PNR 206/PNR206 Exam 3 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient with a T6 spinal cord injury reports a pounding headache and has a blood
pressure of 198/110 mmHg. Which action should the nurse perform first?
A. Administer a prescribed antihypertensive medication.
B. Notify the healthcare provider immediately.
C. Check the patient’s urinary catheter for kinks.
D. Place the patient in a sitting position.
Correct Answer: D
Expert Explanation: The symptoms of severe headache and hypertension in a patient with
a T6 injury indicate autonomic dysreflexia. Elevating the head of the bed to a sitting
position is the priority to help lower the blood pressure through orthostatic changes. After
positioning, the nurse should investigate and remove the triggering stimulus, such as a
distended bladder.
2. Which clinical manifestation should the nurse expect to find in a patient diagnosed with
Cushing’s Syndrome?
A. Hypotension and weight loss.
B. Hyperkalemia and hyponatremia.
,C. Truncal obesity and a buffalo hump.
D. Increased muscle mass in the extremities.
Correct Answer: C
Expert Explanation: Cushing’s Syndrome is characterized by an overproduction of
cortisol, leading to a redistribution of fat. This results in classic signs like truncal obesity, a
‘buffalo hump’ on the upper back, and a ‘moon face.’ Patients also typically experience
thinning of the skin and muscle wasting in the limbs.
3. A nurse is caring for a patient following a total hip arthroplasty. Which position should the
nurse maintain the affected extremity in to prevent dislocation?
A. Adduction and internal rotation.
B. Internal rotation and extension.
C. Flexion greater than 90 degrees.
D. Abduction and neutral rotation.
Correct Answer: D
Expert Explanation: Maintaining the hip in abduction prevents the femoral head from
popping out of the acetabular cup. An abduction pillow is frequently used between the legs
to ensure the extremity stays in the correct alignment. It is also vital to avoid hip flexion
beyond 90 degrees during the early postoperative phase.
, 4. A patient with Type 1 Diabetes Mellitus is found unconscious and clammy. What is the
nurse’s priority action?
A. Administer 15 grams of simple carbohydrates orally.
B. Administer Glucagon subcutaneously or IM.
C. Call the laboratory for a STAT fasting blood glucose.
D. Check the patient’s urine for ketones.
Correct Answer: B
Expert Explanation: An unconscious patient cannot safely swallow, making oral
carbohydrates a choking risk. Glucagon is the emergency treatment of choice to rapidly
increase blood glucose levels in an unresponsive patient. Once the patient regains
consciousness and can swallow safely, complex carbohydrates should be provided.
5. The nurse is assessing a patient with a fractured femur who has developed sudden chest
pain, dyspnea, and petechiae on the chest. What does the nurse suspect?
A. Pulmonary Embolism.
B. Myocardial Infarction.
C. Fat Embolism Syndrome.
D. Pneumothorax.
Correct Answer: C
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient with a T6 spinal cord injury reports a pounding headache and has a blood
pressure of 198/110 mmHg. Which action should the nurse perform first?
A. Administer a prescribed antihypertensive medication.
B. Notify the healthcare provider immediately.
C. Check the patient’s urinary catheter for kinks.
D. Place the patient in a sitting position.
Correct Answer: D
Expert Explanation: The symptoms of severe headache and hypertension in a patient with
a T6 injury indicate autonomic dysreflexia. Elevating the head of the bed to a sitting
position is the priority to help lower the blood pressure through orthostatic changes. After
positioning, the nurse should investigate and remove the triggering stimulus, such as a
distended bladder.
2. Which clinical manifestation should the nurse expect to find in a patient diagnosed with
Cushing’s Syndrome?
A. Hypotension and weight loss.
B. Hyperkalemia and hyponatremia.
,C. Truncal obesity and a buffalo hump.
D. Increased muscle mass in the extremities.
Correct Answer: C
Expert Explanation: Cushing’s Syndrome is characterized by an overproduction of
cortisol, leading to a redistribution of fat. This results in classic signs like truncal obesity, a
‘buffalo hump’ on the upper back, and a ‘moon face.’ Patients also typically experience
thinning of the skin and muscle wasting in the limbs.
3. A nurse is caring for a patient following a total hip arthroplasty. Which position should the
nurse maintain the affected extremity in to prevent dislocation?
A. Adduction and internal rotation.
B. Internal rotation and extension.
C. Flexion greater than 90 degrees.
D. Abduction and neutral rotation.
Correct Answer: D
Expert Explanation: Maintaining the hip in abduction prevents the femoral head from
popping out of the acetabular cup. An abduction pillow is frequently used between the legs
to ensure the extremity stays in the correct alignment. It is also vital to avoid hip flexion
beyond 90 degrees during the early postoperative phase.
, 4. A patient with Type 1 Diabetes Mellitus is found unconscious and clammy. What is the
nurse’s priority action?
A. Administer 15 grams of simple carbohydrates orally.
B. Administer Glucagon subcutaneously or IM.
C. Call the laboratory for a STAT fasting blood glucose.
D. Check the patient’s urine for ketones.
Correct Answer: B
Expert Explanation: An unconscious patient cannot safely swallow, making oral
carbohydrates a choking risk. Glucagon is the emergency treatment of choice to rapidly
increase blood glucose levels in an unresponsive patient. Once the patient regains
consciousness and can swallow safely, complex carbohydrates should be provided.
5. The nurse is assessing a patient with a fractured femur who has developed sudden chest
pain, dyspnea, and petechiae on the chest. What does the nurse suspect?
A. Pulmonary Embolism.
B. Myocardial Infarction.
C. Fat Embolism Syndrome.
D. Pneumothorax.
Correct Answer: C
