NUR 201/NUR201 Final Exam 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 an abdominal
surgery. The patient reports sudden chest pain and shortness of breath. Which action should
the nurse take first?
A. Place the patient in High-Fowler’s position and apply oxygen
B. Encourage the patient to use the incentive spirometer
C. Administer the prescribed PRN analgesic
D. Assess the surgical incision for signs of dehiscence
Correct Answer: A
Expert Explanation: Sudden chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism. Placing the patient in High-Fowler’s position optimizes
lung expansion and gas exchange immediately. The nurse must prioritize respiratory
stability and oxygenation before proceeding with further diagnostic assessments.
2. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen
at 2 L/min via nasal cannula. The nurse notes the client’s oxygen saturation is 89%. Which of
the following is the most appropriate nursing action?
A. Increase the oxygen flow rate to 6 L/min immediately
,B. Continue to monitor as this is an expected finding for COPD
C. Switch the delivery method to a non-rebreather mask
D. Prepare the client for emergency endotracheal intubation
Correct Answer: B
Expert Explanation: Patients with COPD often have a baseline oxygen saturation between
88% and 92% due to chronic carbon dioxide retention. High levels of supplemental oxygen
can suppress the hypoxic drive to breathe in these individuals. The nurse should recognize
this as a stable finding unless the patient shows signs of acute respiratory distress.
3. The nurse is reviewing the lab results for a patient with hyperparathyroidism. Which of the
following electrolyte imbalances should the nurse expect to see?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: A
Expert Explanation: Hyperparathyroidism leads to the excessive secretion of parathyroid
hormone, which increases bone resorption and calcium release into the blood. This process
results in hypercalcemia, which can lead to complications such as kidney stones and bone
, pain. Monitoring serum calcium levels is a critical component of nursing care for these
patients.
4. A patient with Type 1 Diabetes Mellitus is found unconscious and clammy. What is the
priority nursing intervention?
A. Administer subcutaneous glucagon or IV dextrose
B. Administer 15 grams of simple carbohydrates orally
C. Check the blood glucose level using a glucometer
D. Call the healthcare provider for an insulin order
Correct Answer: A
Expert Explanation: In an unconscious patient with suspected hypoglycemia, the nurse
cannot safely provide oral carbohydrates due to the risk of aspiration. Glucagon or
intravenous 50% dextrose is required to rapidly elevate the blood glucose level. Once the
patient regains consciousness, a complex carbohydrate and protein snack should be
provided to maintain stability.
5. Which clinical manifestation should the nurse monitor for in a patient with a serum
potassium level of 2.8 mEq/L?
A. Peaked T waves on the ECG
B. Muscle weakness and shallow respirations
C. Hyperactive bowel sounds and diarrhea
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient who is 24 hours postoperative following an abdominal
surgery. The patient reports sudden chest pain and shortness of breath. Which action should
the nurse take first?
A. Place the patient in High-Fowler’s position and apply oxygen
B. Encourage the patient to use the incentive spirometer
C. Administer the prescribed PRN analgesic
D. Assess the surgical incision for signs of dehiscence
Correct Answer: A
Expert Explanation: Sudden chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism. Placing the patient in High-Fowler’s position optimizes
lung expansion and gas exchange immediately. The nurse must prioritize respiratory
stability and oxygenation before proceeding with further diagnostic assessments.
2. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen
at 2 L/min via nasal cannula. The nurse notes the client’s oxygen saturation is 89%. Which of
the following is the most appropriate nursing action?
A. Increase the oxygen flow rate to 6 L/min immediately
,B. Continue to monitor as this is an expected finding for COPD
C. Switch the delivery method to a non-rebreather mask
D. Prepare the client for emergency endotracheal intubation
Correct Answer: B
Expert Explanation: Patients with COPD often have a baseline oxygen saturation between
88% and 92% due to chronic carbon dioxide retention. High levels of supplemental oxygen
can suppress the hypoxic drive to breathe in these individuals. The nurse should recognize
this as a stable finding unless the patient shows signs of acute respiratory distress.
3. The nurse is reviewing the lab results for a patient with hyperparathyroidism. Which of the
following electrolyte imbalances should the nurse expect to see?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: A
Expert Explanation: Hyperparathyroidism leads to the excessive secretion of parathyroid
hormone, which increases bone resorption and calcium release into the blood. This process
results in hypercalcemia, which can lead to complications such as kidney stones and bone
, pain. Monitoring serum calcium levels is a critical component of nursing care for these
patients.
4. A patient with Type 1 Diabetes Mellitus is found unconscious and clammy. What is the
priority nursing intervention?
A. Administer subcutaneous glucagon or IV dextrose
B. Administer 15 grams of simple carbohydrates orally
C. Check the blood glucose level using a glucometer
D. Call the healthcare provider for an insulin order
Correct Answer: A
Expert Explanation: In an unconscious patient with suspected hypoglycemia, the nurse
cannot safely provide oral carbohydrates due to the risk of aspiration. Glucagon or
intravenous 50% dextrose is required to rapidly elevate the blood glucose level. Once the
patient regains consciousness, a complex carbohydrate and protein snack should be
provided to maintain stability.
5. Which clinical manifestation should the nurse monitor for in a patient with a serum
potassium level of 2.8 mEq/L?
A. Peaked T waves on the ECG
B. Muscle weakness and shallow respirations
C. Hyperactive bowel sounds and diarrhea
