PNR 201/PNR201 Final Exam V1 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is providing preoperative teaching to a client scheduled for abdominal surgery.
Which of the following statements should the nurse include regarding the use of an incentive
spirometer?
A. Exhale forcefully into the device to expand the lungs.
B. Inhale deeply and hold your breath for 3 to 5 seconds.
C. Use the device only if you develop a cough or fever.
D. Limit the use of the device to twice a day after surgery.
Correct Answer: B
Expert Explanation: Proper use of an incentive spirometer requires the patient to inhale
slowly and deeply to keep the ball or piston elevated. Holding the breath for at least 3
seconds helps maintain open alveoli and prevents atelectasis. This intervention is a critical
component of postoperative respiratory care to prevent pneumonia.
2. A nurse is assessing a patient with a potassium level of 6.2 mEq/L. Which of the following
findings is the priority for the nurse to monitor?
A. Increased bowel sounds and diarrhea
B. Cardiac rhythm changes on the ECG monitor
,C. Muscle weakness in the lower extremities
D. Paresthesia of the fingers and toes
Correct Answer: B
Expert Explanation: Hyperkalemia can cause life-threatening cardiac arrhythmias, such as
peaked T waves or ventricular fibrillation. While muscle weakness and GI upset are
common symptoms, the cardiac system is the most critical to monitor for safety. The nurse
must prioritize cardiac monitoring to detect early signs of instability.
3. A nurse is caring for a client who is postoperative and has a Jackson-Pratt (JP) drain. Which
action should the nurse take to ensure the drain functions correctly?
A. Keep the drain bulb fully inflated at all times.
B. Compress the bulb after emptying to create suction.
C. Empty the drain only when it is completely full.
D. Position the drain higher than the surgical site.
Correct Answer: B
Expert Explanation: A Jackson-Pratt drain relies on negative pressure to pull fluid from
the surgical site into the collection bulb. Compressing the bulb before closing the port
creates the necessary vacuum for suction. Without this compression, the drain will fail to
remove excess fluid effectively.
, 4. A client with type 1 diabetes mellitus is found unconscious and clammy. Which of the
following is the nurse’s first priority action?
A. Administer glucagon intramuscularly or subcutaneously.
B. Check the client’s blood glucose level immediately.
C. Administer 15 grams of simple carbohydrates orally.
D. Call the provider to obtain a stat insulin order.
Correct Answer: A
Expert Explanation: If a diabetic patient is unconscious and hypoglycemia is suspected,
the nurse cannot safely provide oral glucose due to the risk of aspiration. Administering
glucagon is the fastest way to raise blood glucose levels in an emergency when the patient
is unable to swallow. Following administration, the nurse should reassess the glucose level
once the patient is stable.
5. A nurse is caring for a patient with right-sided heart failure. Which clinical manifestation
should the nurse expect to observe?
A. Crackles and wheezes in the lung bases
B. Peripheral edema and jugular vein distention
C. Productive cough with frothy pink sputum
D. Orthopnea and paroxysmal nocturnal dyspnea
Correct Answer: B
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is providing preoperative teaching to a client scheduled for abdominal surgery.
Which of the following statements should the nurse include regarding the use of an incentive
spirometer?
A. Exhale forcefully into the device to expand the lungs.
B. Inhale deeply and hold your breath for 3 to 5 seconds.
C. Use the device only if you develop a cough or fever.
D. Limit the use of the device to twice a day after surgery.
Correct Answer: B
Expert Explanation: Proper use of an incentive spirometer requires the patient to inhale
slowly and deeply to keep the ball or piston elevated. Holding the breath for at least 3
seconds helps maintain open alveoli and prevents atelectasis. This intervention is a critical
component of postoperative respiratory care to prevent pneumonia.
2. A nurse is assessing a patient with a potassium level of 6.2 mEq/L. Which of the following
findings is the priority for the nurse to monitor?
A. Increased bowel sounds and diarrhea
B. Cardiac rhythm changes on the ECG monitor
,C. Muscle weakness in the lower extremities
D. Paresthesia of the fingers and toes
Correct Answer: B
Expert Explanation: Hyperkalemia can cause life-threatening cardiac arrhythmias, such as
peaked T waves or ventricular fibrillation. While muscle weakness and GI upset are
common symptoms, the cardiac system is the most critical to monitor for safety. The nurse
must prioritize cardiac monitoring to detect early signs of instability.
3. A nurse is caring for a client who is postoperative and has a Jackson-Pratt (JP) drain. Which
action should the nurse take to ensure the drain functions correctly?
A. Keep the drain bulb fully inflated at all times.
B. Compress the bulb after emptying to create suction.
C. Empty the drain only when it is completely full.
D. Position the drain higher than the surgical site.
Correct Answer: B
Expert Explanation: A Jackson-Pratt drain relies on negative pressure to pull fluid from
the surgical site into the collection bulb. Compressing the bulb before closing the port
creates the necessary vacuum for suction. Without this compression, the drain will fail to
remove excess fluid effectively.
, 4. A client with type 1 diabetes mellitus is found unconscious and clammy. Which of the
following is the nurse’s first priority action?
A. Administer glucagon intramuscularly or subcutaneously.
B. Check the client’s blood glucose level immediately.
C. Administer 15 grams of simple carbohydrates orally.
D. Call the provider to obtain a stat insulin order.
Correct Answer: A
Expert Explanation: If a diabetic patient is unconscious and hypoglycemia is suspected,
the nurse cannot safely provide oral glucose due to the risk of aspiration. Administering
glucagon is the fastest way to raise blood glucose levels in an emergency when the patient
is unable to swallow. Following administration, the nurse should reassess the glucose level
once the patient is stable.
5. A nurse is caring for a patient with right-sided heart failure. Which clinical manifestation
should the nurse expect to observe?
A. Crackles and wheezes in the lung bases
B. Peripheral edema and jugular vein distention
C. Productive cough with frothy pink sputum
D. Orthopnea and paroxysmal nocturnal dyspnea
Correct Answer: B
