NUR104 | NUR104 Medsurg 2 Exam 3 Version 2
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is assessing a client who had a total hip arthroplasty 4 hours ago. Which of
the following findings should the nurse identify as the priority to report to the
provider?
A. A temperature of 37.5 C (99.5 F)
B. Sudden onset of shortness of breath and chest pain
C. Pain level of 6 on a scale of 0 to 10
D. Urine output of 40 mL over the last 2 hours
Correct Answer: B
Expert Explanation: Postoperative patients are at high risk for venous
thromboembolism which can lead to a pulmonary embolism. Sudden respiratory
distress and chest pain are classic signs of this life-threatening complication. The
nurse must prioritize airway, breathing, and circulation when assessing
postoperative patients. Immediate intervention is required to stabilize the client
and prevent further respiratory failure. Reporting these findings promptly ensures
the provider can initiate emergency protocols such as anticoagulation or imaging.
,2. A client is diagnosed with osteoporosis and is prescribed alendronate. Which
instruction should the nurse include in the teaching?
A. Take the medication with a full glass of milk.
B. Lie down for 30 minutes after taking the medication.
C. Take the medication right before bedtime.
D. Take the medication on an empty stomach with water.
Correct Answer: D
Expert Explanation: Alendronate is a bisphosphonate that requires specific
administration to ensure absorption and prevent esophageal irritation. The client
must take it with at least 8 ounces of plain water on an empty stomach. It is essential
to remain upright for at least 30 minutes to prevent gastric reflux and esophageal
erosion. Avoid taking the medication with food, juice, or coffee as they significantly
reduce its efficacy. Proper education helps the client manage the risks of the
medication while improving bone mineral density.
3. A nurse is caring for a client with a compound fracture of the tibia. Which
assessment finding is most suggestive of compartment syndrome?
A. Capillary refill of 2 seconds
B. Pain that is unrelieved by opioid analgesics
C. Warmth and redness at the site
,D. Palpable peripheral pulses distal to the injury
Correct Answer: B
Expert Explanation: Compartment syndrome is a surgical emergency caused by
increased pressure within a muscle compartment. The most common early sign is
intense pain that is out of proportion to the injury and not relieved by medication.
While pulselessness is a sign, it usually occurs very late in the progression of the
syndrome. Nurses must perform frequent neurovascular checks to identify sensory
or motor changes early. If suspected, the nurse should immediately notify the
surgeon and keep the limb at heart level.
4. A client with rheumatoid arthritis (RA) is experiencing significant morning stiffness.
What should the nurse recommend to help alleviate this symptom?
A. Take a cold shower immediately upon awakening.
B. Perform range-of-motion exercises in a warm shower.
C. Remain in bed until the stiffness naturally subsides.
D. Avoid all movement for the first two hours of the day.
Correct Answer: B
Expert Explanation: Rheumatoid arthritis is a systemic inflammatory disease
characterized by joint pain and prolonged morning stiffness. Heat application, such
as a warm shower, helps to relax muscles and decrease joint viscosity. Encouraging
, gentle range-of-motion exercises while in the shower enhances mobility and
reduces the duration of stiffness. Patients should be taught to balance rest with
activity to prevent joint contractures. Consistent morning routines can significantly
improve a client’s functional status throughout the day.
5. Which clinical manifestation should a nurse expect to find in a client with a
fractured hip?
A. Internal rotation of the affected leg
B. External rotation and shortening of the affected leg
C. Abduction of the affected leg
D. Lengthening of the affected extremity
Correct Answer: B
Expert Explanation: A hip fracture typically presents with characteristic physical
findings due to muscle spasms and displacement. The affected leg often appears
shorter than the unaffected leg and is externally rotated. Patients usually report
severe pain in the hip or groin area and are unable to bear weight. Early recognition
of these signs allows for prompt immobilization and surgical consultation. Proper
assessment of the neurovascular status distal to the fracture is also a nursing
priority.
