NUR 220 | NUR 220 Medical Surgical Nursing Exam
3 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient with sickle cell anemia is admitted in a vaso-occlusive crisis. Which
nursing intervention should be prioritized first?
A. Administering high-flow oxygen via non-rebreather mask
B. Administering prescribed intravenous morphine sulfate
C. Initiating intravenous fluid replacement at 200 mL/hr
D. Applying cold compresses to the affected painful joints
Correct Answer: C
Expert Explanation: In a sickle cell vaso-occlusive crisis, the priority is to reduce
blood viscosity and improve perfusion to distal tissues. Intravenous hydration helps
dilute the concentrated red blood cells and promotes the flow of oxygenated blood.
While pain management and oxygen are important, they are often secondary to
resolving the mechanical blockage of vessels. Cold compresses should be avoided as
they cause vasoconstriction and worsen the sickling process. Effective hydration is
the cornerstone of preventing permanent organ damage during these acute
episodes.
,2. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). Which
action is essential for patient safety during the first 15 minutes of the transfusion?
A. Infusing the blood at a rapid rate of 150 mL/hr to complete the unit quickly
B. Remaining at the bedside to monitor for signs of a hemolytic reaction
C. Mixing the blood with 5% Dextrose in Water to prevent clotting
D. Checking the patient’s temperature every 30 minutes throughout the process
Correct Answer: B
Expert Explanation: The first 15 minutes of a blood transfusion are the most
critical for detecting life-threatening acute hemolytic reactions. The nurse must stay
with the patient to observe for symptoms like fever, chills, back pain, or dyspnea.
The infusion should be started slowly, typically no faster than 2 mL/min, to limit the
severity of any potential reaction. Only normal saline should be used as a primary
line fluid to avoid hemolysis or clotting in the tubing. Constant monitoring during
this window allows for immediate cessation of the infusion if complications arise.
3. A patient with Disseminated Intravascular Coagulation (DIC) is showing signs of
active bleeding. Which laboratory finding most specifically supports this diagnosis?
A. Increased hemoglobin and hematocrit levels
B. Decreased Prothrombin Time (PT) and Partial Thromboplastin Time (PTT)
C. Elevated platelet count and decreased serum potassium
,D. Elevated D-dimer and decreased fibrinogen levels
Correct Answer: D
Expert Explanation: DIC is characterized by the simultaneous occurrence of
massive clotting and systemic bleeding. Elevated D-dimer levels indicate high levels
of fibrin degradation products, which occur when the body tries to break down
excessive clots. Fibrinogen is consumed during the clotting process, leading to the
low levels seen in active DIC cases. Prothrombin time and PTT are typically
prolonged, not decreased, due to the consumption of clotting factors. Identifying
these specific lab markers is essential for differentiating DIC from other hematologic
disorders.
4. A patient is diagnosed with pernicious anemia. The nurse should include which
information in the discharge teaching plan?
A. The patient will need oral Vitamin B12 supplements for the next six months
B. Increasing dietary intake of leafy green vegetables will cure the condition
C. Monthly intramuscular Vitamin B12 injections will be required for life
D. The patient should avoid all dairy products to improve iron absorption
Correct Answer: C
Expert Explanation: Pernicious anemia is caused by a lack of intrinsic factor, which
is necessary for Vitamin B12 absorption in the ileum. Because the body cannot
, absorb oral B12, parenteral administration via intramuscular injection is the
standard treatment. This therapy is lifelong because the underlying gastric
pathology generally does not resolve. Failure to maintain these injections can lead to
irreversible neurological damage and severe anemia. Patient education must
emphasize that dietary changes alone are insufficient to manage this specific type of
anemia.
5. The nurse is caring for a patient with a white blood cell count of 1,200/mm3 and a
neutrophil count of 400/mm3. Which intervention is most critical for this patient?
A. Encouraging the patient to eat fresh fruits and salads to boost immunity
B. Placing the patient in a private room with reverse isolation precautions
C. Administering aspirin for any fever over 100 degrees Fahrenheit
D. Assisting the patient with vigorous tooth brushing and flossing twice daily
Correct Answer: B
Expert Explanation: The patient is severely neutropenic, which puts them at
extreme risk for life-threatening infections from opportunistic organisms. Reverse
isolation, or neutropenic precautions, helps protect the patient from bacteria carried
by staff and visitors. Fresh fruits and vegetables should be avoided because they
may harbor soil-borne bacteria or fungi. Oral care should be gentle to prevent
mucosal trauma that could serve as a portal for infection. Low-grade fevers in
3 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient with sickle cell anemia is admitted in a vaso-occlusive crisis. Which
nursing intervention should be prioritized first?
