NUR 201/NUR201 Exam 4 V3 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A client with Type 1 Diabetes Mellitus presents with a blood glucose of 600 mg/dL and
fruity breath. Which acid-base imbalance does the nurse expect to find in the arterial blood
gas (ABG) results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Metabolic Acidosis
Correct Answer: D
Expert Explanation: Diabetic Ketoacidosis (DKA) results in the accumulation of ketones,
which are acidic byproducts of fat metabolism. This lead to a decrease in serum pH and
bicarbonate levels, characteristic of metabolic acidosis. The nurse should monitor for
Kussmaul respirations as the body attempts to compensate for this state.
2. When caring for a patient post-thyroidectomy, which assessment finding requires
immediate intervention by the nurse?
A. Sore throat when speaking
B. Laryngeal stridor
,C. Pain at the incision site
D. Small amount of serosanguinous drainage
Correct Answer: B
Expert Explanation: Laryngeal stridor is a harsh, high-pitched sound indicating airway
obstruction or laryngeal nerve damage. This is a medical emergency that requires
immediate notification of the surgeon and preparation for possible intubation. The nurse
must always keep a tracheostomy kit at the bedside for these patients.
3. A client is diagnosed with Cushing’s syndrome. Which clinical manifestation should the
nurse anticipate during the physical assessment?
A. Weight loss and hypotension
B. Hyperpigmentation of the skin
C. Truncal obesity and a buffalo hump
D. Decreased blood glucose levels
Correct Answer: C
Expert Explanation: Cushing’s syndrome is characterized by an excess of corticosteroids,
particularly glucocorticoids. Common physical findings include adipose tissue
redistribution leading to truncal obesity, a rounded ‘moon face,’ and a ‘buffalo hump’ on the
upper back. The nurse should also monitor for hypertension and hyperglycemia in these
clients.
, 4. A patient with Addison’s disease is admitted for an adrenal crisis. Which of the following
provider orders should the nurse prioritize?
A. Low-sodium diet
B. Rapid infusion of IV Normal Saline and Hydrocortisone
C. Daily weight monitoring
D. Oral potassium supplements
Correct Answer: B
Expert Explanation: Adrenal crisis is a life-threatening emergency characterized by
severe hypotension, hyponatremia, and hyperkalemia. Immediate treatment involves
aggressive fluid resuscitation to restore blood pressure and IV glucocorticoid replacement.
Failure to treat this condition promptly can lead to vascular collapse and death.
5. Which laboratory value is the most sensitive indicator of acute kidney injury (AKI)?
A. Serum Sodium
B. Blood Urea Nitrogen (BUN)
C. Serum Creatinine
D. Hemoglobin
Correct Answer: C
Expert Explanation: Serum creatinine is the most reliable indicator of kidney function
because it is a waste product of muscle metabolism excreted solely by the kidneys. BUN can
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A client with Type 1 Diabetes Mellitus presents with a blood glucose of 600 mg/dL and
fruity breath. Which acid-base imbalance does the nurse expect to find in the arterial blood
gas (ABG) results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Metabolic Acidosis
Correct Answer: D
Expert Explanation: Diabetic Ketoacidosis (DKA) results in the accumulation of ketones,
which are acidic byproducts of fat metabolism. This lead to a decrease in serum pH and
bicarbonate levels, characteristic of metabolic acidosis. The nurse should monitor for
Kussmaul respirations as the body attempts to compensate for this state.
2. When caring for a patient post-thyroidectomy, which assessment finding requires
immediate intervention by the nurse?
A. Sore throat when speaking
B. Laryngeal stridor
,C. Pain at the incision site
D. Small amount of serosanguinous drainage
Correct Answer: B
Expert Explanation: Laryngeal stridor is a harsh, high-pitched sound indicating airway
obstruction or laryngeal nerve damage. This is a medical emergency that requires
immediate notification of the surgeon and preparation for possible intubation. The nurse
must always keep a tracheostomy kit at the bedside for these patients.
3. A client is diagnosed with Cushing’s syndrome. Which clinical manifestation should the
nurse anticipate during the physical assessment?
A. Weight loss and hypotension
B. Hyperpigmentation of the skin
C. Truncal obesity and a buffalo hump
D. Decreased blood glucose levels
Correct Answer: C
Expert Explanation: Cushing’s syndrome is characterized by an excess of corticosteroids,
particularly glucocorticoids. Common physical findings include adipose tissue
redistribution leading to truncal obesity, a rounded ‘moon face,’ and a ‘buffalo hump’ on the
upper back. The nurse should also monitor for hypertension and hyperglycemia in these
clients.
, 4. A patient with Addison’s disease is admitted for an adrenal crisis. Which of the following
provider orders should the nurse prioritize?
A. Low-sodium diet
B. Rapid infusion of IV Normal Saline and Hydrocortisone
C. Daily weight monitoring
D. Oral potassium supplements
Correct Answer: B
Expert Explanation: Adrenal crisis is a life-threatening emergency characterized by
severe hypotension, hyponatremia, and hyperkalemia. Immediate treatment involves
aggressive fluid resuscitation to restore blood pressure and IV glucocorticoid replacement.
Failure to treat this condition promptly can lead to vascular collapse and death.
5. Which laboratory value is the most sensitive indicator of acute kidney injury (AKI)?
A. Serum Sodium
B. Blood Urea Nitrogen (BUN)
C. Serum Creatinine
D. Hemoglobin
Correct Answer: C
Expert Explanation: Serum creatinine is the most reliable indicator of kidney function
because it is a waste product of muscle metabolism excreted solely by the kidneys. BUN can
