppressive therapy with anti-thymocyte globulin (ATG). Which nursing priority is MOST important during the infusion?

Administer the infusion rapidly over 30 minutes
Ensure the patient is NPO for 8 hours before infusion
Position the patient in Trendelenburg to improve venous return
Monitor for anaphylaxis and serum sickness reactions (Correct answer)

Correct answer: Monitor for anaphylaxis and serum sickness reactions

ATG is derived from animal serum and carries a significant risk of anaphylaxis and serum sickness; close monitoring for allergic reactions during and after infusion is the top priority.

Question 107: Which patient with anemia requires the MOST urgent assessment by the nurse?

A patient with hemoglobin of 8.4 g/dL who reports difficulty walking long distances
A patient with hemoglobin of 7.2 g/dL who reports chest pain and dyspnea at rest (Correct answer)
A patient with hemoglobin of 9.8 g/dL who reports mild fatigue
A patient with hemoglobin of 10.5 g/dL with pallor of the mucous membranes

Correct answer: A patient with hemoglobin of 7.2 g/dL who reports chest pain and dyspnea at rest

Chest pain and dyspnea at rest with a hemoglobin of 7.2 g/dL indicates severe anemia with cardiopulmonary compromise requiring immediate intervention.

Question 108: A dying patient's family asks why the nurse is administering morphine for dyspnea when the patient is not in pain. The best response is:

'Morphine is only for pain; I'll check the order again.'
'This medication will keep the patient sedated so the family can have peace.'
'Low-dose morphine reduces the sensation of air hunger in dying patients without hastening death when used appropriately.' (Correct answer)
'We are using morphine to help the patient die more comfortably and quickly.'

Correct answer: 'Low-dose morphine reduces the sensation of air hunger in dying patients without hastening death when used appropriately.'

Low-dose opioids are evidence-based for relieving dyspnea in terminal illness by reducing the brain's response to hypercapnia and the sensation of breathlessness.

Question 109: Which tool is most appropriate for assessing pain in a non-verbal patient with dementia on a medical-surgical unit?

Numeric Rating Scale (NRS 0–10)
PAINAD (Pain Assessment in Advanced Dementia) scale (Correct answer)
Wong-Baker FACES scale
Visual Analog Scale (VAS)

Correct answer: PAINAD (Pain Assessment in Advanced Dementia) scale

The PAINAD scale assesses behavioral pain indicators (breathing, vocalization, facial expression, body language, consolability) in non-verbal dementia patients.

Question 110: A patient with a peritoneal dialysis catheter reports cloudy dialysate effluent and abdominal pain. The nurse should suspect:

Catheter malposition
Peritonitis — a serious infection complication (Correct answer)
Excessive dextrose absorption
Normal catheter functioning

Correct answer: Peritonitis — a serious infection complication

Cloudy peritoneal effluent with abdominal pain indicates peritonitis, the most serious complication of peritoneal dialysis, requiring immediate culture and antibiotics.

Question 111: A nurse is caring for a patient with a dehisced abdominal wound healing by secondary intention with a wound VAC. The nurse understands that the primary goal of secondary intention healing is:

Applying skin grafts immediately
Delayed primary closure after 3–5 days
Gradual filling of the wound with granulation tissue from the base upward (Correct answer)
Direct edge-to-edge surgical closure

Correct answer: Gradual filling of the wound with granulation tissue from the base upward

Secondary intention healing allows wounds to fill from the base with granulation tissue; wound contraction and epithelialization occur over time without surgical closure.

Question 112: A patient undergoing radiation therapy develops moist desquamation of the irradiated skin area. The nurse should:

Apply ice packs to the area
Debride the area with wet-to-dry dressings
Gently cleanse with water, apply moisture barrier, and avoid friction (Correct answer)
Apply alcohol-based skin products to dry the area quickly

Correct answer: Gently cleanse with water, apply moisture barrier, and avoid friction

Moist desquamation from radiation requires gentle cleansing, moisture barrier protection, and avoidance of friction to prevent further injury to fragile skin.

Question 113: A patient with chronic cancer pain is on scheduled long-acting opioids. The nurse's understanding of equianalgesic dosing is important when:

Converting between opioid formulations or routes to maintain equivalent pain control (Correct answer)
Calculating antibiotic dosages
Titrating antihypertensive medications
Adjusting insulin sliding scale doses

Correct answer: Converting between opioid formulations or routes to maintain equivalent pain control

Equianalgesic dosing tables allow safe conversion between different opioids or routes (oral to IV) while maintaining equivalent pain control without under- or over-dosing.

Question 114: A nurse is caring for a patient with a seizure disorder. Which action is MOST important during an active tonic-clonic seizure?

