NUR201 | NUR201 Medical Surgical Exam 1
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A patient with heart failure presents with a weight gain of 3 pounds in 24 hours and
crackles in the lung bases. Which nursing diagnosis should the nurse prioritize?
A. Fluid Volume Excess
B. Deficient Knowledge
C. Risk for Infection
D. Activity Intolerance
Correct Answer: A
Expert Explanation: The sudden weight gain and pulmonary crackles are classic
indicators of fluid retention in heart failure. This condition requires immediate
intervention to prevent further respiratory compromise and cardiac strain. The
nurse must prioritize addressing the physical threat to the patient’s airway and
breathing status. Managing excess fluid volume often involves diuretic therapy and
strict intake monitoring. This physiological need takes precedence over educational
or activity-related concerns according to Maslow’s hierarchy.
,2. A nurse is reviewing the lab results of a patient receiving a potassium-sparing
diuretic and notes a potassium level of 5.8 mEq/L. Which clinical finding is the nurse
most likely to observe?
A. Hyporeflexia
B. Prominent U waves
C. Peaked T waves on ECG
D. Increased thirst
Correct Answer: C
Expert Explanation: Hyperkalemia is defined as a serum potassium level greater
than 5.0 mEq/L and can be life-threatening. The most significant concern with
elevated potassium is its effect on cardiac rhythm and electrical conduction. Peaked
T waves are an early electrocardiogram change associated with rising potassium
levels in the bloodstream. If left untreated, this can progress to ventricular
fibrillation or cardiac arrest. The nurse must notify the provider immediately and
prepare for potential emergency treatments like insulin or calcium gluconate.
3. The nurse is caring for a patient diagnosed with Clostridium difficile (C. diff). Which
infection control measure is most critical for this patient?
A. Using alcohol-based hand rub after every contact
B. Wearing a surgical mask within 3 feet
,C. Placing the patient in a room with negative pressure
D. Hand hygiene with soap and water
Correct Answer: D
Expert Explanation: C. diff is an enteric pathogen that produces spores which are
highly resistant to many disinfectants. Alcohol-based hand sanitizers are ineffective
at killing these spores, making mechanical removal necessary. Washing hands with
soap and water provides the friction needed to rinse the spores off the skin surface.
Contact precautions must also be strictly followed, including the use of gloves and
gowns. Ensuring proper environmental cleaning with bleach-based products is also
a standard part of managing this infection.
4. Which patient should the nurse assess first after receiving the morning shift report?
A. A patient who is 1 day postoperative and reports sudden onset of shortness of
breath
B. A patient who had a hip replacement 2 days ago and needs assistance to the chair
C. A patient with a history of asthma reporting a dry cough and itchy eyes
D. A patient scheduled for a colonoscopy in 4 hours
Correct Answer: A
, Expert Explanation: The nurse must use the ABC (Airway, Breathing, Circulation)
framework to prioritize patient care. Sudden shortness of breath in a postoperative
patient could indicate a pulmonary embolism or other acute respiratory distress.
This represents a life-threatening emergency that requires immediate assessment
and intervention. The other patients described are stable or have non-urgent needs
that can wait. Prompt recognition of complications is essential for improving patient
outcomes in acute care settings.
5. A patient has been admitted with severe vomiting and diarrhea for three days.
Which vital sign change would the nurse expect to find first as a sign of compensatory
hypovolemia?
A. Decreased respiratory rate
B. Increased heart rate
C. Increased blood pressure
D. Decreased body temperature
Correct Answer: B
Expert Explanation: When fluid volume decreases significantly, the body triggers
the sympathetic nervous system to maintain cardiac output. Tachycardia is often the
earliest sign of compensatory fluid volume deficit as the heart beats faster to
circulate remaining blood. Blood pressure may remain normal initially due to
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A patient with heart failure presents with a weight gain of 3 pounds in 24 hours and
crackles in the lung bases. Which nursing diagnosis should the nurse prioritize?
A. Fluid Volume Excess
B. Deficient Knowledge
C. Risk for Infection
D. Activity Intolerance
Correct Answer: A
Expert Explanation: The sudden weight gain and pulmonary crackles are classic
indicators of fluid retention in heart failure. This condition requires immediate
intervention to prevent further respiratory compromise and cardiac strain. The
nurse must prioritize addressing the physical threat to the patient’s airway and
breathing status. Managing excess fluid volume often involves diuretic therapy and
strict intake monitoring. This physiological need takes precedence over educational
or activity-related concerns according to Maslow’s hierarchy.
,2. A nurse is reviewing the lab results of a patient receiving a potassium-sparing
diuretic and notes a potassium level of 5.8 mEq/L. Which clinical finding is the nurse
most likely to observe?
A. Hyporeflexia
B. Prominent U waves
C. Peaked T waves on ECG
D. Increased thirst
Correct Answer: C
Expert Explanation: Hyperkalemia is defined as a serum potassium level greater
than 5.0 mEq/L and can be life-threatening. The most significant concern with
elevated potassium is its effect on cardiac rhythm and electrical conduction. Peaked
T waves are an early electrocardiogram change associated with rising potassium
levels in the bloodstream. If left untreated, this can progress to ventricular
fibrillation or cardiac arrest. The nurse must notify the provider immediately and
prepare for potential emergency treatments like insulin or calcium gluconate.
3. The nurse is caring for a patient diagnosed with Clostridium difficile (C. diff). Which
infection control measure is most critical for this patient?
A. Using alcohol-based hand rub after every contact
B. Wearing a surgical mask within 3 feet
,C. Placing the patient in a room with negative pressure
D. Hand hygiene with soap and water
Correct Answer: D
Expert Explanation: C. diff is an enteric pathogen that produces spores which are
highly resistant to many disinfectants. Alcohol-based hand sanitizers are ineffective
at killing these spores, making mechanical removal necessary. Washing hands with
soap and water provides the friction needed to rinse the spores off the skin surface.
Contact precautions must also be strictly followed, including the use of gloves and
gowns. Ensuring proper environmental cleaning with bleach-based products is also
a standard part of managing this infection.
4. Which patient should the nurse assess first after receiving the morning shift report?
A. A patient who is 1 day postoperative and reports sudden onset of shortness of
breath
B. A patient who had a hip replacement 2 days ago and needs assistance to the chair
C. A patient with a history of asthma reporting a dry cough and itchy eyes
D. A patient scheduled for a colonoscopy in 4 hours
Correct Answer: A
, Expert Explanation: The nurse must use the ABC (Airway, Breathing, Circulation)
framework to prioritize patient care. Sudden shortness of breath in a postoperative
patient could indicate a pulmonary embolism or other acute respiratory distress.
This represents a life-threatening emergency that requires immediate assessment
and intervention. The other patients described are stable or have non-urgent needs
that can wait. Prompt recognition of complications is essential for improving patient
outcomes in acute care settings.
5. A patient has been admitted with severe vomiting and diarrhea for three days.
Which vital sign change would the nurse expect to find first as a sign of compensatory
hypovolemia?
A. Decreased respiratory rate
B. Increased heart rate
C. Increased blood pressure
D. Decreased body temperature
Correct Answer: B
Expert Explanation: When fluid volume decreases significantly, the body triggers
the sympathetic nervous system to maintain cardiac output. Tachycardia is often the
earliest sign of compensatory fluid volume deficit as the heart beats faster to
circulate remaining blood. Blood pressure may remain normal initially due to
