NUR105 Medical Surgical Exam 2 with Answers
NUR105_M4EQ0077
Ten minutes after starting a transfusion of packed red cells the patient reports back pain. The RN
notes an oral temperature of 101.3° F and a heart rate of 114 beats per minute. What is the RN’s
priority response?
a. Obtain an ECG.
b. Flush the IV line with normal saline.
c. Notify the physician.
d. Discontinue the transfusion.
Answer: d. Discontinue the transfusion.
NUR105_M4EQ0078
The RN encourages the postoperative patient to use the incentive spirometer. He states “I don’t
like this thing. What good does it do anyway?” What is the appropriate RN response?
a. “It helps reduce spasm in the alveolar capillaries.”
b. “It is used to reduce the risk of atelectasis and pneumonia.”
c. “Incentive spirometry is used to strengthen the muscles of respiration.”
d. “Incentive spirometry promotes thinning of secretions to clear the airway.”
Answer: d. “Incentive spirometry promotes thinning of secretions to clear the airway.”
NUR105_M4EQ0079
The RN is caring for an acutely ill patient with chronic pulmonary disease and notes labored
respiration. How would the RN position the patient to promote ventilation of the lung?
a. Partially supine with a small pillow supporting the head.
b. Right Sims position with the knees flexed.
c. Leaning forward with arms resting on over bed table.
d. Semi-Fowlers with arms positioned at shoulder level.
Answer: c. Leaning forward with arms resting on over bed table.
NUR105_M4EQ0152
When assessing a 9-month-old, which finding would require the RN to collect additional data?
a. Abdominal breathing.
b. Irregular depth of respirations.
c. Round chest with visible ribs.
d. Respiratory rate of 44.
Answer: c. Round chest with visible ribs.
NUR105_M4EQ0153
Which instruction would the RN give to a patient when auscultating the lungs?
a. Take a deep breath in and hold it.
b. Breathe slowly in and out.
c. Breathe in through the nose, and then cough.
d. Take a slow, deep breath in through your mouth.
Answer: a. Take a deep breath in and hold it.
NUR105_M4EQ0082
A patient uses a peak flow meter at home to monitor airflow. Which statement indicates an
understanding of the purpose of the procedure?
a. “The airways to my lungs must be really wide open today; I set a new personal high this
morning.”
b. “Clamping down on the mouthpiece to my peak flow meter really makes me be able to take a
very deep breath.”
c. “I keep my meter next to my bed so I can use it when I am all stretched out just before I put
out the light.”
d. “I only had to exhale into my flow meter one time last night because I matched my best flow
level on the first try.”
Answer: a. “The airways to my lungs must be really wide open today; I set a new personal high
this morning.”
NUR105_M4EQ0083
Which expected outcome is most appropriately applied to a patient with a nursing diagnosis of
Impaired gas exchange?
a. The patient respirations will be quiet and of normal depth.
b. The patient’s pulse oximetry readings will be 95% or greater.
c. The patient will have a decrease in cyanosis within 2 hours.
d. The patient will be maintained in an upright sitting position.
Answer: c. The patient will have a decrease in cyanosis within 2 hours.
NUR105_M4EQ0084
Which assessment data supports the nursing diagnosis Ineffective airway clearance?
a. Use of pursed lip breathing after activity.
b. Episodes of non-productive cough with minimal expectoration.
c. Shallow, irregular, hyperventilation pattern.
d. Arterial blood gas analysis indicating respiratory acidosis.
Answer: c. Shallow, irregular, hyperventilation pattern.
NUR105_M4EQ0154
The RN is performing an assessment on a 5-year-old child. Which is an abnormal finding?
a. Diaphragmatic breathing.
b. Respiratory rate of 24.
c. Enlarged tonsils.
d. Retractions of upper chest muscles.
Answer: d. Retractions of upper chest muscles.