Restrain the patient's extremities to prevent injury
Turn the patient to the side and protect the head (Correct answer)
Insert an oral airway to prevent tongue biting
Administer oral diazepam immediately

Correct answer: Turn the patient to the side and protect the head

Positioning the patient on their side prevents aspiration of secretions and protecting the head reduces injury during a tonic-clonic seizure.

Question 115: Which laboratory value requires IMMEDIATE intervention in a patient with multiple myeloma?

Platelet count 150,000/mm³
Hemoglobin 10.2 g/dL
BUN 24 mg/dL
Serum calcium 13.8 mg/dL (Correct answer)

Correct answer: Serum calcium 13.8 mg/dL

A serum calcium of 13.8 mg/dL indicates hypercalcemia, a serious complication of multiple myeloma that can cause cardiac dysrhythmias, altered mental status, and renal failure.

Question 116: Which of the following is a common symptom of acute myocardial infarction (heart attack)?

Gradual onset of leg pain
Intermittent headaches
Sudden onset of chest pain radiating to the left arm (Correct answer)
Sharp pain in the lower abdomen

Correct answer: Sudden onset of chest pain radiating to the left arm

Acute myocardial infarction (AMI), commonly known as a heart attack, is characterized by the sudden blockage of blood flow to the heart muscle. The classic and most common symptom is severe chest pain, often described as pressure or tightness, which frequently radiates to the left arm. This distinct presentation is a critical indicator for prompt diagnosis and treatment.

Question 117: The nurse differentiates a myasthenic crisis from a cholinergic crisis in a patient with myasthenia gravis. Which finding suggests a cholinergic crisis?

SLUDGE symptoms: salivation, lacrimation, urination, defecation, GI upset, emesis (Correct answer)
Muscle weakness that improves with edrophonium (Tensilon)
Rapid fatigue with repetitive muscle use
Ptosis and diplopia without other autonomic symptoms

Correct answer: SLUDGE symptoms: salivation, lacrimation, urination, defecation, GI upset, emesis

Cholinergic crisis from excessive anticholinesterase medication causes SLUDGE symptoms due to excessive acetylcholine stimulation.

Question 118: A patient presents with painful voiding, urinary frequency, and urine that is dark and foul-smelling. Urinalysis shows positive nitrites, leukocyte esterase, and WBC >10/hpf. The nurse anticipates:

Interstitial nephritis
Bacterial urinary tract infection requiring antibiotic therapy (Correct answer)
Chronic kidney disease diagnosis
Nephrolithiasis requiring lithotripsy

Correct answer: Bacterial urinary tract infection requiring antibiotic therapy

The combination of symptoms and urinalysis findings (positive nitrites, leukocyte esterase, pyuria) confirms bacterial UTI requiring antibiotic treatment.

Question 119: A patient with a skin tear on the forearm requires wound care. The nurse should first:

Scrub the wound with a stiff brush to clean it
Gently irrigate with normal saline and approximate the skin flap if viable before dressing (Correct answer)
Apply a tight compression bandage immediately
Apply povidone-iodine to prevent infection

Correct answer: Gently irrigate with normal saline and approximate the skin flap if viable before dressing

Skin tears should be gently irrigated with saline, with the skin flap repositioned if viable to minimize tissue loss before applying a non-adherent dressing.

Question 120: The nurse is assessing a patient's surgical wound and notes the wound edges are well-approximated with no drainage. This type of healing is called:

Primary intention (Correct answer)
Tertiary intention
Secondary intention
Eschar formation

Correct answer: Primary intention

Primary intention (first intention) healing occurs when wound edges are directly approximated (sutured or stapled) with minimal tissue loss and scarring.

Question 121: What is the recommended lifestyle modification for a patient with hypertension to reduce cardiovascular risk?

Engaging in regular physical activity (Correct answer)
Increasing salt intake
Reducing water intake
Consuming a high-fat diet

Correct answer: Engaging in regular physical activity

Engaging in regular physical activity is a cornerstone of lifestyle modification for managing hypertension and reducing overall cardiovascular risk. Exercise helps lower blood pressure, improve cholesterol levels, manage weight, and enhance cardiovascular health. This intervention is highly effective in preventing and controlling cardiovascular diseases.

Question 122: What is the most common cause of acute respiratory distress syndrome (ARDS)?

Heart failure
Lung infection (Correct answer)
Chronic asthma
Trauma

Correct answer: Lung infection

Acute respiratory distress syndrome (ARDS) is a severe lung condition characterized by widespread inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. While various factors can trigger ARDS, severe lung infection, such as pneumonia or sepsis originating from a lung infection, is the most common direct cause. This infection initiates the overwhelming inflammatory response in the lungs.

Question 123: A patient passes a kidney stone. The nurse correctly instructs the patient to:

Strain all urine and save the stone for laboratory analysis (Correct answer)
Avoid pain medication to accurately assess symptom progression
Restrict all fluids for 24 hours
Discard the stone as it has no diagnostic value

Correct answer: Strain all urine and save the stone for laboratory analysis

Stone analysis determines composition (calcium, uric acid, struvite, cystine), which guides dietary modifications and medication therapy to prevent recurrence.

