NURS 216-Adv MedSurg Midterm
QUESTIONS AND ANSWERS GRADED A
Course
NURS 216
1. Question: A nurse is caring for a client with acute respiratory distress
syndrome (ARDS). Which of the following interventions should the nurse
anticipate?
A. Administering high-flow oxygen via nasal cannula
B. Initiating mechanical ventilation with PEEP
C. Placing the client in a supine position
D. Administering diuretics to increase urine output
Answer: B. Initiating mechanical ventilation with PEEP
Rationale: ARDS is managed with mechanical ventilation and positive end-expiratory pressure
(PEEP) to improve oxygenation and prevent alveolar collapse.
2. Question: A client with cirrhosis is experiencing ascites. Which nursing
intervention is the priority?
A. Monitor for signs of spontaneous bacterial peritonitis
B. Encourage increased oral fluid intake
C. Perform daily weights and abdominal girth measurements
D. Administer lactulose to reduce ammonia levels
Answer: C. Perform daily weights and abdominal girth measurements
Rationale: Measuring weight and abdominal girth helps monitor fluid accumulation and assess
the effectiveness of treatment.
3. Question: A client with septic shock is receiving norepinephrine. Which
finding indicates the medication is effective?
A. Increased urine output
B. Decreased serum lactate levels
C. Decreased heart rate
D. Increased respiratory rate
,Answer: B. Decreased serum lactate levels
Rationale: Serum lactate is a key marker of tissue perfusion. A decrease indicates improved
oxygen delivery and reduced anaerobic metabolism.
4. Question: A nurse is caring for a client with a spinal cord injury at T4. The
client suddenly develops a severe headache, hypertension (190/100 mmHg), and
diaphoresis. What is the nurse’s first action?
A. Administer IV antihypertensive medication
B. Place the client in high Fowler’s position
C. Check the client's bladder for distension
D. Call the healthcare provider immediately
Answer: B. Place the client in high Fowler’s position
Rationale: These symptoms indicate autonomic dysreflexia. The first action is to sit the client
up to lower blood pressure while identifying the cause.
5. Question: A client with diabetic ketoacidosis (DKA) is receiving an insulin
infusion. The nurse should monitor for which potential complication?
A. Hypokalemia
B. Hypernatremia
C. Metabolic alkalosis
D. Hypoglycemia
Answer: A. Hypokalemia
Rationale: Insulin drives potassium into cells, which can cause hypokalemia. Potassium levels
should be monitored and supplemented as needed.
6. Question: A client with acute pancreatitis has a serum calcium level of 7.8
mg/dL. Which clinical finding is associated with this condition?
A. Positive Chvostek’s sign
B. Polyuria
C. Hypertension
D. Hypoactive deep tendon reflexes
,Answer: A. Positive Chvostek’s sign
Rationale: Hypocalcemia causes neuromuscular excitability, including Chvostek’s and
Trousseau’s signs.
7. Question: A nurse is assessing a client with an acute myocardial infarction
(MI). Which assessment finding suggests cardiogenic shock?
A. Warm, flushed skin
B. Bradycardia and bounding pulses
C. Cool, clammy skin with weak pulses
D. Decreased urine output and hypertension
Answer: C. Cool, clammy skin with weak pulses
Rationale: Cardiogenic shock occurs when the heart fails to pump effectively, leading to poor
perfusion, weak pulses, and cold, clammy skin.
8. Question: A client with a head injury has a Glasgow Coma Scale (GCS) score
of 6. What does this indicate?
A. Mild brain injury
B. Moderate brain injury
C. Severe brain injury
D. Normal neurological function
Answer: C. Severe brain injury
Rationale: A GCS score of ≤8 indicates a severe brain injury, requiring close monitoring for
increased intracranial pressure.
9. Question: A nurse is preparing to administer packed red blood cells (PRBCs)
to a client. Which action is essential before starting the transfusion?
A. Warming the blood product to body temperature
B. Administering a diuretic before infusion
C. Verifying blood compatibility with two licensed nurses
D. Infusing the blood product over 6 hours
Answer: C. Verifying blood compatibility with two licensed nurses
Rationale: Blood transfusion safety includes confirming compatibility to prevent hemolytic
reactions.
, 10. Question: A client receiving total parenteral nutrition (TPN) has a blood
glucose level of 250 mg/dL. What is the nurse’s best action?
A. Stop the TPN infusion immediately
B. Administer IV insulin as prescribed
C. Increase the infusion rate to compensate
D. Switch to enteral feeding immediately
Answer: B. Administer IV insulin as prescribed
Rationale: Hyperglycemia is a common complication of TPN. Insulin should be given as
ordered while continuing the infusion.
11. Question: A client with a history of atrial fibrillation is receiving warfarin. Which lab value
should the nurse monitor to determine the medication’s effectiveness?
A. aPTT
B. INR
C. Platelet count
D. D-dimer
Answer: B. INR
Rationale: INR (International Normalized Ratio) is used to monitor warfarin therapy. A
therapeutic range for atrial fibrillation is 2.0–3.0.
12. Question: A client with a traumatic brain injury has a Cushing’s triad response. Which vital
sign changes would the nurse expect?
A. Bradycardia, hypertension, irregular respirations
B. Tachycardia, hypotension, hyperventilation
C. Bradycardia, hypotension, rapid breathing
D. Tachycardia, hypertension, shallow respirations
Answer: A. Bradycardia, hypertension, irregular respirations
Rationale: Cushing’s triad indicates increased intracranial pressure (ICP) and includes widened
pulse pressure, bradycardia, and irregular breathing.
13. Question: A client with acute kidney injury has a potassium level of 6.5 mEq/L. Which
medication should the nurse expect to administer first?