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is assessing a client who had a total hip arthroplasty 4 hours ago. Which of
the following findings should the nurse identify as the priority to report to the
provider?
A. A temperature of 37.5 C (99.5 F)
B. Sudden onset of shortness of breath and chest pain
C. Pain level of 6 on a scale of 0 to 10
D. Urine output of 40 mL over the last 2 hours
Correct Answer: B
Expert Explanation: Postoperative patients are at high risk for venous
thromboembolism which can lead to a pulmonary embolism. Sudden respiratory
distress and chest pain are classic signs of this life-threatening complication. The
nurse must prioritize airway, breathing, and circulation when assessing
postoperative patients. Immediate intervention is required to stabilize the client
and prevent further respiratory failure. Reporting these findings promptly ensures
the provider can initiate emergency protocols such as anticoagulation or imaging.
,2. A client is diagnosed with osteoporosis and is prescribed alendronate. Which
instruction should the nurse include in the teaching?
A. Take the medication with a full glass of milk.
B. Lie down for 30 minutes after taking the medication.
C. Take the medication right before bedtime.
D. Take the medication on an empty stomach with water.
Correct Answer: D
Expert Explanation: Alendronate is a bisphosphonate that requires specific
administration to ensure absorption and prevent esophageal irritation. The client
must take it with at least 8 ounces of plain water on an empty stomach. It is essential
to remain upright for at least 30 minutes to prevent gastric reflux and esophageal
erosion. Avoid taking the medication with food, juice, or coffee as they significantly
reduce its efficacy. Proper education helps the client manage the risks of the
medication while improving bone mineral density.
3. A nurse is caring for a client with a compound fracture of the tibia. Which
assessment finding is most suggestive of compartment syndrome?
A. Capillary refill of 2 seconds
B. Pain that is unrelieved by opioid analgesics
C. Warmth and redness at the site
,D. Palpable peripheral pulses distal to the injury
Correct Answer: B
Expert Explanation: Compartment syndrome is a surgical emergency caused by
increased pressure within a muscle compartment. The most common early sign is
intense pain that is out of proportion to the injury and not relieved by medication.
While pulselessness is a sign, it usually occurs very late in the progression of the
syndrome. Nurses must perform frequent neurovascular checks to identify sensory
or motor changes early. If suspected, the nurse should immediately notify the
surgeon and keep the limb at heart level.
4. A client with rheumatoid arthritis (RA) is experiencing significant morning stiffness.
What should the nurse recommend to help alleviate this symptom?
A. Take a cold shower immediately upon awakening.
B. Perform range-of-motion exercises in a warm shower.
C. Remain in bed until the stiffness naturally subsides.
D. Avoid all movement for the first two hours of the day.
Correct Answer: B
Expert Explanation: Rheumatoid arthritis is a systemic inflammatory disease
characterized by joint pain and prolonged morning stiffness. Heat application, such
as a warm shower, helps to relax muscles and decrease joint viscosity. Encouraging
, gentle range-of-motion exercises while in the shower enhances mobility and
reduces the duration of stiffness. Patients should be taught to balance rest with
activity to prevent joint contractures. Consistent morning routines can significantly
improve a client’s functional status throughout the day.
5. Which clinical manifestation should a nurse expect to find in a client with a
fractured hip?
A. Internal rotation of the affected leg
B. External rotation and shortening of the affected leg
C. Abduction of the affected leg
D. Lengthening of the affected extremity
Correct Answer: B
Expert Explanation: A hip fracture typically presents with characteristic physical
findings due to muscle spasms and displacement. The affected leg often appears
shorter than the unaffected leg and is externally rotated. Patients usually report
severe pain in the hip or groin area and are unable to bear weight. Early recognition
of these signs allows for prompt immobilization and surgical consultation. Proper
assessment of the neurovascular status distal to the fracture is also a nursing
priority.
