NUR 304 | NUR304 Exam 4: Med Surg - MCPHS
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient who suffered a traumatic brain injury and is displaying signs
of increased intracranial pressure (ICP). Which of the following nursing interventions is the
priority to decrease ICP?
A. Encourage the patient to cough and deep breathe every 2 hours.
B. Provide a cluster of nursing activities to allow for long rest periods.
C. Perform vigorous suctioning every hour to maintain airway patency.
D. Maintain the head of the bed at 30 to 45 degrees with the head in a neutral position.
Correct Answer: D
Rationale: Positioning is a critical nursing intervention for managing intracranial pressure
because it promotes venous drainage from the brain. Elevating the head of the bed helps
reduce cerebral edema and prevents further spikes in ICP. Neutral alignment is essential to
prevent jugular vein compression which would otherwise impede outflow. Coughing and
vigorous suctioning are contraindicated as they significantly increase intra-thoracic and
intra-abdominal pressure, leading to elevated ICP. Clustered care should actually be
avoided in these patients because prolonged stimulation can cause sustained elevations in
pressure.
2. A patient who underwent a total hip arthroplasty 24 hours ago reports sudden onset of
shortness of breath and chest pain. The nurse notes petechiae on the patient’s chest and
neck. What is the nurse’s priority action?
A. Initiate a rapid response team and prepare for oxygen administration.
B. Administer a dose of prescribed subcutaneous heparin.
C. Assess the surgical site for signs of hemorrhage or hematoma.
D. Perform a neurovascular check on the affected extremity.
Correct Answer: A
Rationale: The presentation of sudden dyspnea, chest pain, and petechiae after a long-
bone surgery is classic for a fat embolism syndrome. This is a life-threatening emergency
that requires immediate stabilization of the respiratory system and notification of the rapid
response team. Petechiae are a late but pathognomonic sign that distinguishes fat
embolism from a pulmonary embolism. While heparin is used for DVT prophylaxis, it is not
the immediate treatment for an active fat embolus. Assessing the surgical site or distal
pulses is secondary to addressing the patient’s acute respiratory distress.
,3. A nurse is assessing a patient with a spinal cord injury at the T6 level. The patient reports a
severe, pounding headache and has a blood pressure of 190/100 mmHg. What is the first
action the nurse should take?
A. Check the patient’s bladder for distension or a kinked catheter.
B. Administer PRN nifedipine as ordered for hypertension.
C. Lower the head of the bed to a flat position immediately.
D. Notify the healthcare provider of the change in status.
Correct Answer: A
Rationale: This patient is exhibiting symptoms of Autonomic Dysreflexia, a medical
emergency occurring in patients with T6 or higher spinal cord injuries. The priority is to
identify and remove the triggering stimulus, which is most commonly a distended bladder
or impacted bowel. The nurse should check the catheter for kinks or perform a bladder
scan immediately. Sitting the patient upright (not laying flat) is the correct positioning to
help lower blood pressure through orthostatic effects. While the provider must be notified
and medication may be needed, the priority is removing the noxious stimulus.
4. A patient with Myasthenia Gravis is admitted to the ICU with respiratory failure. Which
assessment finding would help the nurse distinguish a Myasthenic Crisis from a Cholinergic
Crisis?
A. The patient’s pupils are constricted and non-reactive to light.
B. The patient exhibits generalized weakness and respiratory distress.
C. The patient has excessive salivation, lacrimation, and diarrhea.
D. The patient shows improvement in muscle strength after receiving edrophonium
(Tensilon).
Correct Answer: D
Rationale: The Tensilon test is used to differentiate between Myasthenic and Cholinergic
crises by observing the response to an acetylcholinesterase inhibitor. In a Myasthenic
Crisis, the patient lacks enough acetylcholine, so the drug improves muscle strength. In a
Cholinergic Crisis, the patient has an overabundance of acetylcholine, and the drug will
worsen the weakness. Excessive salivation and diarrhea (SLUDGE symptoms) are
indicative of a Cholinergic Crisis caused by overmedication. Distinguishing these two is
vital because the treatments are opposite and giving more medication during a cholinergic
crisis can be fatal.
5. A nurse is caring for a patient in skeletal traction for a femur fracture. Which of the
following actions by the nurse is appropriate?
A. Ensure the weights are hanging freely and not touching the floor.
B. Remove the weights for 5 minutes every shift to check skin integrity.
, C. Apply antibiotic ointment to the pin sites every 4 hours.
