NUR 304 | NUR304 Final Exam: Med Surg - MCPHS
Updated and Latest Questions and Correct
Answers with Rationale
1. A patient with heart failure is receiving intravenous furosemide. Which assessment finding
is the most critical for the nurse to report to the healthcare provider?
A. Muscle weakness and irregular heart rhythm.
B. Urinary output of 50 mL/hour.
C. Weight loss of 2 lbs in 24 hours.
D. Occasional dry cough at night.
Correct Answer: A
Rationale: Furosemide is a loop diuretic that can cause significant potassium loss leading
to hypokalemia. Muscle weakness and cardiac dysrhythmias are classic signs of low
potassium levels. The nurse must prioritize these findings as they can lead to life-
threatening complications. While weight loss and urinary output are expected outcomes,
they are not immediate dangers. This scenario requires the nurse to link pharmacological
action with physiological safety.
2. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen at 2L/min via nasal cannula. The patient’s SpO2 is 89%. What is the nurse’s
best action?
A. Continue to monitor and document the finding as expected.
B. Switch the patient to a non-rebreather mask.
C. Increase the oxygen flow to 6L/min immediately.
D. Position the patient in a supine position to rest.
Correct Answer: A
Rationale: Patients with COPD often have a lower baseline oxygen saturation, typically
ranging between 88% and 92%. Increasing oxygen too drastically can suppress the hypoxic
drive in these patients, leading to respiratory failure. The nurse must understand the
pathophysiology of chronic CO2 retention before intervening. Maintaining the current flow
and monitoring for distress is the safest evidence-based practice. High-flow oxygen is
contraindicated unless there is an acute emergency.
3. A patient is admitted to the emergency department with Diabetic Ketoacidosis (DKA).
Which provider order should the nurse implement first?
A. Administer 10 units of regular insulin IV bolus.
,B. Obtain an arterial blood gas (ABG) sample.
C. Begin a continuous potassium chloride infusion.
D. Infuse 1 liter of 0.9% normal saline over 1 hour.
Correct Answer: D
Rationale: The priority in treating DKA is fluid resuscitation to correct dehydration and
restore perfusion. Dehydration in DKA is often severe due to osmotic diuresis from
hyperglycemia. While insulin is necessary to lower blood sugar, it should follow initial
volume expansion. Potassium is also critical but usually follows fluid and insulin
management. Following the ABC prioritization framework, circulation and volume come
before specific metabolic corrections.
4. The nurse is assigned to four patients. Which patient should be assessed first after shift
report?
A. A patient 2 hours post-thyroidectomy reporting tingling in the fingers.
B. A patient with pneumonia who has an oxygen saturation of 90% on room air.
C. A patient with a history of seizures who had a seizure 4 hours ago.
D. A patient with a hip fracture requesting pain medication (6/10).
Correct Answer: A
Rationale: Tingling in the fingers after a thyroidectomy is a sign of hypocalcemia,
potentially due to accidental parathyroid damage. This can lead to laryngospasm and
airway obstruction, making it a priority. The patient with pneumonia is stable at 90% but
requires monitoring. The seizure patient is in a post-ictal state but currently stable. Pain
management for the hip fracture is important but not life-threatening.
5. A patient with Stage 4 Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L.
Which medication should the nurse prepare to administer to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate).
B. Erythropoietin.
C. Calcium gluconate.
D. Furosemide.
Correct Answer: C
Rationale: Calcium gluconate is administered in severe hyperkalemia to stabilize the
myocardial cell membrane and prevent arrhythmias. It does not lower the potassium level
but provides immediate cardiac protection. Kayexalate is used to remove potassium from
the body but takes longer to act. Erythropoietin addresses anemia in CKD, not electrolyte
imbalances. Furosemide may be used but is less effective in advanced kidney disease.
, 6. Which task is most appropriate for the RN to delegate to an Unlicensed Assistive Personnel
(UAP)?
A. Feeding a patient who was admitted with an acute stroke 2 hours ago.
B. Measuring and recording the intake and output for a patient with heart failure.
C. Performing a sterile dressing change on a post-operative wound.
D. Assessing the lung sounds of a patient with a new chest tube.
Correct Answer: B
Rationale: Measuring intake and output is a routine, non-invasive task that falls within the
scope of practice for a UAP. Feeding a new stroke patient requires a swallow assessment,
which must be performed by an RN or speech therapist. Sterile dressing changes and
physical assessments require professional nursing judgment and licensure. Delegating
appropriately allows the RN to focus on complex clinical decisions. The nurse must always
verify that the UAP is competent in the delegated task.
7. A patient is receiving a Heparin infusion for a deep vein thrombosis (DVT). The aPTT is 110
seconds (Control: 30 seconds). What is the nurse’s priority action?
