PNR 206/PNR206 Exam 4 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is 4 hours postoperative following a subtotal
thyroidectomy. Which of the following is the priority assessment finding?
A. A heart rate of 90 beats per minute
B. Pain at the incision site
C. Hoarseness when speaking
D. Laryngeal stridor
Correct Answer: D
Expert Explanation: Laryngeal stridor is a high-pitched sound indicating airway
obstruction and is a medical emergency following thyroid surgery. The nurse must
prioritize airway patency above pain management or minor voice changes. Immediate
intervention with oxygen and preparation for a tracheostomy may be necessary to ensure
the client’s safety.
2. A nurse is assessing a client with Cushing’s syndrome. Which of the following clinical
manifestations should the nurse expect to find?
A. Trunkal obesity and moon face
B. Hyperpigmentation of the skin
,C. Hypotension and weight loss
D. Decreased blood glucose levels
Correct Answer: A
Expert Explanation: Cushing’s syndrome is characterized by the oversecretion of cortisol,
which leads to fat redistribution resulting in a moon face and trunkal obesity. Other
common signs include purple striae and hypertension rather than hypotension.
Understanding these hallmark features helps the nurse differentiate this condition from
Addison’s disease.
3. A nurse is teaching a client who has Type 1 Diabetes Mellitus about the peaks of various
insulins. Which of the following insulins peaks 2 to 4 hours after administration?
A. Regular insulin
B. Insulin glargine
C. NPH insulin
D. Insulin lispro
Correct Answer: A
Expert Explanation: Regular insulin is short-acting and typically peaks between 2 and 4
hours after subcutaneous injection. Lispro is rapid-acting with a much earlier peak, while
NPH is intermediate-acting and peaks later in the day. The nurse must monitor for
hypoglycemia specifically during these peak times to ensure patient safety.
, 4. A client is diagnosed with Addison’s disease. Which of the following diet instructions is
appropriate for the nurse to provide?
A. Restrict sodium intake to 1 gram per day
B. Avoid foods rich in protein
C. Maintain a diet high in sodium and low in potassium
D. Increase intake of potassium-rich foods
Correct Answer: C
Expert Explanation: Clients with Addison’s disease experience mineralocorticoid
deficiency, which leads to sodium wasting and potassium retention. To counteract this, the
nurse should encourage increased sodium intake and decreased potassium intake. Proper
dietary management is essential to prevent adrenal crisis and electrolyte imbalances.
5. Which of the following laboratory results should the nurse expect for a client in Diabetic
Ketoacidosis (DKA)?
A. Bicarbonate 12 mEq/L
B. pH 7.48
C. Blood glucose 110 mg/dL
D. Negative ketones in the urine
Correct Answer: A
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is 4 hours postoperative following a subtotal
thyroidectomy. Which of the following is the priority assessment finding?
A. A heart rate of 90 beats per minute
B. Pain at the incision site
C. Hoarseness when speaking
D. Laryngeal stridor
Correct Answer: D
Expert Explanation: Laryngeal stridor is a high-pitched sound indicating airway
obstruction and is a medical emergency following thyroid surgery. The nurse must
prioritize airway patency above pain management or minor voice changes. Immediate
intervention with oxygen and preparation for a tracheostomy may be necessary to ensure
the client’s safety.
2. A nurse is assessing a client with Cushing’s syndrome. Which of the following clinical
manifestations should the nurse expect to find?
A. Trunkal obesity and moon face
B. Hyperpigmentation of the skin
,C. Hypotension and weight loss
D. Decreased blood glucose levels
Correct Answer: A
Expert Explanation: Cushing’s syndrome is characterized by the oversecretion of cortisol,
which leads to fat redistribution resulting in a moon face and trunkal obesity. Other
common signs include purple striae and hypertension rather than hypotension.
Understanding these hallmark features helps the nurse differentiate this condition from
Addison’s disease.
3. A nurse is teaching a client who has Type 1 Diabetes Mellitus about the peaks of various
insulins. Which of the following insulins peaks 2 to 4 hours after administration?
A. Regular insulin
B. Insulin glargine
C. NPH insulin
D. Insulin lispro
Correct Answer: A
Expert Explanation: Regular insulin is short-acting and typically peaks between 2 and 4
hours after subcutaneous injection. Lispro is rapid-acting with a much earlier peak, while
NPH is intermediate-acting and peaks later in the day. The nurse must monitor for
hypoglycemia specifically during these peak times to ensure patient safety.
, 4. A client is diagnosed with Addison’s disease. Which of the following diet instructions is
appropriate for the nurse to provide?
A. Restrict sodium intake to 1 gram per day
B. Avoid foods rich in protein
C. Maintain a diet high in sodium and low in potassium
D. Increase intake of potassium-rich foods
Correct Answer: C
Expert Explanation: Clients with Addison’s disease experience mineralocorticoid
deficiency, which leads to sodium wasting and potassium retention. To counteract this, the
nurse should encourage increased sodium intake and decreased potassium intake. Proper
dietary management is essential to prevent adrenal crisis and electrolyte imbalances.
5. Which of the following laboratory results should the nurse expect for a client in Diabetic
Ketoacidosis (DKA)?
A. Bicarbonate 12 mEq/L
B. pH 7.48
C. Blood glucose 110 mg/dL
D. Negative ketones in the urine
Correct Answer: A
