NUR 201/NUR201 Final Exam V3 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a history of COPD who is receiving oxygen at 2 L/min via
nasal cannula. The client reports sudden shortness of breath. Which of the following is the
priority nursing action?
A. Increase the oxygen flow rate to 5 L/min immediately.
B. Place the client in a high-Fowler’s position.
C. Request an arterial blood gas (ABG) analysis from the provider.
D. Assess the client’s respiratory rate and lung sounds.
Correct Answer: B
Expert Explanation: Placing the client in high-Fowler’s position is the immediate priority
as it allows for maximum chest expansion and improves gas exchange. While assessment is
critical, repositioning provides immediate physical relief for dyspnea. Increasing oxygen to
high levels in COPD patients can suppress their respiratory drive, so it must be done with
caution.
2. A nurse is reviewing the laboratory results of a client who is taking furosemide. Which of
the following results should the nurse report to the provider?
A. Potassium 3.1 mEq/L
,B. Sodium 138 mEq/L
C. Creatinine 1.0 mg/dL
D. Glucose 105 mg/dL
Correct Answer: A
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of potassium,
leading to hypokalemia. A potassium level of 3.1 mEq/L is below the normal range of 3.5 to
5.0 mEq/L and increases the risk of cardiac dysrhythmias. The nurse must monitor for
muscle weakness and cardiac changes when levels are low.
3. A client is scheduled for an elective surgery. During the preoperative assessment, the client
mentions a family history of high fever during anesthesia. What is the nurse’s priority action?
A. Notify the surgeon and the anesthesiologist immediately.
B. Administer an antipyretic as a prophylactic measure.
C. Document the information in the medical record.
D. Ask the client which specific medication caused the fever.
Correct Answer: A
Expert Explanation: A family history of high fever during anesthesia is a primary indicator
for Malignant Hyperthermia, a life-threatening genetic complication. The surgical team
must be notified to prepare alternative anesthetic agents and ensure Dantrolene is
, available. This condition is triggered by volatile inhalational anesthetics and
succinylcholine.
4. A nurse is teaching a client with Type 1 Diabetes Mellitus about ‘sick day’ management.
Which instruction should the nurse include?
A. Stop taking insulin if you are unable to eat solid foods.
B. Test urine for ketones only if the glucose is above 300 mg/dL.
C. Decrease fluid intake to prevent vomiting.
D. Monitor blood glucose levels every 4 hours.
Correct Answer: D
Expert Explanation: During illness, stress hormones increase blood glucose levels,
necessitating frequent monitoring even if the client is not eating. Clients should continue
taking their basal insulin and use supplemental doses as prescribed. Ketone testing and
adequate hydration are also essential to prevent diabetic ketoacidosis (DKA).
5. Which clinical manifestation should a nurse expect to find in a client diagnosed with
Grave’s disease?
A. Exophthalmos and tachycardia.
B. Lethargy and cold intolerance.
C. Bradycardia and weight gain.
D. Dry skin and constipation.
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a history of COPD who is receiving oxygen at 2 L/min via
nasal cannula. The client reports sudden shortness of breath. Which of the following is the
priority nursing action?
A. Increase the oxygen flow rate to 5 L/min immediately.
B. Place the client in a high-Fowler’s position.
C. Request an arterial blood gas (ABG) analysis from the provider.
D. Assess the client’s respiratory rate and lung sounds.
Correct Answer: B
Expert Explanation: Placing the client in high-Fowler’s position is the immediate priority
as it allows for maximum chest expansion and improves gas exchange. While assessment is
critical, repositioning provides immediate physical relief for dyspnea. Increasing oxygen to
high levels in COPD patients can suppress their respiratory drive, so it must be done with
caution.
2. A nurse is reviewing the laboratory results of a client who is taking furosemide. Which of
the following results should the nurse report to the provider?
A. Potassium 3.1 mEq/L
,B. Sodium 138 mEq/L
C. Creatinine 1.0 mg/dL
D. Glucose 105 mg/dL
Correct Answer: A
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of potassium,
leading to hypokalemia. A potassium level of 3.1 mEq/L is below the normal range of 3.5 to
5.0 mEq/L and increases the risk of cardiac dysrhythmias. The nurse must monitor for
muscle weakness and cardiac changes when levels are low.
3. A client is scheduled for an elective surgery. During the preoperative assessment, the client
mentions a family history of high fever during anesthesia. What is the nurse’s priority action?
A. Notify the surgeon and the anesthesiologist immediately.
B. Administer an antipyretic as a prophylactic measure.
C. Document the information in the medical record.
D. Ask the client which specific medication caused the fever.
Correct Answer: A
Expert Explanation: A family history of high fever during anesthesia is a primary indicator
for Malignant Hyperthermia, a life-threatening genetic complication. The surgical team
must be notified to prepare alternative anesthetic agents and ensure Dantrolene is
, available. This condition is triggered by volatile inhalational anesthetics and
succinylcholine.
4. A nurse is teaching a client with Type 1 Diabetes Mellitus about ‘sick day’ management.
Which instruction should the nurse include?
A. Stop taking insulin if you are unable to eat solid foods.
B. Test urine for ketones only if the glucose is above 300 mg/dL.
C. Decrease fluid intake to prevent vomiting.
D. Monitor blood glucose levels every 4 hours.
Correct Answer: D
Expert Explanation: During illness, stress hormones increase blood glucose levels,
necessitating frequent monitoring even if the client is not eating. Clients should continue
taking their basal insulin and use supplemental doses as prescribed. Ketone testing and
adequate hydration are also essential to prevent diabetic ketoacidosis (DKA).
5. Which clinical manifestation should a nurse expect to find in a client diagnosed with
Grave’s disease?
A. Exophthalmos and tachycardia.
B. Lethargy and cold intolerance.
C. Bradycardia and weight gain.
D. Dry skin and constipation.
