PNR 206/PNR206 Exam 1 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L/min via nasal cannula. Which physiological factor explains why the
nurse should avoid high concentrations of oxygen in this patient?
A. High oxygen levels can cause surfactant inactivation.
B. Excessive oxygen suppresses the hypercapnic drive to breathe.
C. Increased oxygen leads to pulmonary membrane thickening.
D. High oxygen concentrations may cause systemic vasoconstriction.
Correct Answer: B
Expert Explanation: In patients with chronic COPD, the respiratory center becomes less
sensitive to high carbon dioxide levels, shifting the primary stimulus for breathing to low
oxygen levels. Administering high concentrations of oxygen can eliminate this ‘hypoxic
drive,’ leading to hypoventilation and potential respiratory arrest. The nurse must carefully
balance oxygen administration to maintain adequate saturation without suppressing the
patient’s natural urge to breathe.
2. A patient is diagnosed with pernicious anemia. The nurse understands that this condition is
primarily caused by a deficiency of which substance?
A. Dietary iron intake
,B. Intrinsic factor
C. Erythropoietin production
D. Folic acid stores
Correct Answer: B
Expert Explanation: Pernicious anemia is an autoimmune condition characterized by a
lack of intrinsic factor, which is secreted by the gastric parietal cells. Intrinsic factor is
essential for the absorption of Vitamin B12 in the distal ileum of the small intestine.
Without sufficient B12, red blood cell production is impaired, necessitating lifelong
parenteral or intranasal vitamin supplementation.
3. While monitoring a patient during a blood transfusion, the nurse notes the patient is
experiencing chills, low back pain, and tachycardia. What is the nurse’s priority action?
A. Slow the infusion rate and notify the physician.
B. Administer diphenhydramine as prescribed for the reaction.
C. Stop the transfusion immediately and disconnect the tubing.
D. Document the symptoms and continue monitoring the patient.
Correct Answer: C
Expert Explanation: Chills, low back pain, and tachycardia are classic signs of an acute
hemolytic transfusion reaction, which is a life-threatening emergency. The nurse must stop
the infusion immediately to prevent further exposure to the incompatible blood product.
,Following the cessation of the transfusion, the nurse should maintain the IV access with
normal saline and alert the rapid response team or physician.
4. A nurse is teaching a patient with neutropenia about infection prevention. Which
instruction should the nurse include in the teaching plan?
A. Eat plenty of fresh fruits and vegetables daily.
B. Keep fresh flowers in the room to improve mood.
C. Avoid crowds and people who are visibly ill.
D. Use a commercial mouthwash containing alcohol.
Correct Answer: C
Expert Explanation: Neutropenia significantly reduces the body’s ability to fight infection,
making the patient highly susceptible to pathogens. Avoiding crowds and sick individuals is
a critical environmental control measure to reduce the risk of exposure. Additionally,
patients should avoid raw produce and fresh flowers, as these can harbor fungi and
bacteria that pose a risk to immunocompromised individuals.
5. An arterial blood gas (ABG) result shows a pH of 7.30, PaCO2 of 50 mmHg, and HCO3 of 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
, D. Respiratory Alkalosis
Correct Answer: B
Expert Explanation: The pH of 7.30 indicates acidosis, as it is below the normal range of
7.35 to 7.45. The PaCO2 of 50 mmHg is elevated, which suggests that the primary cause is
respiratory retention of carbon dioxide. Since the bicarbonate level is within the normal
range, the condition is identified as uncompensated respiratory acidosis.
6. Which type of precautions should the nurse implement for a patient suspected of having
active pulmonary tuberculosis?
A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. Standard precautions only
Correct Answer: A
Expert Explanation: Pulmonary tuberculosis is caused by Mycobacterium tuberculosis,
which is transmitted through small droplets that remain suspended in the air. Airborne
precautions include placing the patient in a negative-pressure room and requiring
healthcare workers to wear N95 respirators. These measures are essential to prevent the
spread of the infection to other patients and staff members.