NUR105_M4EQ0086
Which of the following delivery methods provides the most precise amount of oxygen?
a. Partial rebreather
b. Simple face mask
c. Nasal cannula
d. Venturi mask
Answer: b. Simple face mask
NUR105_M4EQ0087
The RN is caring for a patient with long term pulmonary disease who is receiving oxygen 2 liters
per minute via nasal cannula continuously at home. Which of the following statements indicates
the patient needs additional teaching?
a. “I’ll check behind my ears for soreness every day.”
b. “I’ll clean the nasal cannula with soap and warm water if it becomes soiled.”
c. “If I get short of breath, I can turn the oxygen up to 4 liters per minute until I feel better.”
d. “It’s important to keep the oxygen away from people who are smoking cigarettes.”
Answer: c. “If I get short of breath, I can turn the oxygen up to 4 liters per minute until I feel
better.”
NUR105_M4EQ0088
The RN wants to obtain non-invasive estimate of arterial blood oxygen saturation (SaO2). Which
diagnostic test or procedure would be performed?
a. Chest X-Ray
b. Pulse Oximetry
c. Peak Flow Meter
d. Arterial Blood Gas Analysis
Answer: b. Pulse Oximetry
NUR105_M4EQ0155
Which lifestyle modification would be included in the teaching plan for a woman who
experiences urinary incontinence?
a. Modify diet to avoid constipating foods.
b. Encourage the use of a bladder diary.
c. Use absorbent pads on furniture and bed.
d. Decrease oral fluid intake.
Answer: b. Encourage the use of a bladder diary.
NUR105_M4EQ0160
Following surgery a patient voids small, frequent amounts of urine. Upon further assessment, the
RN applies the nursing diagnosis, Urinary Retention. Which of the following evaluation
statements would indicate progress toward resolution of the problem?
a. Urine volume is greater than 125 mL with each patient’s voiding.
b. Patient urinates three in times in a 24 hour period.
c. The patient’s post voiding residual volume is less than 150 mL.
d. Patient verbalizes hesitancy and urgency is decreased.
Answer: a. Urine volume is greater than 125 mL with each patient’s voiding.
NUR105_M4EQ0092
The parents of an 11-month-old are worried their infant is constipated because there may be two
days without a bowel movement. Which is an appropriate RN response related to this concern?
a. “If the baby is constipated small amounts of liquid stool seep from the anus.”
b. “As long as the stool is soft your baby is not constipated.”
c. “Five to seven days between bowel movements is not uncommon for infants of this age.”
d. “You do not worry about it unless your baby grunts and grimaces when defecating.”
Answer: b. “As long as the stool is soft your baby is not constipated.”
NUR105_M4EQ0094
The RN is discussing prevention of constipation with a patient. Which statement would indicate
the need for further teaching?
a. “I will exercise regularly 3 to 5 times per week.”
b. “I will avoid consuming large amounts of caffeine and sugar.”
c. “I will take a stool softener if I do not have a bowel movement each day.”
d. “I will eat at least 20-35 grams of fiber every day.”
Answer: c. “I will take a stool softener if I do not have a bowel movement each day.”
NUR105_M4EQ0095
Which instruction would the RN provide when teaching a patient about changing an ostomy
appliance?
a. Apply lotion to the peristomal skin and let dry thoroughly before applying a new appliance.
b. Cut a circular opening on the back of the appliance ¼ inch larger than the stoma diameter.
c. After removing the used appliance, cleanse the stoma with mild soap and water.
d. Ease the appliance over the stoma and press smoothly to the skin holding for 30-60 seconds.
Answer: c. After removing the used appliance, cleanse the stoma with mild soap and water.
NUR105_M4EQ0096
During the instillation of a large-volume enema, the patient says, “I have cramps and have to let
the fluid out.” Which is the appropriate action for the RN to take?
a. Withdraw the enema tube 2-3 inches.
b. Decrease the height of the solution bag.
c. Put the patient on a bed pan.
d. Increase the flow rate of the solution.
Answer: c. Put the patient on a bed pan.
NUR105_M4EQ0165
A patient has not had a bowel movement for three (3) days and requests a laxative. The RN notes
a PRN order for bisocodyl (Dulcolax) in the patient’s medical record. Which of the following
demonstrates safe nursing judgment?
a. Administer the laxative to the patient.
b. Consult with the health care provider about the medication.
c. Instruct the UAP to have the patient drink more fluids.
d. Discuss dietary modification with the dietitian.
Answer: a. Administer the laxative to the patient.
