PNR 206/PNR206 Final Exam V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take first?
A. Turn the client to a side-lying position.
B. Restrain the client’s arms and legs to prevent injury.
C. Insert a padded tongue blade into the client’s mouth.
D. Administer oral lorazepam immediately.
Correct Answer: A
Expert Explanation: Turning the client to a side-lying position is the priority to maintain a
patent airway and prevent aspiration. The nurse should never insert objects into the mouth
during a seizure as it can cause dental or mucosal injury. Restraining the client is
contraindicated because it can lead to musculoskeletal injuries during the convulsive
phase.
2. A client with a history of left-sided stroke (CVA) displays expressive aphasia. Which area of
the brain is most likely affected?
A. Wernicke’s area
B. Occipital lobe
,C. Broca’s area
D. Cerebellum
Correct Answer: C
Expert Explanation: Broca’s area, located in the frontal lobe, is responsible for motor
speech production and its impairment results in expressive aphasia. Wernicke’s area is
associated with sensory speech and comprehension, which would result in receptive
aphasia. Damage to the occipital lobe typically affects vision, while the cerebellum governs
coordination and balance.
3. A nurse is calculating the fluid resuscitation for a client with burns covering 30% of their
body using the Parkland Formula. The client weighs 70 kg. How much fluid should be given in
the first 8 hours?
A. 6,300 mL
B. 8,400 mL
C. 2,100 mL
D. 4,200 mL
Correct Answer: D
Expert Explanation: The Parkland Formula is 4 mL x kg x % TBSA, which equals 8,400 mL
total for 24 hours (4 x 70 x 30). Half of this total volume, which is 4,200 mL, must be
administered within the first 8 hours from the time of the burn. The remaining half is
administered over the subsequent 16 hours to prevent hypovolemic shock.
, 4. Which lab value is most important for a nurse to monitor in a client receiving Highly Active
Antiretroviral Therapy (HAART) for HIV?
A. Hemoglobin levels
B. CD4+ T-cell count
C. Serum sodium
D. Platelet count
Correct Answer: B
Expert Explanation: The CD4+ T-cell count is a primary indicator of immune system
function and the effectiveness of HAART in HIV-positive clients. A rising CD4+ count
suggests that the viral load is decreasing and the immune system is recovering. Monitoring
this value helps the healthcare provider determine the stage of the disease and the risk for
opportunistic infections.
5. A client is 12 hours post-operative following a total hip arthroplasty. Which nursing
intervention is essential to prevent dislocation?
A. Keep the affected leg in an adducted position.
B. Use an abduction pillow between the client’s legs.
C. Maintain the client in a high-Fowler’s position.
D. Encourage the client to cross their legs while sitting.
Correct Answer: B
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take first?
A. Turn the client to a side-lying position.
B. Restrain the client’s arms and legs to prevent injury.
C. Insert a padded tongue blade into the client’s mouth.
D. Administer oral lorazepam immediately.
Correct Answer: A
Expert Explanation: Turning the client to a side-lying position is the priority to maintain a
patent airway and prevent aspiration. The nurse should never insert objects into the mouth
during a seizure as it can cause dental or mucosal injury. Restraining the client is
contraindicated because it can lead to musculoskeletal injuries during the convulsive
phase.
2. A client with a history of left-sided stroke (CVA) displays expressive aphasia. Which area of
the brain is most likely affected?
A. Wernicke’s area
B. Occipital lobe
,C. Broca’s area
D. Cerebellum
Correct Answer: C
Expert Explanation: Broca’s area, located in the frontal lobe, is responsible for motor
speech production and its impairment results in expressive aphasia. Wernicke’s area is
associated with sensory speech and comprehension, which would result in receptive
aphasia. Damage to the occipital lobe typically affects vision, while the cerebellum governs
coordination and balance.
3. A nurse is calculating the fluid resuscitation for a client with burns covering 30% of their
body using the Parkland Formula. The client weighs 70 kg. How much fluid should be given in
the first 8 hours?
A. 6,300 mL
B. 8,400 mL
C. 2,100 mL
D. 4,200 mL
Correct Answer: D
Expert Explanation: The Parkland Formula is 4 mL x kg x % TBSA, which equals 8,400 mL
total for 24 hours (4 x 70 x 30). Half of this total volume, which is 4,200 mL, must be
administered within the first 8 hours from the time of the burn. The remaining half is
administered over the subsequent 16 hours to prevent hypovolemic shock.
, 4. Which lab value is most important for a nurse to monitor in a client receiving Highly Active
Antiretroviral Therapy (HAART) for HIV?
A. Hemoglobin levels
B. CD4+ T-cell count
C. Serum sodium
D. Platelet count
Correct Answer: B
Expert Explanation: The CD4+ T-cell count is a primary indicator of immune system
function and the effectiveness of HAART in HIV-positive clients. A rising CD4+ count
suggests that the viral load is decreasing and the immune system is recovering. Monitoring
this value helps the healthcare provider determine the stage of the disease and the risk for
opportunistic infections.
5. A client is 12 hours post-operative following a total hip arthroplasty. Which nursing
intervention is essential to prevent dislocation?
A. Keep the affected leg in an adducted position.
B. Use an abduction pillow between the client’s legs.
C. Maintain the client in a high-Fowler’s position.
D. Encourage the client to cross their legs while sitting.
Correct Answer: B
