NUR 209/NUR209 Final Exam V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient who has a chest tube connected to a water-seal drainage
system. The nurse notes that the water level in the water-seal chamber is fluctuating with the
patient’s respirations. Which of the following actions should the nurse take?
A. Check the system for a leak.
B. Clamp the chest tube.
C. Notify the healthcare provider immediately.
D. Continue to monitor the patient.
Correct Answer: D
Expert Explanation: Fluctuation in the water-seal chamber, also known as tidaling, is a
normal finding that indicates the system is patent and responding to pressure changes in
the pleural space. If tidaling stops, it could mean the lung has re-expanded or there is an
obstruction in the tubing. The nurse should simply continue to monitor the patient unless
other symptoms of distress appear.
2. A patient with a history of heart failure is admitted with a potassium level of 2.8 mEq/L
and is prescribed Digoxin. What is the nurse’s priority concern?
A. Decreased cardiac output
,B. Development of hypernatremia
C. Increased risk of Digoxin toxicity
D. Potential for metabolic acidosis
Correct Answer: C
Expert Explanation: Hypokalemia significantly increases the risk of Digoxin toxicity
because low potassium levels enhance the effect of Digoxin on the heart. The nurse must
monitor for symptoms such as visual disturbances, nausea, and arrhythmias.
Supplementing potassium or adjusting the medication dose is often necessary to ensure
patient safety.
3. The nurse is assessing a patient with a suspected tension pneumothorax. Which of the
following findings is the most indicative of this condition?
A. Muffled heart sounds
B. Tracheal deviation to the unaffected side
C. Flattened neck veins
D. Inspiratory crackles in the bases
Correct Answer: B
Expert Explanation: Tracheal deviation toward the unaffected side is a hallmark sign of a
tension pneumothorax, occurring as pressure builds in the pleural space. This condition is a
,medical emergency because the pressure can compress the heart and opposite lung. The
nurse should also expect to see distended neck veins and asymmetrical chest expansion.
4. Which arterial blood gas (ABG) result should the nurse expect for a patient in the early
stages of a panic attack?
A. pH 7.32, PaCO2 48, HCO3 24
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.30, PaCO2 35, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: B
Expert Explanation: During a panic attack, hyperventilation leads to excessive loss of
carbon dioxide, resulting in respiratory alkalosis. This is characterized by a high pH
(greater than 7.45) and a low PaCO2 (less than 35 mmHg). The nurse should encourage the
patient to breathe slowly or use a paper bag to re-inhale CO2.
5. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which clinical manifestation is characteristic of the ‘refractory hypoxemia’ seen in ARDS?
A. Oxygen saturation improves with 2L of oxygen via nasal cannula.
B. The patient’s PaO2 increases significantly when placed in the prone position.
C. The patient exhibits rapid, shallow breathing that resolves with rest.
D. Oxygen saturation remains low despite high concentrations of supplemental oxygen.
, Correct Answer: D
Expert Explanation: Refractory hypoxemia is a defining characteristic of ARDS where the
patient’s blood oxygen levels do not improve even with high-flow oxygen administration.
This occurs due to severe inflammation and fluid accumulation in the alveoli, preventing
gas exchange. Prone positioning may help, but the core issue is the lack of response to
standard oxygen therapy.
6. The nurse is preparing to administer the Parkland formula for fluid resuscitation to a
patient with 40% total body surface area (TBSA) burns. The patient weighs 70 kg. How much
fluid should be administered in the first 8 hours?
A. 11,200 mL
B. 2,800 mL
C. 5,600 mL
D. 7,200 mL
Correct Answer: C
Expert Explanation: The Parkland formula is calculated as 4 mL x kg x % TBSA, which in
this case is 4 x 70 x 40 = 11,200 mL for the first 24 hours. Half of this total (5,600 mL) must
be administered within the first 8 hours from the time of the burn injury. Accurate
calculation is vital to prevent hypovolemic shock and maintain organ perfusion in burn
patients.