NUR105_M4EQ0098
Which patient outcome is appropriate for a patient with the nursing diagnosis Constipation
related to inadequate fiber intake?
a. Respond to the urge to defecate.
b. Have a soft formed stool within two days.
c. Eat five servings of vegetables daily.
d. Verbalize correct use of stool softeners.
Answer: c. Eat five servings of vegetables daily.
NUR105_M4EQ0099
The RN assesses a patient who verbalizes “a loss of urine without even realizing my bladder is
full.” The RN begins to plan teaching for which type of incontinence?
a. Urge
b. Reflex
c. Transient
d. Stress
Answer: c. Transient
NUR105_M4EQ0100
Which question would the RN ask when assessing a patient’s usual urination pattern?
a. “How many caffeinated beverages do you drink daily?”
b. “Have you noticed a change in the appearance of your urine?”
c. “Have you ever had surgery on your urinary tract?”
d. “Do you get up to urinate during the night?”
Answer: d. “Do you get up to urinate during the night?”
NUR105_M4EQ0101
The RN is providing care for a patient who has a wound and requires a high protein diet. Which
statement indicates the patient understands the function of proteins?
a. “My stomach needs protein to absorb water to increase fecal bulk.”
b. “Increasing my weight with protein will insulate my body.”
c. “Proteins enable tissue growth and repair.”
d. “Proteins provide support to internal organs.”
Answer: c. “Proteins enable tissue growth and repair.”
NUR105_M4EQ0162
A patient on continuous enteral tube feedings reports nausea. Which intervention is collaborative
and would require the RN to contact the provider?
a. Slow the rate of the feeding.
b. Administer a prn antiemetic.
c. Flush the tubing with water.
d. Aspirate the residual gastric contents.
Answer: a. Slow the rate of the feeding.
NUR105_M4EQ0103
During a home visit the family caretaker informs the RN the patient reports nausea and bloating
following intermittent tube feedings. The RN collects additional data to determine if which of the
following has occurred?
a. Tube placement may have been disrupted.
b. The feeding may have been administered too rapidly.
c. Ratio of fluid intake to protein content of the feeding may be inadequate.
d. Dumping syndrome may have developed.
Answer: b. The feeding may have been administered too rapidly.
NUR105_M4EQ0158
The RN is conducting a nutritional assessment on a newly admitted patient. What can be
delegated to the Licensed Practical Nurse/Licensed Vocational Nurse?
a. Collaborate with the dietitian.
b. Collect nutritional history. submitted
c. Analyze lab results
d. Perform physical assessment
Answer: b. Collect nutritional history.
NUR105_M4EQ0105
Which information must be documented in the patient’s health record following insertion of a
nasogastric tube for temporary enteral nutrition? Select all that apply.
a. The Nare in which the tube was inserted.
b. The length of the tube from the tip of the nose.
c. Patient’s response to the procedure.
d. Type of feeding solution that will be ordered.
e. Date and time of insertion.
Answer:
a. The Nare in which the tube was inserted.
b. The length of the tube from the tip of the nose.
c. Patient’s response to the procedure.
e. Date and time of insertion.
NUR105_M4EQ0106
The spouse of a patient receiving total parenteral nutrition (TPN) via the subclavian vein requests
the catheter changed to an arm vein so it will be more comfortable. On which principle will the
RN base a response?
a. The intravenous insertion sites must be changed daily with peripheral veins.
b. There is a high risk of infection associated with arm veins and TPN administration.
c. TPN solutions are hypertonic and need to be infused through a high flow vein for dilution.
d. TPN administration rate must flow into a large vein to allow time for patient adaptation.
Answer: c. TPN solutions are hypertonic and need to be infused through a high flow vein for
dilution.
NUR105_M4EQ0107
A patient who observes the Mormon religion is on a clear liquid diet and reports being hungry
and thirsty. Which item could the RN offer this patient?
a. Ice pop
b. Custard
c. Green Tea
d. Sherbet
Answer: a. Ice pop
NUR105_M4EQ0110
The RN monitors a patient’s prealbumin. What is the rationale for its role in nutritional
assessment?
a. Identify chronic protein depletion.
b. Determine the liver’s ability to synthesize proteins.
c. Detect daily changes in protein status.
d. Indicate level of somatic protein stores.
