NUR 201/NUR201 Exam 2 V2 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient who is 24 hours postoperative following a cholecystectomy.
Which assessment finding is the priority to report to the provider?
A. Pain level of 6 on a 1-10 scale
B. Absence of bowel sounds in all quadrants
C. Productive cough with yellow sputum
D. Urine output of 20 mL over the last 2 hours
Correct Answer: D
Expert Explanation: Urine output less than 30 mL/hr is a critical finding that may indicate
hypovolemia or acute kidney injury. The nurse must prioritize perfusion and renal function
following surgery to prevent further complications. Although pain and bowel sounds are
important, a significant drop in urine output requires immediate medical intervention.
2. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula at 2 L/min. The nurse notes the patient’s respiratory rate has decreased from 20 to
10 breaths/min. Which action should the nurse take first?
A. Increase the oxygen flow rate to 4 L/min
B. Encourage the patient to perform pursed-lip breathing
,C. Obtain an arterial blood gas (ABG) sample
D. Assess the patient’s level of consciousness
Correct Answer: D
Expert Explanation: A significant drop in respiratory rate in a COPD patient receiving
oxygen can indicate CO2 retention and subsequent respiratory depression. Assessing the
level of consciousness is the first step in determining the severity of the patient’s
neurological status. This assessment provides immediate data on whether the patient is
experiencing CO2 narcosis before invasive procedures are performed.
3. A nurse is teaching a patient about a newly prescribed nitroglycerin sublingual tablet for
stable angina. Which instruction should the nurse include?
A. Swallow the tablet with a full glass of water
B. Take one tablet every 15 minutes up to three doses
C. Place the tablet under the tongue and let it dissolve
D. Discard the tablets if they cause a tingling sensation
Correct Answer: C
Expert Explanation: Nitroglycerin sublingual tablets must be dissolved under the tongue
to bypass the first-pass metabolism of the liver. The patient should be instructed to take
one tablet every 5 minutes for a maximum of three doses if chest pain persists. A tingling
sensation actually indicates that the medication is potent and fresh, rather than being a
reason to discard it.
,4. A patient is admitted with a diagnosis of left-sided heart failure. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Jugular venous distention
B. Peripheral edema in the lower extremities
C. Crackles in the lungs
D. Hepatosplenomegaly
Correct Answer: C
Expert Explanation: Left-sided heart failure leads to pulmonary congestion because the
left ventricle cannot pump blood effectively into the systemic circulation. This results in
fluid backing up into the pulmonary veins and capillaries, causing crackles, dyspnea, and
orthopnea. Jugular venous distention and peripheral edema are classic signs of right-sided
heart failure.
5. A nurse is preparing to administer digoxin to a patient with heart failure. Which laboratory
value should the nurse check before administration to prevent toxicity?
A. Serum potassium level
B. Serum sodium level
C. Serum calcium level
D. Serum magnesium level
Correct Answer: A
, Expert Explanation: Hypokalemia significantly increases the risk of digoxin toxicity
because potassium and digoxin compete for binding sites on the sodium-potassium ATPase
pump. The nurse must ensure the potassium level is within the normal range (3.5 to 5.0
mEq/L) before giving the dose. Monitoring this value is a safety priority to prevent life-
threatening cardiac arrhythmias associated with toxicity.
6. A patient with Type 1 Diabetes Mellitus is found confused and diaphoretic. What is the
priority nursing action?
A. Administer 15 grams of fast-acting carbohydrates
B. Call the healthcare provider immediately
C. Check the patient’s blood glucose level
D. Administer the scheduled dose of regular insulin
Correct Answer: C
Expert Explanation: Confusion and diaphoresis are classic signs of hypoglycemia, but the
nurse must first verify the blood glucose level to confirm the diagnosis. Once hypoglycemia
is confirmed, the 15-15 rule should be implemented to raise the blood sugar safely.
Administering insulin to a patient who is already hypoglycemic would be a fatal error.
7. Which assessment finding in a patient with a deep vein thrombosis (DVT) in the right leg
requires immediate intervention?