A. Administering high-flow oxygen via non-rebreather mask
B. Administering prescribed intravenous morphine sulfate
C. Initiating intravenous fluid replacement at 200 mL/hr
D. Applying cold compresses to the affected painful joints
Correct Answer: C
Expert Explanation: In a sickle cell vaso-occlusive crisis, the priority is to reduce
blood viscosity and improve perfusion to distal tissues. Intravenous hydration helps
dilute the concentrated red blood cells and promotes the flow of oxygenated blood.
While pain management and oxygen are important, they are often secondary to
resolving the mechanical blockage of vessels. Cold compresses should be avoided as
they cause vasoconstriction and worsen the sickling process. Effective hydration is
the cornerstone of preventing permanent organ damage during these acute
episodes.
,2. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). Which
action is essential for patient safety during the first 15 minutes of the transfusion?
A. Infusing the blood at a rapid rate of 150 mL/hr to complete the unit quickly
B. Remaining at the bedside to monitor for signs of a hemolytic reaction
C. Mixing the blood with 5% Dextrose in Water to prevent clotting
D. Checking the patient’s temperature every 30 minutes throughout the process
Correct Answer: B
Expert Explanation: The first 15 minutes of a blood transfusion are the most
critical for detecting life-threatening acute hemolytic reactions. The nurse must stay
with the patient to observe for symptoms like fever, chills, back pain, or dyspnea.
The infusion should be started slowly, typically no faster than 2 mL/min, to limit the
severity of any potential reaction. Only normal saline should be used as a primary
line fluid to avoid hemolysis or clotting in the tubing. Constant monitoring during
this window allows for immediate cessation of the infusion if complications arise.
3. A patient with Disseminated Intravascular Coagulation (DIC) is showing signs of
active bleeding. Which laboratory finding most specifically supports this diagnosis?
A. Increased hemoglobin and hematocrit levels
B. Decreased Prothrombin Time (PT) and Partial Thromboplastin Time (PTT)
C. Elevated platelet count and decreased serum potassium
,D. Elevated D-dimer and decreased fibrinogen levels
Correct Answer: D
Expert Explanation: DIC is characterized by the simultaneous occurrence of
massive clotting and systemic bleeding. Elevated D-dimer levels indicate high levels
of fibrin degradation products, which occur when the body tries to break down
excessive clots. Fibrinogen is consumed during the clotting process, leading to the
low levels seen in active DIC cases. Prothrombin time and PTT are typically
prolonged, not decreased, due to the consumption of clotting factors. Identifying
these specific lab markers is essential for differentiating DIC from other hematologic
disorders.
4. A patient is diagnosed with pernicious anemia. The nurse should include which
information in the discharge teaching plan?
A. The patient will need oral Vitamin B12 supplements for the next six months
B. Increasing dietary intake of leafy green vegetables will cure the condition
C. Monthly intramuscular Vitamin B12 injections will be required for life
D. The patient should avoid all dairy products to improve iron absorption
Correct Answer: C
Expert Explanation: Pernicious anemia is caused by a lack of intrinsic factor, which
is necessary for Vitamin B12 absorption in the ileum. Because the body cannot
, absorb oral B12, parenteral administration via intramuscular injection is the
standard treatment. This therapy is lifelong because the underlying gastric
pathology generally does not resolve. Failure to maintain these injections can lead to
irreversible neurological damage and severe anemia. Patient education must
emphasize that dietary changes alone are insufficient to manage this specific type of
anemia.
5. The nurse is caring for a patient with a white blood cell count of 1,200/mm3 and a
neutrophil count of 400/mm3. Which intervention is most critical for this patient?
A. Encouraging the patient to eat fresh fruits and salads to boost immunity
B. Placing the patient in a private room with reverse isolation precautions
C. Administering aspirin for any fever over 100 degrees Fahrenheit
D. Assisting the patient with vigorous tooth brushing and flossing twice daily
Correct Answer: B
Expert Explanation: The patient is severely neutropenic, which puts them at
extreme risk for life-threatening infections from opportunistic organisms. Reverse
isolation, or neutropenic precautions, helps protect the patient from bacteria carried
by staff and visitors. Fresh fruits and vegetables should be avoided because they
may harbor soil-borne bacteria or fungi. Oral care should be gentle to prevent
mucosal trauma that could serve as a portal for infection. Low-grade fevers in