Answer: b. Determine the liver’s ability to synthesize proteins.
NUR105_M4EQ0111
What nursing instructions would the RN include when responding to a patient who has asked for
assistance stating, “I want to do something about being overweight”? Select all that apply.
a. Write down the desired goals and the plans to achieve them.
b. Inform about the need to drink 32 ounces of water per day.
c. Suggest walking for 20 minutes four times per week.
d. Provide frequent rest periods during activities.
e. Recognize that lifestyle changes need to be long term.
Answer:
a. Write down the desired goals and the plans to achieve them.
c. Suggest walking for 20 minutes four times per week.
e. Recognize that lifestyle changes need to be long term.
NUR105_M4EQ0112
The RN performs a nutritional screening on an older adult and categorizes which finding as a
major indicator of impaired nutritional status?
a. Significant reduction in midarm circumference.
b. Decreased transferrin level.
c. Poor dental status.
d. Change in bowel habits.
Answer: c. Poor dental status.
NUR105_M4EQ0166
Which action demonstrates the RN applies standards of practice when inserting a nasogastric
tube?
a. Tape the tube securely to the forehead.
b. Obstruct each Nare to check for air passage through the other.
c. Measure the tube from the nose to the xyphoid process.
d. Position the patient in a low-Fowlers position.
Answer: c. Measure the tube from the nose to the xyphoid process.
NUR105_M4EQ0114
A patient has been on a mechanical soft diet for 6 days. Which would be a concern to the RN
when caring for this patient?
a. Inadequate supply of calories.
b. Risk for constipation.
c. Lack of a high protein supplement.
d. Progression toward nutritious diet.
Answer: c. Lack of a high protein supplement.
NUR105_M4EQ0116
Which biochemical test result indicates a patient may be at risk for a nutrition imbalance?
a. Blood urea nitrogen level of 17 mg/dL.
b. Creatinine level of 1.0 mg/dL.
c. Hemoglobin level of 14 g/dL.
d. Serum albumin level of 3.0 g/dL.
Answer: d. Serum albumin level of 3.0 g/dL.
NUR105_M4EQ0117
Which patient would the RN expect to have a negative nitrogen level?
a. A man who is overweight.
b. A woman who is breast feeding.
c. A man who has recovering from second degree burns.
d. A woman who is in her first trimester of pregnancy.
Answer: c. A man who has recovering from second degree burns.
NUR105_M4EQ0118
The RN is teaching a patient about the American Heart Association Recommendations to help
lower cholesterol levels. What information would be included in the instructions? Select all that
apply
a. Eat a variety of whole grains.
b. Limit intake of whole-milk dairy products.
c. Consume fatty fish at least twice weekly.
d. Avoid foods low in saturated fat.
e. Decrease intake of daily protein.
Answer: a. Eat a variety of whole grains.
c. Consume fatty fish at least twice weekly.
NUR105_M4EQ0157
What assessment data would the RN expect for a patient experiencing malnutrition?
a. Low blood pressure, dry skin, and attentive.
b. Protuberant abdomen, reddened eyes, and increased heart rate.
c. High blood pressure, fainting, and excessive weight loss.
d. Brittle nails, muscle atrophy, and decreased heart rate.
Answer: c. High blood pressure, fainting, and excessive weight loss.
NUR105_M4EQ0121
A patient with osteomalacia requires teaching to prevent further complications. Which statement
made by the patient indicates understanding of the teaching provided by the RN?
a. “I should include lemon juice in my morning tea.”
b. “I need to drink fortified milk every day.”
c. “I should eat nuts for my mid-morning snack.”
d. “I need to include dark leafy vegetables in my daily menu.”
Answer: b. “I need to drink fortified milk every day.”
NUR105_M4EQ0168
The RN developed a plan of care for a patient and included obesity as a priority nursing
diagnosis. Which patient statement indicates the need for additional education?
a. “I should eat 5-6 small meals per day.”
b. “I will have my neighbor walk with me when I get home.”
c. “I will keep a food journal.”
d. “My goal is to lose 3-5 pounds per week.”