D. Assist the patient to turn side-to-side to prevent pressure ulcers.
Correct Answer: A
Rationale: For skeletal traction to be effective, the weights must remain hanging freely at
all times to maintain the necessary pulling force for bone alignment. Removing weights can
cause muscle spasms and disrupt the alignment of the fracture. Pin site care typically
follows hospital protocol and doesn’t usually involve antibiotic ointment every 4 hours,
which could promote fungal growth. Patients in skeletal traction should not be turned side-
to-side as it can shift the bone fragments; instead, they should use a trapeze to lift the
pelvis. Skin integrity is monitored by inspecting under the patient and ensuring the pull
remains consistent.
6. The nurse is evaluating a patient’s understanding of the management of Rheumatoid
Arthritis (RA). Which statement by the patient indicates a need for further teaching?
A. ‘I should use warm compresses in the morning to help with my stiffness.’
B. ‘I will make sure to schedule rest periods between my daily activities.’
C. ‘I should use a large-handled spoon to make it easier to grip when I eat.’
D. ‘When my joints are inflamed, I will perform high-impact exercises to keep them
moving.’
Correct Answer: D
Rationale: During periods of active inflammation in Rheumatoid Arthritis, high-impact
exercises can cause further joint damage and increase pain. Patients are encouraged to
perform gentle range-of-motion exercises rather than strenuous activity when joints are
flared. Warm compresses are excellent for relieving morning stiffness, which is a hallmark
sign of RA. Scheduling rest periods is vital to manage the systemic fatigue associated with
this autoimmune disease. Using assistive devices like large-handled spoons helps protect
small joints from excessive stress and promotes independence.
7. A patient is admitted with a suspected ischemic stroke. Which diagnostic test is the priority
to perform within the first 25 minutes of arrival at the hospital?
A. Magnetic Resonance Imaging (MRI) of the brain.
B. Non-contrast Computed Tomography (CT) scan.
C. Electroencephalogram (EEG).
D. Carotid Doppler Ultrasound.
Correct Answer: B
Rationale: A non-contrast CT scan is the gold standard initial diagnostic test for a
suspected stroke to rule out intracranial hemorrhage. This distinction is critical because if
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient who suffered a traumatic brain injury and is displaying signs
of increased intracranial pressure (ICP). Which of the following nursing interventions is the
priority to decrease ICP?
A. Encourage the patient to cough and deep breathe every 2 hours.
B. Provide a cluster of nursing activities to allow for long rest periods.
C. Perform vigorous suctioning every hour to maintain airway patency.
D. Maintain the head of the bed at 30 to 45 degrees with the head in a neutral position.
Correct Answer: D
Rationale: Positioning is a critical nursing intervention for managing intracranial pressure
because it promotes venous drainage from the brain. Elevating the head of the bed helps
reduce cerebral edema and prevents further spikes in ICP. Neutral alignment is essential to
prevent jugular vein compression which would otherwise impede outflow. Coughing and
vigorous suctioning are contraindicated as they significantly increase intra-thoracic and
intra-abdominal pressure, leading to elevated ICP. Clustered care should actually be
avoided in these patients because prolonged stimulation can cause sustained elevations in
pressure.
2. A patient who underwent a total hip arthroplasty 24 hours ago reports sudden onset of
shortness of breath and chest pain. The nurse notes petechiae on the patient’s chest and
neck. What is the nurse’s priority action?
A. Initiate a rapid response team and prepare for oxygen administration.
B. Administer a dose of prescribed subcutaneous heparin.
C. Assess the surgical site for signs of hemorrhage or hematoma.
D. Perform a neurovascular check on the affected extremity.
Correct Answer: A
Rationale: The presentation of sudden dyspnea, chest pain, and petechiae after a long-
bone surgery is classic for a fat embolism syndrome. This is a life-threatening emergency
that requires immediate stabilization of the respiratory system and notification of the rapid
response team. Petechiae are a late but pathognomonic sign that distinguishes fat
embolism from a pulmonary embolism. While heparin is used for DVT prophylaxis, it is not
the immediate treatment for an active fat embolus. Assessing the surgical site or distal
pulses is secondary to addressing the patient’s acute respiratory distress.
,3. A nurse is assessing a patient with a spinal cord injury at the T6 level. The patient reports a
severe, pounding headache and has a blood pressure of 190/100 mmHg. What is the first
action the nurse should take?
