NUR 242 EXAM 3
Medical-Surgical Nursing Concepts
Galen College of Nursing
High-Yield Qs to mirror the Exam
Verified Answers with Rationales
This Exam Features:
NUR 242 Exam 3 Mental Health Nursing (Galen
College) including 50 high-yield questions
written to mirror actual course exams. Covers
core Medical-Surgical Nursing Concepts with clear,
accurate, and student-friendly explanations. Perfect for mastering
high-priority topics and boosting exam confidence.
,The nurse recognizes that a patient with sleep apnea may benefit from
which intervention(s)? (Select all that apply.)
A. Weight loss
B. Nasal mask to deliver BiPAP
C. A change in sleeping position
D. Medication to increase daytime sleepiness
E. Position-fixing device that prevents tongue subluxation
ANS: A, B, C, E
All interventions listed are viable interventions that can be of benefit to
patients who have sleep apnea. Patients should work with their providers of
care to determine the severity of their sleep apnea and which specific
interventions would be of most importance to them. Encouraging daytime
sleepiness is the opposite of the effect needed for this patient.
Based on the patient’s diagnosis, which clinical manifestations would
the nurse expect to see when assessing this patient? (Select all that
apply.)
A. Bradycardia
B. Shortness of breath
C. Use of accessory muscles
D. Sitting in a forward posture
E. Barrel chest appearance
ANS: B, C, D, E
The patient with COPD often has a barrel chest appearance, is short of
breath, and may use accessory muscles when breathing. These patients
tend to move slowly and are slightly stooped. Usually they sit with a
forward-bending posture. With severe dyspnea, they exhibit activity
intolerance and activities such as bathing and grooming are avoided.
,When the patient arrives to the unit, she is assessed and is in acute
respiratory distress. Her respirations are labored and her respiratory
rate is 34. She states that she had a peak flow meter measurement of
"Red Zone" on the way and is severely short of air. Her oxygen
saturation is 82% on O2 at 2 L via nasal cannula.
Based on these findings, what should the nurse do next?
ANS: The Rapid Response Team should be notified immediately. All of
these assessment findings indicate acute respiratory distress. The peak
flow meter is in the RED Zone. The oxygen saturation should be at least
90% on 2 L per NC.
While the Rapid Response Team is at the bedside, the patient's
healthcare provider arrives. The provider writes several orders.
Which order is most important for the nurse to implement
immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 minutes after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP
ANS: B
All of the provider’s orders are very important, but based on the patient’s
severe shortness of breath, the first thing that should be done is to increase
her oxygen. Once her oxygen is increased, the nurse should note the time
and remember to call for stat ABGs in 30 minutes. The patient should then
be transferred to the ICU as soon as possible. Once the patient arrives in
the ICU, they can administer the one-time dose of Solu-Medrol.
,The patient is in the ICU for 3 days and then transferred back to the
pulmonary stepdown unit. She is still slightly short of breath with
exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula.
She denies any shortness of breath when resting during the
assessment. The provider plans to discharge the patient on home
oxygen in the morning.
What should the nurse include in this patient's discharge teaching?
ANS: Make sure that the patient understands any new medication regimen.
She should be instructed to call 911 for any severe respiratory distress.
Because she is being discharged with home oxygen, home health services
should be arranged.
The nurse immediately checks on the patient and finds that she
appears anxious and her vital signs are as follows:
ØBlood pressure: 128/84 mm Hg
ØHeart rate: 114 (sinus tachycardia)
ØRespiratory rate: 24, labored and restless
ØTemperature: 99.4° F (axillary)
ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?
ANS: **The BP is within normal range and only slightly elevated. **The
temperature is only slightly elevated. **Her heart rate is elevated; the nurse
should check the patient’s medications to see if she is on a bronchodilator
or other medication that could cause her heart rate to increase. The priority
concern is the RESTLESSNESS with increased respiratory rate and the
decreased oxygen saturation despite the 40% oxygen setting.
A patient with a history of chronic obstructive pulmonary disease is
admitted with shortness of breath. Which nursing intervention is most
appropriate?
,A. Do not administer oxygen.
B. Administer oxygen via Venturi mask.
C. Use nasal cannula to administer high flow oxygen.
D. Administer oxygen at 6L per simple face mask.
ANS: B
Oxygen therapy is prescribed at the lowest liter flow needed to manage
hypoxemia. A system that delivers more precise oxygen levels (e.g., a
Venturi mask) is preferred. Monitor the patient’s response to therapy
closely to ensure adequate gas exchange and correction of hypoxemia.