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L/min via nasal cannula. Which physiological factor explains why the
nurse should avoid high concentrations of oxygen in this patient?
A. High oxygen levels can cause surfactant inactivation.
B. Excessive oxygen suppresses the hypercapnic drive to breathe.
C. Increased oxygen leads to pulmonary membrane thickening.
D. High oxygen concentrations may cause systemic vasoconstriction.
Correct Answer: B
Expert Explanation: In patients with chronic COPD, the respiratory center becomes less
sensitive to high carbon dioxide levels, shifting the primary stimulus for breathing to low
oxygen levels. Administering high concentrations of oxygen can eliminate this ‘hypoxic
drive,’ leading to hypoventilation and potential respiratory arrest. The nurse must carefully
balance oxygen administration to maintain adequate saturation without suppressing the
patient’s natural urge to breathe.
2. A patient is diagnosed with pernicious anemia. The nurse understands that this condition is
primarily caused by a deficiency of which substance?
A. Dietary iron intake
,B. Intrinsic factor
C. Erythropoietin production
D. Folic acid stores
Correct Answer: B
Expert Explanation: Pernicious anemia is an autoimmune condition characterized by a
lack of intrinsic factor, which is secreted by the gastric parietal cells. Intrinsic factor is
essential for the absorption of Vitamin B12 in the distal ileum of the small intestine.
Without sufficient B12, red blood cell production is impaired, necessitating lifelong
parenteral or intranasal vitamin supplementation.
3. While monitoring a patient during a blood transfusion, the nurse notes the patient is
experiencing chills, low back pain, and tachycardia. What is the nurse’s priority action?
A. Slow the infusion rate and notify the physician.
B. Administer diphenhydramine as prescribed for the reaction.
C. Stop the transfusion immediately and disconnect the tubing.
D. Document the symptoms and continue monitoring the patient.
Correct Answer: C
Expert Explanation: Chills, low back pain, and tachycardia are classic signs of an acute
hemolytic transfusion reaction, which is a life-threatening emergency. The nurse must stop
the infusion immediately to prevent further exposure to the incompatible blood product.
,Following the cessation of the transfusion, the nurse should maintain the IV access with
normal saline and alert the rapid response team or physician.
4. A nurse is teaching a patient with neutropenia about infection prevention. Which
instruction should the nurse include in the teaching plan?
A. Eat plenty of fresh fruits and vegetables daily.
B. Keep fresh flowers in the room to improve mood.
C. Avoid crowds and people who are visibly ill.
D. Use a commercial mouthwash containing alcohol.
Correct Answer: C
Expert Explanation: Neutropenia significantly reduces the body’s ability to fight infection,
making the patient highly susceptible to pathogens. Avoiding crowds and sick individuals is
a critical environmental control measure to reduce the risk of exposure. Additionally,
patients should avoid raw produce and fresh flowers, as these can harbor fungi and
bacteria that pose a risk to immunocompromised individuals.
5. An arterial blood gas (ABG) result shows a pH of 7.30, PaCO2 of 50 mmHg, and HCO3 of 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
, D. Respiratory Alkalosis
Correct Answer: B
Expert Explanation: The pH of 7.30 indicates acidosis, as it is below the normal range of
7.35 to 7.45. The PaCO2 of 50 mmHg is elevated, which suggests that the primary cause is
respiratory retention of carbon dioxide. Since the bicarbonate level is within the normal
range, the condition is identified as uncompensated respiratory acidosis.
6. Which type of precautions should the nurse implement for a patient suspected of having
active pulmonary tuberculosis?
A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. Standard precautions only
Correct Answer: A
Expert Explanation: Pulmonary tuberculosis is caused by Mycobacterium tuberculosis,
which is transmitted through small droplets that remain suspended in the air. Airborne
precautions include placing the patient in a negative-pressure room and requiring
healthcare workers to wear N95 respirators. These measures are essential to prevent the
spread of the infection to other patients and staff members.
