PNR 201/PNR201 Exam 3 V2 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L/min via nasal cannula. The client’s oxygen saturation is 89%. Which of
the following actions should the nurse take?
A. Increase the oxygen flow rate to 6 L/min.
B. Switch the client to a non-rebreather mask.
C. Continue to monitor the client’s respiratory status.
D. Place the client in a supine position.
Correct Answer: C
Expert Explanation: Clients with COPD often have a target oxygen saturation between
88% and 92% because their respiratory drive is triggered by low oxygen levels rather than
high CO2 levels. Increasing the oxygen too much can suppress their drive to breathe,
leading to respiratory failure. Monitoring the client is appropriate as 89% is within the
expected range for this specific pathology.
2. Which of the following clinical manifestations should a nurse expect to find in a client
diagnosed with Grave’s disease?
A. Exophthalmos and tachycardia.
,B. Lethargy and cold intolerance.
C. Bradycardia and weight gain.
D. Constipation and dry skin.
Correct Answer: A
Expert Explanation: Grave’s disease is a form of hyperthyroidism which results in a
hypermetabolic state. Clinical signs include bulging eyes (exophthalmos), rapid heart rate,
and weight loss despite increased appetite. These symptoms are caused by the
overproduction of thyroid hormones which speed up bodily functions.
3. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following actions is the priority before administration?
A. Check the client’s blood pressure.
B. Auscultate the apical pulse for 1 full minute.
C. Measure the client’s weight.
D. Review the client’s serum creatinine level.
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and
strengthens contractions. The nurse must assess the apical pulse for one full minute to
ensure the rate is at least 60 beats per minute before giving the dose. If the heart rate is too
low, the medication must be withheld and the provider notified to prevent toxicity.
, 4. A client with type 1 diabetes mellitus presents with a blood glucose of 50 mg/dL. Which of
the following is the most appropriate initial action?
A. Administer 10 units of regular insulin.
B. Provide a meal containing high fat and protein.
C. Encourage the client to take a nap.
D. Give the client 15 grams of a fast-acting carbohydrate.
Correct Answer: D
Expert Explanation: The ‘Rule of 15’ is applied when treating hypoglycemia, which is
characterized by a blood glucose level below 70 mg/dL. The nurse should provide 15g of
simple carbs, like 4 oz of juice, and recheck the sugar in 15 minutes. This provides a rapid
increase in blood glucose to prevent neurological damage or loss of consciousness.
5. When assessing a client with right-sided heart failure, the nurse should expect to observe
which of the following?
A. Crackles in the lungs.
B. Peripheral edema and jugular vein distention.
C. Pink frothy sputum.
D. Orthopnea and dyspnea.
Correct Answer: B
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L/min via nasal cannula. The client’s oxygen saturation is 89%. Which of
the following actions should the nurse take?
A. Increase the oxygen flow rate to 6 L/min.
B. Switch the client to a non-rebreather mask.
C. Continue to monitor the client’s respiratory status.
D. Place the client in a supine position.
Correct Answer: C
Expert Explanation: Clients with COPD often have a target oxygen saturation between
88% and 92% because their respiratory drive is triggered by low oxygen levels rather than
high CO2 levels. Increasing the oxygen too much can suppress their drive to breathe,
leading to respiratory failure. Monitoring the client is appropriate as 89% is within the
expected range for this specific pathology.
2. Which of the following clinical manifestations should a nurse expect to find in a client
diagnosed with Grave’s disease?
A. Exophthalmos and tachycardia.
,B. Lethargy and cold intolerance.
C. Bradycardia and weight gain.
D. Constipation and dry skin.
Correct Answer: A
Expert Explanation: Grave’s disease is a form of hyperthyroidism which results in a
hypermetabolic state. Clinical signs include bulging eyes (exophthalmos), rapid heart rate,
and weight loss despite increased appetite. These symptoms are caused by the
overproduction of thyroid hormones which speed up bodily functions.
3. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following actions is the priority before administration?
A. Check the client’s blood pressure.
B. Auscultate the apical pulse for 1 full minute.
C. Measure the client’s weight.
D. Review the client’s serum creatinine level.
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and
strengthens contractions. The nurse must assess the apical pulse for one full minute to
ensure the rate is at least 60 beats per minute before giving the dose. If the heart rate is too
low, the medication must be withheld and the provider notified to prevent toxicity.
, 4. A client with type 1 diabetes mellitus presents with a blood glucose of 50 mg/dL. Which of
the following is the most appropriate initial action?
A. Administer 10 units of regular insulin.
B. Provide a meal containing high fat and protein.
C. Encourage the client to take a nap.
D. Give the client 15 grams of a fast-acting carbohydrate.
Correct Answer: D
Expert Explanation: The ‘Rule of 15’ is applied when treating hypoglycemia, which is
characterized by a blood glucose level below 70 mg/dL. The nurse should provide 15g of
simple carbs, like 4 oz of juice, and recheck the sugar in 15 minutes. This provides a rapid
increase in blood glucose to prevent neurological damage or loss of consciousness.
5. When assessing a client with right-sided heart failure, the nurse should expect to observe
which of the following?
A. Crackles in the lungs.
B. Peripheral edema and jugular vein distention.
C. Pink frothy sputum.
D. Orthopnea and dyspnea.
Correct Answer: B