A. Check the patient’s bladder for distension or a kinked catheter.
B. Administer PRN nifedipine as ordered for hypertension.
C. Lower the head of the bed to a flat position immediately.
D. Notify the healthcare provider of the change in status.
Correct Answer: A
Rationale: This patient is exhibiting symptoms of Autonomic Dysreflexia, a medical
emergency occurring in patients with T6 or higher spinal cord injuries. The priority is to
identify and remove the triggering stimulus, which is most commonly a distended bladder
or impacted bowel. The nurse should check the catheter for kinks or perform a bladder
scan immediately. Sitting the patient upright (not laying flat) is the correct positioning to
help lower blood pressure through orthostatic effects. While the provider must be notified
and medication may be needed, the priority is removing the noxious stimulus.
4. A patient with Myasthenia Gravis is admitted to the ICU with respiratory failure. Which
assessment finding would help the nurse distinguish a Myasthenic Crisis from a Cholinergic
Crisis?
A. The patient’s pupils are constricted and non-reactive to light.
B. The patient exhibits generalized weakness and respiratory distress.
C. The patient has excessive salivation, lacrimation, and diarrhea.
D. The patient shows improvement in muscle strength after receiving edrophonium
(Tensilon).
Correct Answer: D
Rationale: The Tensilon test is used to differentiate between Myasthenic and Cholinergic
crises by observing the response to an acetylcholinesterase inhibitor. In a Myasthenic
Crisis, the patient lacks enough acetylcholine, so the drug improves muscle strength. In a
Cholinergic Crisis, the patient has an overabundance of acetylcholine, and the drug will
worsen the weakness. Excessive salivation and diarrhea (SLUDGE symptoms) are
indicative of a Cholinergic Crisis caused by overmedication. Distinguishing these two is
vital because the treatments are opposite and giving more medication during a cholinergic
crisis can be fatal.
5. A nurse is caring for a patient in skeletal traction for a femur fracture. Which of the
following actions by the nurse is appropriate?
A. Ensure the weights are hanging freely and not touching the floor.
B. Remove the weights for 5 minutes every shift to check skin integrity.
, C. Apply antibiotic ointment to the pin sites every 4 hours.
D. Assist the patient to turn side-to-side to prevent pressure ulcers.
Correct Answer: A
Rationale: For skeletal traction to be effective, the weights must remain hanging freely at
all times to maintain the necessary pulling force for bone alignment. Removing weights can
cause muscle spasms and disrupt the alignment of the fracture. Pin site care typically
follows hospital protocol and doesn’t usually involve antibiotic ointment every 4 hours,
which could promote fungal growth. Patients in skeletal traction should not be turned side-
to-side as it can shift the bone fragments; instead, they should use a trapeze to lift the
pelvis. Skin integrity is monitored by inspecting under the patient and ensuring the pull
remains consistent.
6. The nurse is evaluating a patient’s understanding of the management of Rheumatoid
Arthritis (RA). Which statement by the patient indicates a need for further teaching?
A. ‘I should use warm compresses in the morning to help with my stiffness.’
B. ‘I will make sure to schedule rest periods between my daily activities.’
C. ‘I should use a large-handled spoon to make it easier to grip when I eat.’
D. ‘When my joints are inflamed, I will perform high-impact exercises to keep them
moving.’
Correct Answer: D
Rationale: During periods of active inflammation in Rheumatoid Arthritis, high-impact
exercises can cause further joint damage and increase pain. Patients are encouraged to
perform gentle range-of-motion exercises rather than strenuous activity when joints are
flared. Warm compresses are excellent for relieving morning stiffness, which is a hallmark
sign of RA. Scheduling rest periods is vital to manage the systemic fatigue associated with
this autoimmune disease. Using assistive devices like large-handled spoons helps protect
small joints from excessive stress and promotes independence.
7. A patient is admitted with a suspected ischemic stroke. Which diagnostic test is the priority
to perform within the first 25 minutes of arrival at the hospital?
A. Magnetic Resonance Imaging (MRI) of the brain.
B. Non-contrast Computed Tomography (CT) scan.
C. Electroencephalogram (EEG).
D. Carotid Doppler Ultrasound.
Correct Answer: B
Rationale: A non-contrast CT scan is the gold standard initial diagnostic test for a
suspected stroke to rule out intracranial hemorrhage. This distinction is critical because if