Answer: d. “My goal is to lose 3-5 pounds per week.”
NUR105_M4EQ0124
The RN notes that a newly-admitted patient lists his religion as Islam. The RN views the meal
tray prior to bringing it into the patient’s room. Which item on the patient’s dinner tray would
make it inappropriate to serve?
a. Baked chicken
b. Roasted turkey
c. Pork chop
d. Lamb chop
Answer: c. Pork chop
NUR105_M4EQ0167
A patient on the Medical-Surgical Unit informs the RN that he is a Seventh-Day Adventist.
Which menu selection will this patient select from the lunch options provided?
a. Seafood salad on a roll
b. Ham sandwich with chips
c. Tomato soup and grilled cheese
d. Pork chop with potato
Answer: c. Tomato soup and grilled cheese
NUR105_M4EQ0126
The RN and the Registered Dietitian are collaborating about an 85-year-old female patient who
is experiencing increasing frailty. Which developmental consideration will be applied when
developing a plan?
a. The need more nutrients but fewer calories due to the decrease in lean body mass and basic
metabolic rate.
b. Reduced renal function requires a reduction in the overall amount of water consumed.
c. More daily calories are needed due to the increase in lean body mass and basic metabolic rate.
d. Avoiding complex carbohydrates to minimize constipation because of diminished
gastrointestinal motility.
Answer: d. Avoiding complex carbohydrates to minimize constipation because of diminished
gastrointestinal motility.
NUR105_M4EQ0127
A 39-year-old patient requests a vegan diet during his hospital stay. Which menu choices meets
the dietary needs of this patient?
a. Broccoli-cheese baked potato
b. Grilled Haddock filet
c. Cheese omelet
d. Red beans and rice
Answer: d. Red beans and rice
NUR105_M4EQ0128
The RN is working with a college athletic coach who wants to measure males’ body fat content
percentage. Which measure would the RN suggest using?
a. Use a goniometer to measure the triceps muscle.
b. Weigh the patient daily while wearing only his underwear.
c. Use a caliper to measure the subscapular area fat.
d. Calculate the patient’s BMI by comparing height and weight.
Answer: d. Calculate the patient’s BMI by comparing height and weight.
NUR105_M4EQ0129
A RN is caring for a patient who is experiencing dysphagia after a stroke. Which precaution is
applied when the patient is eating?
a. Offer chewing gum to encourage peristalsis.
b. Intermittently test gag reflex during feeding periods.
c. Provide a drinking straw for liquids.
d. Keep the head of bed elevated for 30 minutes after meals.
Answer: b. Intermittently test gag reflex during feeding periods.
NUR105_M4EQ0130
A RN is assisting a patient who is visually impaired with eating. The patient also has a casted
right extremity. Which of the following techniques should be used by the RN when providing
assistance to this patient? Select all that apply.
a. Maintain the head of the bed at 30° during the meal.
b. Adjust the overbed table so it is within easy reach.
c. Open containers and cut foods into bite sized pieces.
d. Feed the patient, since it will make eating easier.
e. Identify the locations of food on the tray using a clock face.
Answer: a. Maintain the head of the bed at 30° during the meal.
b. Adjust the overbed table so it is within easy reach.
c. Open containers and cut foods into bite sized pieces.
e. Identify the locations of food on the tray using a clock face.
NUR105_M4EQ0131
The RN is assessing a 14-year-old female whose parents are concerned about her recent habits.
Which behaviors suggest the individual may be at risk for an eating disorder? Select all that
apply.
a. Avoids exercise or physical activity.
b. Tries to please everyone.
c. Will not eat in front of others.
d. Obsesses about weight and clothing size.
e. Exercises beyond normal expectations.
Answer: c. Will not eat in front of others.
d. Obsesses about weight and clothing size.
e. Exercises beyond normal expectations.
NUR105_M4EQ0132
A 50-year-old client is ordered a clear liquid diet on the first postoperative day following a bowel
resection. The RN knows that the patient will be permitted to consume which of the following?
a. Low-fat milk
b. Orange juice
c. Chicken soup
d. Iced tea
Answer: d. Iced tea
NUR105_M4EQ0133
An older adult patient has been ordered a full liquid diet. Which is the main disadvantage of this
type of diet?
a. It provides overly sufficient calories.
b. It is low in carbohydrates.
c. A high-protein supplement is generally required.
d. A range of nutrients necessitates extra cereals.