While suctioning a patient, vagal stimulation occurs. What is the
appropriate nursing action?
A. Instruct the patient to cough.
B. Place the patient in a high Fowler's position.
C. Oxygenate the patient with 100% oxygen.
D. Instruct the patient to breathe slowly and deeply.
ANS: C
Vagal stimulation may occur during suctioning and result in severe
bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or
other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately
and oxygenate the patient manually with 100% oxygen. Repositioning the
patient, slow deep breathing, and coughing will not address the
cardiovascular effects of vagal stimulation.
A patient with COPD presents for a routine follow up. The patient
smokes 1 PPD. Which statement by the patient causes the nurse to
suspect an increase in dyspnea?
A. "I bought a new pillow so I could prop myself up at night to sleep."
B. "I have a productive cough in the morning."
,C. "I have gained weight since I was here last."
D. "The patient is well groomed and is sitting in a tripod position."
ANS: A
Patients with COPD, who smoke, may have a productive morning cough.
Weight loss often occurs when dyspnea is increased due to the increased
metabolic demand. A tripod or orthopneic position is common with COPD
and when combined with a disheveled appearance may indicate an
increase in dyspnea. Buying a new pillow indicates that the patient must
sleep propped up because breathing is worse while lying down. They may
not recognize the increased dyspnea and they try to compensate by using
multiple pillows in order to rest.
The nurse is assessing a patient with a chest tube following a
pneumonectomy. Which assessment finding requires intervention?
A. Bandage around the posterior tube is loose.
B. 2 cm of water is in the second chest tube chamber.
C. The water in the water seal chamber rises and falls with
inhalation/exhalation.
D. Bubbling present in the water seal chamber when the patient
coughs.
ANS: A
After lung surgery, two tubes, anterior and posterior, are used. Dressings
around the wound should not be loose. The wounds should be covered
with airtight dressings.
A home health patient with a history of asthma is having shortness of
breath. The nurse discovers that the peak flowmeter indicates a peak
expiratory flow (PEF) reading that is in the red zone. What is the
priority nursing action?
,A. Call 911 immediately.
B. Take the patient's vital signs.
C. Notify the patient's prescriber.
D. Repeat the PEF reading to verify the results.
ANS: A
A PEF reading in the red zone indicates a range that is 50% below the
patient’s personal best PEF reading and indicates serious respiratory
obstruction requiring 911 or rapid response. Offer medications and stay
with the patient. Repeating the PEF reading and taking vital signs are also
important, but doing so first delays the administration of the rescue drugs
and physician notification.
The patient is assessed and a blood glucose level and vital signs are
obtained upon arrival on the unit. Results are as follows:
BG—239 mg/dL BP—138/88 mm Hg
HR—128 RR—36 breaths/min
O2 saturation—88% (room air) Temperature—101.6º F
Which vital sign or test result requires the nurse's immediate
attention?
A. Blood pressure
B. Respiratory rate
C. Temperature
D. Blood glucose
ANS: B
All of the patient’s vital signs are abnormal. However, the most important
one to report immediately is her increased respirations (and decreased
oxygen saturation). Even though a diagnosis has not been confirmed, it is
very important to address these problems. The patient is experiencing
tachypnea.
, After consulting with the provider, the following orders are received:
Full liquid diabetic diet
IV fluids 1000 mL .9 NS at 60 mL/hr
Oxygen at 2 L per nasal cannula
Blood cultures × 3 and urinalysis
Tylenol grain × every 4 hour for temperature above 101º F
Cefazolin (Ancef) 1 g IVP every 8 hour
Which of the provider's orders should the nurse implement first?
A. IV fluids 1000 mL .9 NS at 60 mL/hr
B. Oxygen at 2 L per nasal cannula
C. Blood cultures and urinalysis
D. Cefazolin (Ancef) 1 g IVP every 8 hour
ANS: B
All of the provider’s orders are very important. However, the most important
one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very
important that supplemental oxygen is started as soon as possible. IV fluids
should be started to enhance pulmonary toileting, and the laboratory should
be notified to draw the needed blood cultures. UAP can obtain the
specimen for urinalysis. The blood cultures and the UA should be obtained
before the IVP Ancef is administered.
The nurse understands that which of the following is the most
common symptom of pneumonia in the older adult patient?