Question 124: A patient in a long leg cast complains of intense pain when the nurse passively extends the toes. This finding is most consistent with:

Deep vein thrombosis
Compartment syndrome (Correct answer)
Wound infection
Expected post-operative pain

Correct answer: Compartment syndrome

Pain with passive stretch of muscles in a casted extremity is a hallmark sign of compartment syndrome, an orthopedic emergency.

Question 125: Which medication is often prescribed to manage symptoms of inflammatory bowel disease (IBD)?

Proton pump inhibitors (PPIs)
Corticosteroids (Correct answer)
Antacids
Statins

Correct answer: Corticosteroids

Corticosteroids are frequently prescribed for inflammatory bowel disease (IBD) due to their powerful anti-inflammatory and immunosuppressive properties. They work by reducing the body's immune response, which helps to decrease the severe inflammation in the gastrointestinal tract characteristic of conditions like Crohn's disease and ulcerative colitis. While effective for managing acute flares and inducing remission, they are often used short-term due to potential side effects.

Question 126: A patient with a recent ischemic stroke is on aspirin and clopidogrel (Plavix) dual antiplatelet therapy. The nurse's priority teaching includes:

Stopping medications if headache occurs
Avoiding all physical activity for 6 weeks
Reporting unusual bleeding, bruising, or black tarry stools (Correct answer)
Taking both medications on an empty stomach

Correct answer: Reporting unusual bleeding, bruising, or black tarry stools

Dual antiplatelet therapy significantly increases bleeding risk; patients must recognize and report signs of bleeding including GI bleeding (melena).

Question 127: A patient recovering from acute tubular necrosis (ATN) is now in the diuretic phase. The nurse's priority is monitoring for:

Dehydration, hypokalemia, and hyponatremia from excessive urine output (Correct answer)
Oliguria returning
Fluid overload and hypertension
Hyperkalemia

Correct answer: Dehydration, hypokalemia, and hyponatremia from excessive urine output

During the diuretic phase of ATN, massive fluid and electrolyte losses (hypokalemia, hyponatremia) can lead to dehydration and hemodynamic instability.

Question 128: A patient with myasthenia gravis receives pyridostigmine (Mestinon). The nurse should administer this medication:

30 minutes before meals (Correct answer)
At bedtime only
With a full glass of milk
Only during periods of symptom flare

Correct answer: 30 minutes before meals

Pyridostigmine should be given 30 minutes before meals so peak drug effect coincides with swallowing, reducing aspiration risk.

Question 129: A postoperative patient's abdominal wound has separated with the bowel protruding through the incision. The nurse's immediate action is:

Push the bowel back into the wound and apply pressure
Cover the wound with moist sterile saline gauze, keep the patient supine with knees flexed, and call the provider STAT (Correct answer)
Irrigate the wound with saline and apply an occlusive dressing
Apply a sterile dry dressing and call the provider

Correct answer: Cover the wound with moist sterile saline gauze, keep the patient supine with knees flexed, and call the provider STAT

Evisceration requires covering exposed bowel with moist sterile saline gauze to prevent drying, keeping the patient still, and calling the surgical team for emergency closure.

Question 130: A patient receiving chemotherapy develops a neutrophil count of 400 cells/mm³. Which intervention is the HIGHEST priority?

Obtain a routine CBC in 24 hours
Initiate neutropenic precautions and reverse isolation (Correct answer)
Administer prophylactic antiemetics
Encourage oral fluid intake

Correct answer: Initiate neutropenic precautions and reverse isolation

A neutrophil count below 500 cells/mm³ indicates severe neutropenia, and reverse isolation (protective precautions) is the priority to prevent life-threatening infection.

Question 131: Which nursing intervention is MOST important for a patient receiving a packed red blood cell (PRBC) transfusion?

Verify the blood type and unit ID with another licensed nurse at the bedside before starting (Correct answer)
Warm the blood to room temperature for 2 hours before administration
Start the infusion at the fastest rate possible to prevent hemolysis
Filter the blood through a 0.2-micron filter to remove bacteria

Correct answer: Verify the blood type and unit ID with another licensed nurse at the bedside before starting

Two-nurse verification of blood product identification, patient identity, and compatibility data at the bedside is the critical safety check that prevents hemolytic transfusion reactions.

Certified Medical-Surgical Registered Nurse (CMSRN)

The CMSRN certification, administered by the Medical-Surgical Nursing Certification Board (MSNCB) under AMSN, validates expertise in medical-surgical nursing practice including patient care management, interprofessional collaboration, and professional nursing concepts.

150

Questions

180 min

Time Limit

71%

To Pass

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