PNR 201/PNR201 Final Exam V2 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A client is diagnosed with Left-sided Heart Failure. Which clinical manifestation should the
nurse expect to find during the assessment?
A. Jugular venous distension
B. Hepatosplenomegaly
C. Dependent edema
D. Crackles in the lungs
Correct Answer: D
Expert Explanation: Left-sided heart failure leads to pulmonary congestion because the
left ventricle cannot effectively pump blood into the systemic circulation. This backflow
into the pulmonary veins causes fluid to leak into the alveoli, resulting in crackles. In
contrast, peripheral edema and jugular vein distension are primary signs of right-sided
heart failure.
2. A nurse is caring for a client with Type 1 Diabetes Mellitus who is sweating and shaky.
What is the priority nursing action?
A. Administer 15g of rapid-acting carbohydrates
B. Provide a complex carbohydrate snack like crackers
,C. Call the healthcare provider immediately
D. Check the client’s blood glucose level
Correct Answer: D
Expert Explanation: The client is exhibiting symptoms of hypoglycemia, such as
diaphoresis and tremors. Before administering treatment, the nurse must confirm the
blood glucose level to ensure the intervention is appropriate. Once hypoglycemia is
confirmed, the 15-15 rule should be followed starting with rapid-acting sugars.
3. Which lab value is the most critical for a nurse to monitor in a client receiving Furosemide
(Lasix)?
A. Serum Sodium
B. Serum Calcium
C. Serum Potassium
D. Serum Creatinine
Correct Answer: C
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of potassium
along with water and sodium. Hypokalemia is a common and dangerous side effect that can
lead to cardiac dysrhythmias. Monitoring potassium levels is essential for patient safety
during diuretic therapy.
, 4. A client presents with a suspected Hip Fracture. Which clinical finding should the nurse
anticipate?
A. Internal rotation of the affected leg
B. Lengthening of the affected extremity
C. Increased range of motion in the hip
D. External rotation and shortening of the leg
Correct Answer: D
Expert Explanation: The classic presentation of a hip fracture includes the affected leg
being shortened and externally rotated due to muscle spasms. The patient will also
typically experience severe pain and an inability to bear weight. Internal rotation and
lengthening are not characteristic of this type of injury.
5. A client is 2 hours postoperative following an abdominal surgery. Which finding requires
immediate intervention?
A. Pain level of 6 on a 1-10 scale
B. Absence of bowel sounds
C. Urine output of 20 mL over the last hour
D. Serosanguinous drainage on the dressing
Correct Answer: C
Surgical Nursing Q&A with Rationale |
Fortis College
1. A client is diagnosed with Left-sided Heart Failure. Which clinical manifestation should the
nurse expect to find during the assessment?
A. Jugular venous distension
B. Hepatosplenomegaly
C. Dependent edema
D. Crackles in the lungs
Correct Answer: D
Expert Explanation: Left-sided heart failure leads to pulmonary congestion because the
left ventricle cannot effectively pump blood into the systemic circulation. This backflow
into the pulmonary veins causes fluid to leak into the alveoli, resulting in crackles. In
contrast, peripheral edema and jugular vein distension are primary signs of right-sided
heart failure.
2. A nurse is caring for a client with Type 1 Diabetes Mellitus who is sweating and shaky.
What is the priority nursing action?
A. Administer 15g of rapid-acting carbohydrates
B. Provide a complex carbohydrate snack like crackers
,C. Call the healthcare provider immediately
D. Check the client’s blood glucose level
Correct Answer: D
Expert Explanation: The client is exhibiting symptoms of hypoglycemia, such as
diaphoresis and tremors. Before administering treatment, the nurse must confirm the
blood glucose level to ensure the intervention is appropriate. Once hypoglycemia is
confirmed, the 15-15 rule should be followed starting with rapid-acting sugars.
3. Which lab value is the most critical for a nurse to monitor in a client receiving Furosemide
(Lasix)?
A. Serum Sodium
B. Serum Calcium
C. Serum Potassium
D. Serum Creatinine
Correct Answer: C
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of potassium
along with water and sodium. Hypokalemia is a common and dangerous side effect that can
lead to cardiac dysrhythmias. Monitoring potassium levels is essential for patient safety
during diuretic therapy.
, 4. A client presents with a suspected Hip Fracture. Which clinical finding should the nurse
anticipate?
A. Internal rotation of the affected leg
B. Lengthening of the affected extremity
C. Increased range of motion in the hip
D. External rotation and shortening of the leg
Correct Answer: D
Expert Explanation: The classic presentation of a hip fracture includes the affected leg
being shortened and externally rotated due to muscle spasms. The patient will also
typically experience severe pain and an inability to bear weight. Internal rotation and
lengthening are not characteristic of this type of injury.
5. A client is 2 hours postoperative following an abdominal surgery. Which finding requires
immediate intervention?
A. Pain level of 6 on a 1-10 scale
B. Absence of bowel sounds
C. Urine output of 20 mL over the last hour
D. Serosanguinous drainage on the dressing
Correct Answer: C