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient who has a chest tube connected to a water-seal drainage
system. The nurse notes that the water level in the water-seal chamber is fluctuating with the
patient’s respirations. Which of the following actions should the nurse take?
A. Check the system for a leak.
B. Clamp the chest tube.
C. Notify the healthcare provider immediately.
D. Continue to monitor the patient.
Correct Answer: D
Expert Explanation: Fluctuation in the water-seal chamber, also known as tidaling, is a
normal finding that indicates the system is patent and responding to pressure changes in
the pleural space. If tidaling stops, it could mean the lung has re-expanded or there is an
obstruction in the tubing. The nurse should simply continue to monitor the patient unless
other symptoms of distress appear.
2. A patient with a history of heart failure is admitted with a potassium level of 2.8 mEq/L
and is prescribed Digoxin. What is the nurse’s priority concern?
A. Decreased cardiac output
,B. Development of hypernatremia
C. Increased risk of Digoxin toxicity
D. Potential for metabolic acidosis
Correct Answer: C
Expert Explanation: Hypokalemia significantly increases the risk of Digoxin toxicity
because low potassium levels enhance the effect of Digoxin on the heart. The nurse must
monitor for symptoms such as visual disturbances, nausea, and arrhythmias.
Supplementing potassium or adjusting the medication dose is often necessary to ensure
patient safety.
3. The nurse is assessing a patient with a suspected tension pneumothorax. Which of the
following findings is the most indicative of this condition?
A. Muffled heart sounds
B. Tracheal deviation to the unaffected side
C. Flattened neck veins
D. Inspiratory crackles in the bases
Correct Answer: B
Expert Explanation: Tracheal deviation toward the unaffected side is a hallmark sign of a
tension pneumothorax, occurring as pressure builds in the pleural space. This condition is a
,medical emergency because the pressure can compress the heart and opposite lung. The
nurse should also expect to see distended neck veins and asymmetrical chest expansion.
4. Which arterial blood gas (ABG) result should the nurse expect for a patient in the early
stages of a panic attack?
A. pH 7.32, PaCO2 48, HCO3 24
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.30, PaCO2 35, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: B
Expert Explanation: During a panic attack, hyperventilation leads to excessive loss of
carbon dioxide, resulting in respiratory alkalosis. This is characterized by a high pH
(greater than 7.45) and a low PaCO2 (less than 35 mmHg). The nurse should encourage the
patient to breathe slowly or use a paper bag to re-inhale CO2.
5. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which clinical manifestation is characteristic of the ‘refractory hypoxemia’ seen in ARDS?
A. Oxygen saturation improves with 2L of oxygen via nasal cannula.
B. The patient’s PaO2 increases significantly when placed in the prone position.
C. The patient exhibits rapid, shallow breathing that resolves with rest.
D. Oxygen saturation remains low despite high concentrations of supplemental oxygen.
, Correct Answer: D
Expert Explanation: Refractory hypoxemia is a defining characteristic of ARDS where the
patient’s blood oxygen levels do not improve even with high-flow oxygen administration.
This occurs due to severe inflammation and fluid accumulation in the alveoli, preventing
gas exchange. Prone positioning may help, but the core issue is the lack of response to
standard oxygen therapy.
6. The nurse is preparing to administer the Parkland formula for fluid resuscitation to a
patient with 40% total body surface area (TBSA) burns. The patient weighs 70 kg. How much
fluid should be administered in the first 8 hours?
A. 11,200 mL
B. 2,800 mL
C. 5,600 mL
D. 7,200 mL
Correct Answer: C
Expert Explanation: The Parkland formula is calculated as 4 mL x kg x % TBSA, which in
this case is 4 x 70 x 40 = 11,200 mL for the first 24 hours. Half of this total (5,600 mL) must
be administered within the first 8 hours from the time of the burn injury. Accurate
calculation is vital to prevent hypovolemic shock and maintain organ perfusion in burn
patients.