Answer: b. It is low in carbohydrates.
NUR105_M4EQ0134
As part of a focused nutritional assessment, the RN is performing an abdominal assessment.
Which of the following finding would be related to malnutrition?
a. Ascites
b. Concave abdomen
c. Hypoactive bowel sounds
d. Protuberant abdomen
Answer: a. Ascites
NUR105_M4EQ0137
The RN is caring for a four-month-old child who is breastfed by the mother. What stool
characteristics would be expected?
a. Green-black stool
b. Firm, dark-brown stool
c. Golden yellow stool
d. Tan stool
Answer: c. Golden yellow stool
NUR105_M4EQ0138
A patient is prescribed an osmotic laxative. What is the mechanism of action for this medication?
a. Coat the stool with a thin, waterproof layer.
b. Draw water into the bowel from surrounding tissues.
c. Penetrate the stool with moisture and fat.
d. Irritate the intestinal wall, stimulating peristalsis.
Answer: b. Draw water into the bowel from surrounding tissues.
NUR105_M4EQ0139
The RN is performing a focused assessment for a patient admitted with abnormal bowel
elimination patterns. Which assessment finding would be documented as normal bowel sounds?
a. Very high-pitched, very frequent bowel sounds on auscultation.
b. No bowel sounds present after 4 minutes of auscultation.
c. High-pitched, moderately frequent bowel sounds on auscultation.
d. Low-pitched, infrequent, quiet bowel sounds on auscultation.
Answer: c. High-pitched, moderately frequent bowel sounds on auscultation.
NUR105_M4EQ0159
The RN is caring for a patient whose stools have become black and tarry in color. The RN
recognizes the need to communicate this information to the health care provider in order for
follow up for which potential health problem?
a. Lower intestinal tract bleeding
b. Intestinal obstruction
c. Bile duct obstruction
d. Upper GI bleeding
Answer: d. Upper GI bleeding
NUR105_M4EQ0164
Which nursing interventions are applied to promote defecation in a patient taking opioid
analgesics? Select all that apply.
a. Ambulate the patient.
b. Allow patient to squat during defecation.
c. Provide extra dietary fiber.
d. Encourage increased water intake.
e. Encourage consumption of caffeinated beverages.
Answer: a. Ambulate the patient.
b. Allow patient to squat during defecation.
c. Provide extra dietary fiber.
d. Encourage increased water intake.
NUR105_M4EQ0142
A RN is preparing to administer an enema to an adult patient. Which factors are considered when
determining patient response to the enema? Select all that apply.
a. Solution container height.
b. Solution total volume.
c. Resistance of rectum.
d. Solution concentration.
e. Speed of solution flow.
Answer: a. Solution container height.
b. Solution total volume.
d. Solution concentration.
e. Speed of solution flow.
NUR105_M4EQ0143
A RN is educating a patient with a new colostomy who is concerned about noticeable odors or
gas that may occur. Which food should the RN encourage the patient to avoid after the patient
informed the RN what they commonly eat?
a. Toast
b. Peanut butter
c. Cranberry juice
d. Yogurt
Answer: d. Yogurt
NUR105_M4EQ0144
The RN is observing an unlicensed assistive personnel (UAP) provide a bedpan to a patient who
is on bedrest. Which action would indicate to the RN the UAP is applying safe practices?
a. Rinsing the bedpan under cool water and dry it.
b. Raising the siderail on the opposite side.
c. Placing the patient into high-Fowler’s position.
d. Placing the bed into its lowest position.
Answer: b. Raising the siderail on the opposite side.
NUR105_M4EQ0145
The RN is performing chest physiotherapy on a patient with a nursing diagnosis of Ineffective
airway clearance. Which of the following components are included in this treatment modality?
