NUR201 Medical Surgical Exam 4 Version 3
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient with left-sided heart failure presents with increased dyspnea and crackles.
Which action should the nurse take first?
A. Check the patient’s oxygen saturation
B. Administer a prescribed diuretic
C. Notify the healthcare provider
D. Assess for peripheral edema
Correct Answer: A
Expert Explanation: The nurse should first assess the patient’s oxygenation status
to determine the severity of the respiratory distress. Left-sided heart failure leads to
pulmonary congestion and impaired gas exchange. Prioritization follows the ABC
framework where airway and breathing are paramount. Once oxygenation is
confirmed, the nurse can proceed with medical interventions like diuretics. Accurate
assessment findings guide the urgency of the subsequent multidisciplinary
notifications.
2. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome
(ARDS). What is the primary pathophysiology associated with this condition?
A. Increased permeability of the alveolar-capillary membrane
,B. Excessive production of thick mucus in the bronchioles
C. Decreased surfactant production leading to atelectasis
D. Obstruction of the pulmonary artery by a blood clot
Correct Answer: A
Expert Explanation: ARDS is characterized by sudden, progressive pulmonary
edema due to increased capillary permeability. This damage allows fluid and
proteins to leak into the alveoli, severely impairing gas exchange. The inflammatory
response triggers a cascade of lung injury and potential multi-organ failure.
Management often requires high levels of positive end-expiratory pressure on a
ventilator. Understanding this pathophysiology helps the nurse anticipate the need
for intensive respiratory monitoring.
3. During the oliguric phase of acute kidney injury (AKI), the nurse should expect
which laboratory finding?
A. Increased serum creatinine
B. Decreased serum potassium
C. Decreased blood urea nitrogen (BUN)
D. Increased serum calcium
Correct Answer: A
,Expert Explanation: The oliguric phase of AKI is marked by a significant decrease
in urine output and the retention of metabolic wastes. Elevated creatinine is a
hallmark indicator of severe renal filtration failure. Potassium levels typically rise
during this phase, requiring close cardiac monitoring for arrhythmias. The nurse
must also monitor for fluid volume excess and potential pulmonary complications.
Interventions focus on maintaining electrolyte balance and preventing further
kidney damage.
4. A patient is receiving a continuous heparin infusion for a pulmonary embolism.
Which lab value indicates the therapy is effective?
A. Prothrombin time (PT) is 1.5 times the control
B. International Normalized Ratio (Ratio) is 2.5
C. Platelet count is 150,000/mm3
D. Activated partial thromboplastin time (aPTT) is 2 times the control
Correct Answer: D
Expert Explanation: Heparin therapy is monitored using the activated partial
thromboplastin time (aPTT) to ensure safe anticoagulation levels. The therapeutic
range is typically 1.5 to 2.5 times the laboratory’s baseline value. If the value is too
high, the patient is at significant risk for spontaneous hemorrhage. If the value is too
, low, the risk for further clot propagation remains high. Nurses must follow titration
protocols precisely to achieve the desired clinical outcome.
5. Which clinical manifestation is a hallmark sign of a tension pneumothorax?
A. Bradypnea and hypertension
B. Dullness on percussion of the affected side
C. Presence of bilateral breath sounds
D. Tracheal deviation to the unaffected side
Correct Answer: D
Expert Explanation: Tension pneumothorax is a medical emergency where air
trapped in the pleural space shifts mediastinal structures. Tracheal deviation
toward the opposite side indicates a significant increase in intrathoracic pressure.
This condition can lead to obstructive shock by preventing venous return to the
heart. The nurse must prepare for immediate needle decompression or chest tube
insertion. Frequent assessment of respiratory effort and hemodynamics is crucial
during the intervention phase.
6. A nurse is caring for a patient with septic shock. What is the priority goal of fluid
resuscitation in this patient?