A. A palpable cord-like vein in the calf
B. Calf tenderness and redness
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient who is 24 hours postoperative following a cholecystectomy.
Which assessment finding is the priority to report to the provider?
A. Pain level of 6 on a 1-10 scale
B. Absence of bowel sounds in all quadrants
C. Productive cough with yellow sputum
D. Urine output of 20 mL over the last 2 hours
Correct Answer: D
Expert Explanation: Urine output less than 30 mL/hr is a critical finding that may indicate
hypovolemia or acute kidney injury. The nurse must prioritize perfusion and renal function
following surgery to prevent further complications. Although pain and bowel sounds are
important, a significant drop in urine output requires immediate medical intervention.
2. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula at 2 L/min. The nurse notes the patient’s respiratory rate has decreased from 20 to
10 breaths/min. Which action should the nurse take first?
A. Increase the oxygen flow rate to 4 L/min
B. Encourage the patient to perform pursed-lip breathing
,C. Obtain an arterial blood gas (ABG) sample
D. Assess the patient’s level of consciousness
Correct Answer: D
Expert Explanation: A significant drop in respiratory rate in a COPD patient receiving
oxygen can indicate CO2 retention and subsequent respiratory depression. Assessing the
level of consciousness is the first step in determining the severity of the patient’s
neurological status. This assessment provides immediate data on whether the patient is
experiencing CO2 narcosis before invasive procedures are performed.
3. A nurse is teaching a patient about a newly prescribed nitroglycerin sublingual tablet for
stable angina. Which instruction should the nurse include?
A. Swallow the tablet with a full glass of water
B. Take one tablet every 15 minutes up to three doses
C. Place the tablet under the tongue and let it dissolve
D. Discard the tablets if they cause a tingling sensation
Correct Answer: C
Expert Explanation: Nitroglycerin sublingual tablets must be dissolved under the tongue
to bypass the first-pass metabolism of the liver. The patient should be instructed to take
one tablet every 5 minutes for a maximum of three doses if chest pain persists. A tingling
sensation actually indicates that the medication is potent and fresh, rather than being a
reason to discard it.
,4. A patient is admitted with a diagnosis of left-sided heart failure. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Jugular venous distention
B. Peripheral edema in the lower extremities
C. Crackles in the lungs
D. Hepatosplenomegaly
Correct Answer: C
Expert Explanation: Left-sided heart failure leads to pulmonary congestion because the
left ventricle cannot pump blood effectively into the systemic circulation. This results in
fluid backing up into the pulmonary veins and capillaries, causing crackles, dyspnea, and
orthopnea. Jugular venous distention and peripheral edema are classic signs of right-sided
heart failure.
5. A nurse is preparing to administer digoxin to a patient with heart failure. Which laboratory
value should the nurse check before administration to prevent toxicity?
A. Serum potassium level
B. Serum sodium level
C. Serum calcium level
D. Serum magnesium level
Correct Answer: A
, Expert Explanation: Hypokalemia significantly increases the risk of digoxin toxicity
because potassium and digoxin compete for binding sites on the sodium-potassium ATPase
pump. The nurse must ensure the potassium level is within the normal range (3.5 to 5.0
mEq/L) before giving the dose. Monitoring this value is a safety priority to prevent life-
threatening cardiac arrhythmias associated with toxicity.
6. A patient with Type 1 Diabetes Mellitus is found confused and diaphoretic. What is the
priority nursing action?
A. Administer 15 grams of fast-acting carbohydrates
B. Call the healthcare provider immediately
C. Check the patient’s blood glucose level
D. Administer the scheduled dose of regular insulin
Correct Answer: C
Expert Explanation: Confusion and diaphoresis are classic signs of hypoglycemia, but the
nurse must first verify the blood glucose level to confirm the diagnosis. Once hypoglycemia
is confirmed, the 15-15 rule should be implemented to raise the blood sugar safely.
Administering insulin to a patient who is already hypoglycemic would be a fatal error.
7. Which assessment finding in a patient with a deep vein thrombosis (DVT) in the right leg
requires immediate intervention?
A. A palpable cord-like vein in the calf
B. Calf tenderness and redness