A. Fever
B. Cough
Medical-Surgical Nursing Concepts
Galen College of Nursing
High-Yield Qs to mirror the Exam
Verified Answers with Rationales
This Exam Features:
NUR 242 Exam 3 Mental Health Nursing (Galen
College) including 50 high-yield questions
written to mirror actual course exams. Covers
core Medical-Surgical Nursing Concepts with clear,
accurate, and student-friendly explanations. Perfect for mastering
high-priority topics and boosting exam confidence.
,The nurse recognizes that a patient with sleep apnea may benefit from
which intervention(s)? (Select all that apply.)
A. Weight loss
B. Nasal mask to deliver BiPAP
C. A change in sleeping position
D. Medication to increase daytime sleepiness
E. Position-fixing device that prevents tongue subluxation
ANS: A, B, C, E
All interventions listed are viable interventions that can be of benefit to
patients who have sleep apnea. Patients should work with their providers of
care to determine the severity of their sleep apnea and which specific
interventions would be of most importance to them. Encouraging daytime
sleepiness is the opposite of the effect needed for this patient.
Based on the patient’s diagnosis, which clinical manifestations would
the nurse expect to see when assessing this patient? (Select all that
apply.)
A. Bradycardia
B. Shortness of breath
C. Use of accessory muscles
D. Sitting in a forward posture
E. Barrel chest appearance
ANS: B, C, D, E
The patient with COPD often has a barrel chest appearance, is short of
breath, and may use accessory muscles when breathing. These patients
tend to move slowly and are slightly stooped. Usually they sit with a
forward-bending posture. With severe dyspnea, they exhibit activity
intolerance and activities such as bathing and grooming are avoided.
,When the patient arrives to the unit, she is assessed and is in acute
respiratory distress. Her respirations are labored and her respiratory
rate is 34. She states that she had a peak flow meter measurement of
"Red Zone" on the way and is severely short of air. Her oxygen
saturation is 82% on O2 at 2 L via nasal cannula.
Based on these findings, what should the nurse do next?
ANS: The Rapid Response Team should be notified immediately. All of
these assessment findings indicate acute respiratory distress. The peak
flow meter is in the RED Zone. The oxygen saturation should be at least
90% on 2 L per NC.
While the Rapid Response Team is at the bedside, the patient's
healthcare provider arrives. The provider writes several orders.
Which order is most important for the nurse to implement
immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 minutes after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP
ANS: B
All of the provider’s orders are very important, but based on the patient’s
severe shortness of breath, the first thing that should be done is to increase
her oxygen. Once her oxygen is increased, the nurse should note the time
and remember to call for stat ABGs in 30 minutes. The patient should then
be transferred to the ICU as soon as possible. Once the patient arrives in
the ICU, they can administer the one-time dose of Solu-Medrol.
,The patient is in the ICU for 3 days and then transferred back to the
pulmonary stepdown unit. She is still slightly short of breath with
exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula.
She denies any shortness of breath when resting during the
assessment. The provider plans to discharge the patient on home
oxygen in the morning.
What should the nurse include in this patient's discharge teaching?
ANS: Make sure that the patient understands any new medication regimen.
She should be instructed to call 911 for any severe respiratory distress.
Because she is being discharged with home oxygen, home health services
should be arranged.
The nurse immediately checks on the patient and finds that she
appears anxious and her vital signs are as follows:
ØBlood pressure: 128/84 mm Hg
ØHeart rate: 114 (sinus tachycardia)
ØRespiratory rate: 24, labored and restless
ØTemperature: 99.4° F (axillary)
ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?
ANS: **The BP is within normal range and only slightly elevated. **The
temperature is only slightly elevated. **Her heart rate is elevated; the nurse
should check the patient’s medications to see if she is on a bronchodilator
or other medication that could cause her heart rate to increase. The priority
concern is the RESTLESSNESS with increased respiratory rate and the
decreased oxygen saturation despite the 40% oxygen setting.
A patient with a history of chronic obstructive pulmonary disease is
admitted with shortness of breath. Which nursing intervention is most
appropriate?
,A. Do not administer oxygen.
B. Administer oxygen via Venturi mask.
C. Use nasal cannula to administer high flow oxygen.
D. Administer oxygen at 6L per simple face mask.
ANS: B
Oxygen therapy is prescribed at the lowest liter flow needed to manage
hypoxemia. A system that delivers more precise oxygen levels (e.g., a
Venturi mask) is preferred. Monitor the patient’s response to therapy
closely to ensure adequate gas exchange and correction of hypoxemia.