Select all that apply.
a. Suctioning
b. Chest percussion
c. Postural drainage
d. Chest vibration
e. Deep breathing
Answer: b. Chest percussion
e. Deep breathing
NUR105_M4EQ0146
The RN is counseling a group of long-term smokers about the health benefits of smoking
cessation. Which of the following are benefits of smoking cessation?
a. Blood pressure increases.
b. Risk of heart attack returns to nonsmoker level in 6 months.
c. Blood carbon dioxide levels increase within 4 hours.
d. Blood oxygen levels improve within 8 hours.
Answer: d. Blood oxygen levels improve within 8 hours.
NUR105_M4EQ0147
A RN is caring for a patient and documents Kussmaul’s respirations in the electronic health
record. Which assessment finding supports this documentation?
a. Regular rhythm, somewhat increased respiratory rate, abnormally deep respirations.
b. Gradually increasing depth of respirations, then a gradual decrease in depth, followed by
apnea.
c. Irregular, shallow respirations alternating with periods of apnea.
d. Steady, rapid respiratory rate of 28 breaths per minute.
Answer: a. Regular rhythm, somewhat increased respiratory rate, abnormally deep respirations.
NUR105_M4EQ0148
The RN is completing a focused respiratory assessment and hears rhonchi on auscultation. What
is the RN’s priority action?
a. Notify the healthcare provider.
b. Document the findings as a normal finding.
c. Ask the patient to cough and reassess.
d. Administer the prescribed bronchodilator.
Answer: c. Ask the patient to cough and reassess.
NUR105_M4EQ0150
The RN is assessing a patient who was admitted to the hospital for shortness of breath. Which of
the following patient assessments describes conversational dyspnea?
a. Inability to speak complete sentences without stopping to breathe.
b. Difficulty breathing unless propped up on three (3) pillows.
c. A high-pitched, harsh inspiratory sound caused by partial obstruction of the larynx.
d. Sudden awakening from sleep with shortness of breath.
Answer: a. Inability to speak complete sentences without stopping to breathe.
NUR105_M4EQ0171
What signs and symptoms would the RN expect to observe for a patient who is having a
hemolytic reaction to a blood transfusion?
a. Urticaria, wheezing, flushing.
b. Hypertension, respiratory crackles, cough.
c. Fever, hypotension, shortness of breath.
d. Flushed skin, body aches, fever.
Answer: c. Fever, hypotension, shortness of breath.
NUR105_M4EQ0173
A 71-year-old was admitted with a diagnosis of chronic obstructive pulmonary disease. The RN
has chosen Impaired gas exchange as the primary NANDA-I nursing diagnosis. Which is an
expected outcome for this NANDA-I nursing diagnosis?
a. The patient will ambulate 20 feet without shortness of breath by the end of the shift.
b. The patient will use nasal cannula when ambulating.
c. The patient will use pursed lipped breathing when short of breath.
d. The patient will maintain pulse oximetry greater than 93% by discharge.
Answer: d. The patient will maintain pulse oximetry greater than 93% by discharge.
NUR105_M4EQ0174
Which is the priority action an RN should perform when a chest tube accidently disconnects
from a chest drainage system?
a. Immerse the distal end of the tube in a bottle of sterile water
b. Notify the physician
c. Start O2 at 10 L/min via non-rebreather mask
d. Assess vital signs, including pulse oximetry
Answer: a. Immerse the distal end of the tube in a bottle of sterile water
NUR105_M4EQ0189
Which dietary recommendation should the RN offer to the client who has microcytic
hypochromic erythrocytes?
a. Take an iron supplement daily
b. Consume orange vegetables daily
c. Switch to sugar substitute
d. Drink low-fat milk daily
Answer: a. Take an iron supplement daily
NUR104_M4EQ0176
Which statement by the new RN indicates the need for further instruction?
a. “I will ask the NAP to perform oral care.”
b. “I will ask the LPN to start the parenteral nutrition.”
c. “I will ask the nutritionist to provide dietary teaching.”
d. “I will ask another RN to insert the nasogastric tube.”
Answer: b. “I will ask the LPN to start the parenteral nutrition.”
NUR105_M4EQ0177
A client who is actively dying and says to the RN “Please stop bringing meal trays to me.”
Which would be the best response for the RN to make?
a. “I will put in a request to stop your meal trays.”
b. “I will have the dietician come to speak to you about your meals.”
c. “I will request that your favorite foods are sent on your tray.”
d. “I will need to inform your next of kin of your request.”
