NU 185 Exam 3: Med-Surg II - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with a head injury displays a blood pressure of 180/60 mm Hg, a pulse of 50 beats/min, and
irregular respirations. Which condition should the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Increased intracranial pressure
D. Pulmonary embolism
Correct Answer: C
Rationale: These vital signs represent Cushing’s triad, which is a late sign of increased intracranial
pressure. The triad includes systolic hypertension with a widening pulse pressure, bradycardia, and
irregular respirations. This physiological response occurs when the brain is no longer able to compensate
for the pressure. Immediate nursing intervention is required to prevent brain herniation. The nurse
should notify the provider and anticipate orders for osmotic diuretics like mannitol.
2. Which assessment finding is most indicative of a perforated peptic ulcer?
A. Hyperactive bowel sounds
B. Hyperresonance on percussion
C. Projectile vomiting
D. Board-like, rigid abdomen
Correct Answer: D
,Rationale: A rigid, board-like abdomen is a classic sign of peritonitis resulting from a perforated ulcer.
Perforation allows gastric or duodenal contents to spill into the peritoneal cavity, causing intense
irritation. Patients typically report sudden, sharp, and severe abdominal pain that radiates to the
shoulder. This is a surgical emergency that requires immediate stabilization and operative repair.
Nursing care focuses on maintaining NPO status and administering IV antibiotics and fluids.
3. A patient with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L. Which medication
should the nurse anticipate administering first?
A. Furosemide
B. Sodium polystyrene sulfonate
C. IV regular insulin and dextrose
D. Calcium carbonate
Correct Answer: C
Rationale: IV regular insulin and dextrose is the fastest temporary way to shift potassium from the
extracellular fluid into the cells. This treatment prevents life-threatening cardiac arrhythmias by
lowering the serum potassium level quickly. While sodium polystyrene sulfonate removes potassium
from the body, it takes much longer to work. Calcium gluconate may also be given to stabilize the cardiac
membrane, but insulin is the standard for rapid shifting. The nurse must monitor blood glucose levels
closely after insulin administration.
4. The nurse is caring for a patient with hepatic encephalopathy. Which laboratory value is most important
to monitor to evaluate treatment effectiveness?
A. Serum ammonia
B. Prothrombin time (PT)
, C. Serum albumin
D. Bilirubin level
Correct Answer: A
Rationale: Hepatic encephalopathy is primarily caused by the accumulation of ammonia in the blood
because the liver cannot convert it to urea. As ammonia levels rise, patients experience altered mental
status and neuromuscular disturbances like asterixis. Treatment with lactulose aims to reduce these
levels by excreting ammonia through the stool. A decrease in serum ammonia levels indicates that the
pharmacological therapy is effective. The nurse should also assess for improvements in the patient’s level
of consciousness.
5. A patient is admitted with a suspected T6 spinal cord injury. Which clinical manifestation would alert the
nurse to the development of autonomic dysreflexia?
A. Extreme hypotension
B. Tachycardia and diaphoresis
C. Flaccid paralysis of all extremities
D. Sudden headache and hypertension
Correct Answer: D
Rationale: Autonomic dysreflexia is a medical emergency occurring in patients with spinal cord injuries
at T6 or higher. It is characterized by severe hypertension, a pounding headache, and bradycardia. This
condition is usually triggered by a noxious stimulus such as a full bladder or impacted bowel. The nurse’s
first priority is to sit the patient upright to lower blood pressure. Following that, the nurse must identify
and remove the triggering stimulus immediately.
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with a head injury displays a blood pressure of 180/60 mm Hg, a pulse of 50 beats/min, and
irregular respirations. Which condition should the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Increased intracranial pressure
D. Pulmonary embolism
Correct Answer: C
Rationale: These vital signs represent Cushing’s triad, which is a late sign of increased intracranial
pressure. The triad includes systolic hypertension with a widening pulse pressure, bradycardia, and
irregular respirations. This physiological response occurs when the brain is no longer able to compensate
for the pressure. Immediate nursing intervention is required to prevent brain herniation. The nurse
should notify the provider and anticipate orders for osmotic diuretics like mannitol.
2. Which assessment finding is most indicative of a perforated peptic ulcer?
A. Hyperactive bowel sounds
B. Hyperresonance on percussion
C. Projectile vomiting
D. Board-like, rigid abdomen
Correct Answer: D
,Rationale: A rigid, board-like abdomen is a classic sign of peritonitis resulting from a perforated ulcer.
Perforation allows gastric or duodenal contents to spill into the peritoneal cavity, causing intense
irritation. Patients typically report sudden, sharp, and severe abdominal pain that radiates to the
shoulder. This is a surgical emergency that requires immediate stabilization and operative repair.
Nursing care focuses on maintaining NPO status and administering IV antibiotics and fluids.
3. A patient with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L. Which medication
should the nurse anticipate administering first?
A. Furosemide
B. Sodium polystyrene sulfonate
C. IV regular insulin and dextrose
D. Calcium carbonate
Correct Answer: C
Rationale: IV regular insulin and dextrose is the fastest temporary way to shift potassium from the
extracellular fluid into the cells. This treatment prevents life-threatening cardiac arrhythmias by
lowering the serum potassium level quickly. While sodium polystyrene sulfonate removes potassium
from the body, it takes much longer to work. Calcium gluconate may also be given to stabilize the cardiac
membrane, but insulin is the standard for rapid shifting. The nurse must monitor blood glucose levels
closely after insulin administration.
4. The nurse is caring for a patient with hepatic encephalopathy. Which laboratory value is most important
to monitor to evaluate treatment effectiveness?
A. Serum ammonia
B. Prothrombin time (PT)
, C. Serum albumin
D. Bilirubin level
Correct Answer: A
Rationale: Hepatic encephalopathy is primarily caused by the accumulation of ammonia in the blood
because the liver cannot convert it to urea. As ammonia levels rise, patients experience altered mental
status and neuromuscular disturbances like asterixis. Treatment with lactulose aims to reduce these
levels by excreting ammonia through the stool. A decrease in serum ammonia levels indicates that the
pharmacological therapy is effective. The nurse should also assess for improvements in the patient’s level
of consciousness.
5. A patient is admitted with a suspected T6 spinal cord injury. Which clinical manifestation would alert the
nurse to the development of autonomic dysreflexia?
A. Extreme hypotension
B. Tachycardia and diaphoresis
C. Flaccid paralysis of all extremities
D. Sudden headache and hypertension
Correct Answer: D
Rationale: Autonomic dysreflexia is a medical emergency occurring in patients with spinal cord injuries
at T6 or higher. It is characterized by severe hypertension, a pounding headache, and bradycardia. This
condition is usually triggered by a noxious stimulus such as a full bladder or impacted bowel. The nurse’s
first priority is to sit the patient upright to lower blood pressure. Following that, the nurse must identify
and remove the triggering stimulus immediately.
