NUR 209/NUR209 Final Exam V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with left-sided heart failure. Which of the following clinical
manifestations should the nurse expect to observe?
A. Peripheral edema and weight gain
B. Crackles in the lung bases
C. Jugular venous distention
D. Hepatomegaly and abdominal distention
Correct Answer: B
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot effectively pump blood into the systemic circulation. This leads to an
accumulation of fluid in the lungs, manifested as crackles, dyspnea, and orthopnea. Right-
sided heart failure is typically associated with systemic symptoms like peripheral edema
and jugular venous distention.
2. A client with chronic kidney disease (CKD) has a serum potassium level of 6.5 mEq/L. Which
medication should the nurse anticipate administering first to protect the heart?
A. Sodium polystyrene sulfonate
B. Calcium gluconate
,C. Regular insulin and 50% dextrose
D. Furosemide
Correct Answer: B
Expert Explanation: Calcium gluconate is the priority medication in severe hyperkalemia
because it stabilizes the cardiac muscle cell membrane to prevent lethal arrhythmias. While
insulin and sodium polystyrene sulfonate help lower potassium levels, they do not provide
the immediate cardiac protection required. The nurse must monitor the ECG continuously
during administration for signs of improvement or worsening.
3. Using the Rule of Nines, a nurse calculates the total body surface area (TBSA) for a client
with burns on the entire left arm and the entire back. What is the percentage?
A. 27%
B. 18%
C. 36%
D. 45%
Correct Answer: A
Expert Explanation: According to the Rule of Nines, the entire back (posterior trunk)
accounts for 18% of the TBSA. The entire left arm accounts for 9% of the TBSA. Adding
18% and 9% results in a total of 27% for the initial assessment.
, 4. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following arterial blood
gas (ABG) results is consistent with this diagnosis?
A. pH 7.32, PaCO2 50, HCO3 28
B. pH 7.50, PaCO2 32, HCO3 24
C. pH 7.30, PaCO2 30, HCO3 18
D. pH 7.48, PaCO2 45, HCO3 30
Correct Answer: C
Expert Explanation: DKA causes metabolic acidosis due to the accumulation of ketones,
which are acidic. The ABG will show a low pH (acidosis) and a low bicarbonate level
(metabolic origin). The low PaCO2 represents respiratory compensation, often seen as
Kussmaul respirations.
5. A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the
water seal chamber. What is the most likely cause?
A. The lung has fully re-expanded
B. Normal operation of the suction system
C. An air leak in the system
D. The client is breathing deeply
Correct Answer: C
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with left-sided heart failure. Which of the following clinical
manifestations should the nurse expect to observe?
A. Peripheral edema and weight gain
B. Crackles in the lung bases
C. Jugular venous distention
D. Hepatomegaly and abdominal distention
Correct Answer: B
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot effectively pump blood into the systemic circulation. This leads to an
accumulation of fluid in the lungs, manifested as crackles, dyspnea, and orthopnea. Right-
sided heart failure is typically associated with systemic symptoms like peripheral edema
and jugular venous distention.
2. A client with chronic kidney disease (CKD) has a serum potassium level of 6.5 mEq/L. Which
medication should the nurse anticipate administering first to protect the heart?
A. Sodium polystyrene sulfonate
B. Calcium gluconate
,C. Regular insulin and 50% dextrose
D. Furosemide
Correct Answer: B
Expert Explanation: Calcium gluconate is the priority medication in severe hyperkalemia
because it stabilizes the cardiac muscle cell membrane to prevent lethal arrhythmias. While
insulin and sodium polystyrene sulfonate help lower potassium levels, they do not provide
the immediate cardiac protection required. The nurse must monitor the ECG continuously
during administration for signs of improvement or worsening.
3. Using the Rule of Nines, a nurse calculates the total body surface area (TBSA) for a client
with burns on the entire left arm and the entire back. What is the percentage?
A. 27%
B. 18%
C. 36%
D. 45%
Correct Answer: A
Expert Explanation: According to the Rule of Nines, the entire back (posterior trunk)
accounts for 18% of the TBSA. The entire left arm accounts for 9% of the TBSA. Adding
18% and 9% results in a total of 27% for the initial assessment.
, 4. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following arterial blood
gas (ABG) results is consistent with this diagnosis?
A. pH 7.32, PaCO2 50, HCO3 28
B. pH 7.50, PaCO2 32, HCO3 24
C. pH 7.30, PaCO2 30, HCO3 18
D. pH 7.48, PaCO2 45, HCO3 30
Correct Answer: C
Expert Explanation: DKA causes metabolic acidosis due to the accumulation of ketones,
which are acidic. The ABG will show a low pH (acidosis) and a low bicarbonate level
(metabolic origin). The low PaCO2 represents respiratory compensation, often seen as
Kussmaul respirations.
5. A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the
water seal chamber. What is the most likely cause?
A. The lung has fully re-expanded
B. Normal operation of the suction system
C. An air leak in the system
D. The client is breathing deeply
Correct Answer: C