A. Maintain a central venous pressure (CVP) of 2 mmHg
B. Achieve a urine output of 100 mL per hour
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient with left-sided heart failure presents with increased dyspnea and crackles.
Which action should the nurse take first?
A. Check the patient’s oxygen saturation
B. Administer a prescribed diuretic
C. Notify the healthcare provider
D. Assess for peripheral edema
Correct Answer: A
Expert Explanation: The nurse should first assess the patient’s oxygenation status
to determine the severity of the respiratory distress. Left-sided heart failure leads to
pulmonary congestion and impaired gas exchange. Prioritization follows the ABC
framework where airway and breathing are paramount. Once oxygenation is
confirmed, the nurse can proceed with medical interventions like diuretics. Accurate
assessment findings guide the urgency of the subsequent multidisciplinary
notifications.
2. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome
(ARDS). What is the primary pathophysiology associated with this condition?
A. Increased permeability of the alveolar-capillary membrane
,B. Excessive production of thick mucus in the bronchioles
C. Decreased surfactant production leading to atelectasis
D. Obstruction of the pulmonary artery by a blood clot
Correct Answer: A
Expert Explanation: ARDS is characterized by sudden, progressive pulmonary
edema due to increased capillary permeability. This damage allows fluid and
proteins to leak into the alveoli, severely impairing gas exchange. The inflammatory
response triggers a cascade of lung injury and potential multi-organ failure.
Management often requires high levels of positive end-expiratory pressure on a
ventilator. Understanding this pathophysiology helps the nurse anticipate the need
for intensive respiratory monitoring.
3. During the oliguric phase of acute kidney injury (AKI), the nurse should expect
which laboratory finding?
A. Increased serum creatinine
B. Decreased serum potassium
C. Decreased blood urea nitrogen (BUN)
D. Increased serum calcium
Correct Answer: A
,Expert Explanation: The oliguric phase of AKI is marked by a significant decrease
in urine output and the retention of metabolic wastes. Elevated creatinine is a
hallmark indicator of severe renal filtration failure. Potassium levels typically rise
during this phase, requiring close cardiac monitoring for arrhythmias. The nurse
must also monitor for fluid volume excess and potential pulmonary complications.
Interventions focus on maintaining electrolyte balance and preventing further
kidney damage.
4. A patient is receiving a continuous heparin infusion for a pulmonary embolism.
Which lab value indicates the therapy is effective?
A. Prothrombin time (PT) is 1.5 times the control
B. International Normalized Ratio (Ratio) is 2.5
C. Platelet count is 150,000/mm3
D. Activated partial thromboplastin time (aPTT) is 2 times the control
Correct Answer: D
Expert Explanation: Heparin therapy is monitored using the activated partial
thromboplastin time (aPTT) to ensure safe anticoagulation levels. The therapeutic
range is typically 1.5 to 2.5 times the laboratory’s baseline value. If the value is too
high, the patient is at significant risk for spontaneous hemorrhage. If the value is too
, low, the risk for further clot propagation remains high. Nurses must follow titration
protocols precisely to achieve the desired clinical outcome.
5. Which clinical manifestation is a hallmark sign of a tension pneumothorax?
A. Bradypnea and hypertension
B. Dullness on percussion of the affected side
C. Presence of bilateral breath sounds
D. Tracheal deviation to the unaffected side
Correct Answer: D
Expert Explanation: Tension pneumothorax is a medical emergency where air
trapped in the pleural space shifts mediastinal structures. Tracheal deviation
toward the opposite side indicates a significant increase in intrathoracic pressure.
This condition can lead to obstructive shock by preventing venous return to the
heart. The nurse must prepare for immediate needle decompression or chest tube
insertion. Frequent assessment of respiratory effort and hemodynamics is crucial
during the intervention phase.
6. A nurse is caring for a patient with septic shock. What is the priority goal of fluid
resuscitation in this patient?
A. Maintain a central venous pressure (CVP) of 2 mmHg
B. Achieve a urine output of 100 mL per hour