Answer: d. “I will need to inform your next of kin of your request.”
NUR105_M4EQ0178
The RN is providing teaching to a client with a skin disorder. Which statement by the client
indicates understanding of the foods that would help their condition?
a. “I will add eggs, yellow fruit and green leafy vegetables to my diet.”
b. “I will add milk, yogurt, and salmon to my diet.”
c. “I will add whole grains, red meat and avocados to my diet.”
d. “I will add enriched breads, peanuts and tuna to my diet.”
Answer: d. “I will add enriched breads, peanuts and tuna to my diet.”
NUR105_M4EQ0179
Which statement by the caregiver of a client with a percutaneous endoscopic gastrostomy (PEG)
tube to the home-care RN indicates the need for further teaching?
a. “I will make sure the client is sitting upright for an hour after the feeding.”
b. “I will flush the PEG with tap water before and after the feeding.”
c. “I will wash the feeding equipment with soap and water every day.”
d. “I will make sure the feedings are chilled when infusing to prevent spoilage.”
Answer: d. “I will make sure the feedings are chilled when infusing to prevent spoilage.”
NUR105_M4EQ0180
Which assessment findings would the RN expect to find in a client with the nursing diagnosis of
Ineffective Breathing pattern?
a. Bradypnea, nasal flaring, pursed-lip breathing
b. Bradycardia, peripheral cyanosis, somnolence
c. Difficulty verbalizing, diminished breath sounds, restlessness
d. O2 saturation below 92%, ineffective cough, barrel chest
Answer: a. Bradypnea, nasal flaring, pursed-lip breathing
NUR105_M4EQ0181
Which of these outcomes should a RN establish with a client who has a nursing diagnosis of
Ineffective Airway clearance?
a. The client will use the incentive spirometer every two hours
b. The client will have clear breath sounds by discharge
c. The client will have less coughing
d. The client will maintain adequate hydration
Answer: b. The client will have clear breath sounds by discharge
NUR105_M4EQ0182
Which of these instructions should an RN not include in a plan for teaching a group of senior
citizens about nutritional needs?
a. Use chewing gum between meals
b. Eat three meals a day
c. Remain upright after meals
d. Eat diet high in fiber
Answer: a. Use chewing gum between meals
NUR105_M4EQ0183
The RN is developing a plan of care with a client who is receiving total parenteral nutrition
(TPN). Which outcome should receive priority in the plan?
a. The patient will remain afebrile throughout therapy
b. The glucose will be checked every 4-6 hours
c. The patient will gain weight rapidly
d. The dressing will be changed every 24 hours
Answer: a. The patient will remain afebrile throughout therapy
NUR105_M4EQ0184
The RN receives an order to infuse one unit containing 250ml of packed red blood cells over 3
hours. What rate should the Intravenous Control Device be set?
a. 62 mL/hour
b. 125 mL/hour
c. 91 mL/hour
d. 83 mL/hour
Answer: d. 83 mL/hour
NUR105_M4EQ0185
The RN is providing discharge instructions to the parents of a 2-year-old with pneumonia. Which
statement by the parent indicates the need for further education?
a. “I will discourage deep breathing and coughing.” submitted
b. “I will see that my child drinks a lot of fluids.”
c. “I will raise the head of the bed for my child.”
d. “I will use a room humidifier in my child’s bedroom.”
Answer: a. “I will discourage deep breathing and coughing.”
NUR105_M4EQ0186
The RN receives an order for diphenhydramine 25mg every 6 hours as needed for cough. The
pharmacy label reads 12.5mg/5mL. How many mL should the RN administer per dose?
a. 12.5mL
b. 10 mL
c. 7.5 mL
d. 5 mL
Answer: b. 10 mL
NUR105_M4EQ0172
The RN is caring for a client who is receiving a blood transfusion and reports hives and itching.
What are the RN’s priority actions? Select all that apply
a. Contact the healthcare provider.
b. Treat shock
c. Stop the blood transfusion.
d. Administer antibiotics
e. Start a saline infusion.
Answer: a. Contact the healthcare provider.
c. Stop the blood transfusion.
e. Start a saline infusion.