While suctioning a patient, vagal stimulation occurs. What is the
appropriate nursing action?
A. Instruct the patient to cough.
B. Place the patient in a high Fowler's position.
C. Oxygenate the patient with 100% oxygen.
D. Instruct the patient to breathe slowly and deeply.
ANS: C
Vagal stimulation may occur during suctioning and result in severe
bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or
other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately
and oxygenate the patient manually with 100% oxygen. Repositioning the
patient, slow deep breathing, and coughing will not address the
cardiovascular effects of vagal stimulation.
A patient with COPD presents for a routine follow up. The patient
smokes 1 PPD. Which statement by the patient causes the nurse to
suspect an increase in dyspnea?
A. "I bought a new pillow so I could prop myself up at night to sleep."
B. "I have a productive cough in the morning."
,C. "I have gained weight since I was here last."
D. "The patient is well groomed and is sitting in a tripod position."
ANS: A
Patients with COPD, who smoke, may have a productive morning cough.
Weight loss often occurs when dyspnea is increased due to the increased
metabolic demand. A tripod or orthopneic position is common with COPD
and when combined with a disheveled appearance may indicate an
increase in dyspnea. Buying a new pillow indicates that the patient must
sleep propped up because breathing is worse while lying down. They may
not recognize the increased dyspnea and they try to compensate by using
multiple pillows in order to rest.
The nurse is assessing a patient with a chest tube following a
pneumonectomy. Which assessment finding requires intervention?
A. Bandage around the posterior tube is loose.
B. 2 cm of water is in the second chest tube chamber.
C. The water in the water seal chamber rises and falls with
inhalation/exhalation.
D. Bubbling present in the water seal chamber when the patient
coughs.
ANS: A
After lung surgery, two tubes, anterior and posterior, are used. Dressings
around the wound should not be loose. The wounds should be covered
with airtight dressings.
A home health patient with a history of asthma is having shortness of
breath. The nurse discovers that the peak flowmeter indicates a peak
expiratory flow (PEF) reading that is in the red zone. What is the
priority nursing action?
,A. Call 911 immediately.
B. Take the patient's vital signs.
C. Notify the patient's prescriber.
D. Repeat the PEF reading to verify the results.
ANS: A
A PEF reading in the red zone indicates a range that is 50% below the
patient’s personal best PEF reading and indicates serious respiratory
obstruction requiring 911 or rapid response. Offer medications and stay
with the patient. Repeating the PEF reading and taking vital signs are also
important, but doing so first delays the administration of the rescue drugs
and physician notification.
The patient is assessed and a blood glucose level and vital signs are
obtained upon arrival on the unit. Results are as follows:
BG—239 mg/dL BP—138/88 mm Hg
HR—128 RR—36 breaths/min
O2 saturation—88% (room air) Temperature—101.6º F
Which vital sign or test result requires the nurse's immediate
attention?
A. Blood pressure
B. Respiratory rate
C. Temperature
D. Blood glucose
ANS: B
All of the patient’s vital signs are abnormal. However, the most important
one to report immediately is her increased respirations (and decreased
oxygen saturation). Even though a diagnosis has not been confirmed, it is
very important to address these problems. The patient is experiencing
tachypnea.
, After consulting with the provider, the following orders are received:
Full liquid diabetic diet
IV fluids 1000 mL .9 NS at 60 mL/hr
Oxygen at 2 L per nasal cannula
Blood cultures × 3 and urinalysis
Tylenol grain × every 4 hour for temperature above 101º F
Cefazolin (Ancef) 1 g IVP every 8 hour
Which of the provider's orders should the nurse implement first?
A. IV fluids 1000 mL .9 NS at 60 mL/hr
B. Oxygen at 2 L per nasal cannula
C. Blood cultures and urinalysis
D. Cefazolin (Ancef) 1 g IVP every 8 hour
ANS: B
All of the provider’s orders are very important. However, the most important
one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very
important that supplemental oxygen is started as soon as possible. IV fluids
should be started to enhance pulmonary toileting, and the laboratory should
be notified to draw the needed blood cultures. UAP can obtain the
specimen for urinalysis. The blood cultures and the UA should be obtained
before the IVP Ancef is administered.
The nurse understands that which of the following is the most
common symptom of pneumonia in the older adult patient?
A. Fever
B. Cough
