NUR 201/NUR201 Exam 4 V1 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is teaching a client with Gastroesophageal Reflux Disease (GERD) about dietary
changes. Which instruction should the nurse include?
A. Drink a glass of milk before bedtime to coat the stomach.
B. Consume three large meals a day rather than frequent snacks.
C. Lie down for 30 minutes immediately after eating.
D. Avoid caffeinated beverages and chocolate.
Correct Answer: D
Expert Explanation: Caffeine and chocolate decrease lower esophageal sphincter (LES)
pressure, which allows gastric contents to reflux. Patients should be advised to eat small,
frequent meals rather than large ones to avoid gastric distention. Lying down after meals
increases the risk of reflux, so patients should remain upright for at least 2 hours.
2. A client is admitted with suspected acute appendicitis. Which assessment finding should
the nurse report to the provider immediately?
A. Nausea and one episode of vomiting.
B. A white blood cell count of 12,000/mm3.
C. Sudden relief of abdominal pain.
,D. Pain localized in the right lower quadrant.
Correct Answer: C
Expert Explanation: Sudden relief of pain in a patient with appendicitis is a classic sign of
appendiceal rupture. Rupture can lead to peritonitis, which is a life-threatening emergency.
The nurse must prioritize this finding over localized pain or mild leukocytosis.
3. Which clinical manifestation should the nurse expect to find in a client with Grave’s
Disease?
A. Exophthalmos and tremors.
B. Bradycardia and cold intolerance.
C. Weight gain and lethargy.
D. Dry skin and constipation.
Correct Answer: A
Expert Explanation: Grave’s Disease is characterized by hyperthyroidism, which increases
the metabolic rate and leads to symptoms like tremors and heat intolerance. Exophthalmos,
or bulging of the eyes, is a specific sign associated with this autoimmune condition.
Bradycardia and weight gain are characteristic of hypothyroidism rather than
hyperthyroidism.
4. The nurse is caring for a client with Type 1 Diabetes who is diaphoretic and complaining of
shakiness. What is the nurse’s first action?
A. Administer 15 grams of rapid-acting carbohydrates.
, B. Call the physician for an insulin order.
C. Check the client’s blood glucose level.
D. Give the client a high-protein snack like peanut butter.
Correct Answer: C
Expert Explanation: The client is showing classic signs of hypoglycemia, which must be
confirmed before treatment if a glucometer is available. Checking the blood glucose level
ensures the nurse is treating the correct condition rather than guessing. If the level is low,
the 15-15 rule (15g carbs) should then be implemented.
5. A client with an ileostomy asks about the consistency of their stool. How should the nurse
respond?
A. The stool will be liquid or semi-liquid.
B. The stool will be solid and well-formed.
C. The stool will vary based on fiber intake.
D. The stool will only occur once per day.
Correct Answer: A
Expert Explanation: An ileostomy bypasses the large intestine, where most water
absorption occurs. Consequently, the output is consistently liquid or pasty and continuous.
Patients with ileostomies are at a higher risk for dehydration due to this lack of water
reabsorption.
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is teaching a client with Gastroesophageal Reflux Disease (GERD) about dietary
changes. Which instruction should the nurse include?
A. Drink a glass of milk before bedtime to coat the stomach.
B. Consume three large meals a day rather than frequent snacks.
C. Lie down for 30 minutes immediately after eating.
D. Avoid caffeinated beverages and chocolate.
Correct Answer: D
Expert Explanation: Caffeine and chocolate decrease lower esophageal sphincter (LES)
pressure, which allows gastric contents to reflux. Patients should be advised to eat small,
frequent meals rather than large ones to avoid gastric distention. Lying down after meals
increases the risk of reflux, so patients should remain upright for at least 2 hours.
2. A client is admitted with suspected acute appendicitis. Which assessment finding should
the nurse report to the provider immediately?
A. Nausea and one episode of vomiting.
B. A white blood cell count of 12,000/mm3.
C. Sudden relief of abdominal pain.
,D. Pain localized in the right lower quadrant.
Correct Answer: C
Expert Explanation: Sudden relief of pain in a patient with appendicitis is a classic sign of
appendiceal rupture. Rupture can lead to peritonitis, which is a life-threatening emergency.
The nurse must prioritize this finding over localized pain or mild leukocytosis.
3. Which clinical manifestation should the nurse expect to find in a client with Grave’s
Disease?
A. Exophthalmos and tremors.
B. Bradycardia and cold intolerance.
C. Weight gain and lethargy.
D. Dry skin and constipation.
Correct Answer: A
Expert Explanation: Grave’s Disease is characterized by hyperthyroidism, which increases
the metabolic rate and leads to symptoms like tremors and heat intolerance. Exophthalmos,
or bulging of the eyes, is a specific sign associated with this autoimmune condition.
Bradycardia and weight gain are characteristic of hypothyroidism rather than
hyperthyroidism.
4. The nurse is caring for a client with Type 1 Diabetes who is diaphoretic and complaining of
shakiness. What is the nurse’s first action?
A. Administer 15 grams of rapid-acting carbohydrates.
, B. Call the physician for an insulin order.
C. Check the client’s blood glucose level.
D. Give the client a high-protein snack like peanut butter.
Correct Answer: C
Expert Explanation: The client is showing classic signs of hypoglycemia, which must be
confirmed before treatment if a glucometer is available. Checking the blood glucose level
ensures the nurse is treating the correct condition rather than guessing. If the level is low,
the 15-15 rule (15g carbs) should then be implemented.
5. A client with an ileostomy asks about the consistency of their stool. How should the nurse
respond?
A. The stool will be liquid or semi-liquid.
B. The stool will be solid and well-formed.
C. The stool will vary based on fiber intake.
D. The stool will only occur once per day.
Correct Answer: A
Expert Explanation: An ileostomy bypasses the large intestine, where most water
absorption occurs. Consequently, the output is consistently liquid or pasty and continuous.
Patients with ileostomies are at a higher risk for dehydration due to this lack of water
reabsorption.