QUESTIONS AND ANSWERS GRADED A
Course
NURS 216
1. Question: A nurse is caring for a client with acute respiratory distress
syndrome (ARDS). Which of the following interventions should the nurse
anticipate?
A. Administering high-flow oxygen via nasal cannula
B. Initiating mechanical ventilation with PEEP
C. Placing the client in a supine position
D. Administering diuretics to increase urine output
Answer: B. Initiating mechanical ventilation with PEEP
Rationale: ARDS is managed with mechanical ventilation and positive end-expiratory pressure
(PEEP) to improve oxygenation and prevent alveolar collapse.
2. Question: A client with cirrhosis is experiencing ascites. Which nursing
intervention is the priority?
A. Monitor for signs of spontaneous bacterial peritonitis
B. Encourage increased oral fluid intake
C. Perform daily weights and abdominal girth measurements
D. Administer lactulose to reduce ammonia levels
Answer: C. Perform daily weights and abdominal girth measurements
Rationale: Measuring weight and abdominal girth helps monitor fluid accumulation and assess
the effectiveness of treatment.
3. Question: A client with septic shock is receiving norepinephrine. Which
finding indicates the medication is effective?
A. Increased urine output
B. Decreased serum lactate levels
C. Decreased heart rate
D. Increased respiratory rate
,Answer: B. Decreased serum lactate levels
Rationale: Serum lactate is a key marker of tissue perfusion. A decrease indicates improved
oxygen delivery and reduced anaerobic metabolism.
4. Question: A nurse is caring for a client with a spinal cord injury at T4. The
client suddenly develops a severe headache, hypertension (190/100 mmHg), and
diaphoresis. What is the nurse’s first action?
A. Administer IV antihypertensive medication
B. Place the client in high Fowler’s position
C. Check the client's bladder for distension
D. Call the healthcare provider immediately
Answer: B. Place the client in high Fowler’s position
Rationale: These symptoms indicate autonomic dysreflexia. The first action is to sit the client
up to lower blood pressure while identifying the cause.
5. Question: A client with diabetic ketoacidosis (DKA) is receiving an insulin
infusion. The nurse should monitor for which potential complication?
A. Hypokalemia
B. Hypernatremia
C. Metabolic alkalosis
D. Hypoglycemia
Answer: A. Hypokalemia
Rationale: Insulin drives potassium into cells, which can cause hypokalemia. Potassium levels
should be monitored and supplemented as needed.
6. Question: A client with acute pancreatitis has a serum calcium level of 7.8
mg/dL. Which clinical finding is associated with this condition?
A. Positive Chvostek’s sign
B. Polyuria
C. Hypertension
D. Hypoactive deep tendon reflexes
,Answer: A. Positive Chvostek’s sign
Rationale: Hypocalcemia causes neuromuscular excitability, including Chvostek’s and
Trousseau’s signs.
7. Question: A nurse is assessing a client with an acute myocardial infarction
(MI). Which assessment finding suggests cardiogenic shock?
A. Warm, flushed skin
B. Bradycardia and bounding pulses
C. Cool, clammy skin with weak pulses
D. Decreased urine output and hypertension
Answer: C. Cool, clammy skin with weak pulses
Rationale: Cardiogenic shock occurs when the heart fails to pump effectively, leading to poor
perfusion, weak pulses, and cold, clammy skin.
8. Question: A client with a head injury has a Glasgow Coma Scale (GCS) score
of 6. What does this indicate?
A. Mild brain injury
B. Moderate brain injury
C. Severe brain injury
D. Normal neurological function
Answer: C. Severe brain injury
Rationale: A GCS score of ≤8 indicates a severe brain injury, requiring close monitoring for
increased intracranial pressure.
9. Question: A nurse is preparing to administer packed red blood cells (PRBCs)
to a client. Which action is essential before starting the transfusion?
A. Warming the blood product to body temperature
B. Administering a diuretic before infusion
C. Verifying blood compatibility with two licensed nurses
D. Infusing the blood product over 6 hours
Answer: C. Verifying blood compatibility with two licensed nurses
Rationale: Blood transfusion safety includes confirming compatibility to prevent hemolytic
reactions.
, 10. Question: A client receiving total parenteral nutrition (TPN) has a blood
glucose level of 250 mg/dL. What is the nurse’s best action?
A. Stop the TPN infusion immediately
B. Administer IV insulin as prescribed
C. Increase the infusion rate to compensate
D. Switch to enteral feeding immediately
Answer: B. Administer IV insulin as prescribed
Rationale: Hyperglycemia is a common complication of TPN. Insulin should be given as
ordered while continuing the infusion.
11. Question: A client with a history of atrial fibrillation is receiving warfarin. Which lab value
should the nurse monitor to determine the medication’s effectiveness?
A. aPTT
B. INR
C. Platelet count
D. D-dimer
Answer: B. INR
Rationale: INR (International Normalized Ratio) is used to monitor warfarin therapy. A
therapeutic range for atrial fibrillation is 2.0–3.0.
12. Question: A client with a traumatic brain injury has a Cushing’s triad response. Which vital
sign changes would the nurse expect?
A. Bradycardia, hypertension, irregular respirations
B. Tachycardia, hypotension, hyperventilation
C. Bradycardia, hypotension, rapid breathing
D. Tachycardia, hypertension, shallow respirations
Answer: A. Bradycardia, hypertension, irregular respirations
Rationale: Cushing’s triad indicates increased intracranial pressure (ICP) and includes widened
pulse pressure, bradycardia, and irregular breathing.
13. Question: A client with acute kidney injury has a potassium level of 6.5 mEq/L. Which
medication should the nurse expect to administer first?