A. Continue the infusion as the value is within therapeutic range.
B. Increase the infusion rate to reach the target range.
C. Stop the infusion and prepare to administer Protamine Sulfate.
D. Draw a stat PT/INR level.
Correct Answer: C
Rationale: A therapeutic aPTT for Heparin is typically 1.5 to 2.5 times the control value,
which would be 45 to 75 seconds. An aPTT of 110 seconds is significantly elevated, placing
the patient at high risk for hemorrhage. The infusion must be stopped immediately to
prevent further anticoagulation. Protamine sulfate is the specific antidote for Heparin
overdose. Monitoring for signs of bleeding is a critical nursing responsibility during this
intervention.
8. A patient with a suspected Pulmonary Embolism (PE) presents with sudden chest pain and
shortness of breath. Which diagnostic test is considered the gold standard for confirmation?
A. CT Pulmonary Angiogram (CTPA).
B. D-dimer assay.
C. Chest X-ray.
D. Electrocardiogram (ECG).
Correct Answer: A
Updated and Latest Questions and Correct
Answers with Rationale
1. A patient with heart failure is receiving intravenous furosemide. Which assessment finding
is the most critical for the nurse to report to the healthcare provider?
A. Muscle weakness and irregular heart rhythm.
B. Urinary output of 50 mL/hour.
C. Weight loss of 2 lbs in 24 hours.
D. Occasional dry cough at night.
Correct Answer: A
Rationale: Furosemide is a loop diuretic that can cause significant potassium loss leading
to hypokalemia. Muscle weakness and cardiac dysrhythmias are classic signs of low
potassium levels. The nurse must prioritize these findings as they can lead to life-
threatening complications. While weight loss and urinary output are expected outcomes,
they are not immediate dangers. This scenario requires the nurse to link pharmacological
action with physiological safety.
2. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen at 2L/min via nasal cannula. The patient’s SpO2 is 89%. What is the nurse’s
best action?
A. Continue to monitor and document the finding as expected.
B. Switch the patient to a non-rebreather mask.
C. Increase the oxygen flow to 6L/min immediately.
D. Position the patient in a supine position to rest.
Correct Answer: A
Rationale: Patients with COPD often have a lower baseline oxygen saturation, typically
ranging between 88% and 92%. Increasing oxygen too drastically can suppress the hypoxic
drive in these patients, leading to respiratory failure. The nurse must understand the
pathophysiology of chronic CO2 retention before intervening. Maintaining the current flow
and monitoring for distress is the safest evidence-based practice. High-flow oxygen is
contraindicated unless there is an acute emergency.
3. A patient is admitted to the emergency department with Diabetic Ketoacidosis (DKA).
Which provider order should the nurse implement first?
A. Administer 10 units of regular insulin IV bolus.
,B. Obtain an arterial blood gas (ABG) sample.
C. Begin a continuous potassium chloride infusion.
D. Infuse 1 liter of 0.9% normal saline over 1 hour.
Correct Answer: D
Rationale: The priority in treating DKA is fluid resuscitation to correct dehydration and
restore perfusion. Dehydration in DKA is often severe due to osmotic diuresis from
hyperglycemia. While insulin is necessary to lower blood sugar, it should follow initial
volume expansion. Potassium is also critical but usually follows fluid and insulin
management. Following the ABC prioritization framework, circulation and volume come
before specific metabolic corrections.
4. The nurse is assigned to four patients. Which patient should be assessed first after shift
report?
A. A patient 2 hours post-thyroidectomy reporting tingling in the fingers.
B. A patient with pneumonia who has an oxygen saturation of 90% on room air.
C. A patient with a history of seizures who had a seizure 4 hours ago.
D. A patient with a hip fracture requesting pain medication (6/10).
Correct Answer: A
Rationale: Tingling in the fingers after a thyroidectomy is a sign of hypocalcemia,
potentially due to accidental parathyroid damage. This can lead to laryngospasm and
airway obstruction, making it a priority. The patient with pneumonia is stable at 90% but
requires monitoring. The seizure patient is in a post-ictal state but currently stable. Pain
management for the hip fracture is important but not life-threatening.
5. A patient with Stage 4 Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L.
Which medication should the nurse prepare to administer to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate).
B. Erythropoietin.
C. Calcium gluconate.
D. Furosemide.
Correct Answer: C
Rationale: Calcium gluconate is administered in severe hyperkalemia to stabilize the
myocardial cell membrane and prevent arrhythmias. It does not lower the potassium level
but provides immediate cardiac protection. Kayexalate is used to remove potassium from
the body but takes longer to act. Erythropoietin addresses anemia in CKD, not electrolyte
imbalances. Furosemide may be used but is less effective in advanced kidney disease.
, 6. Which task is most appropriate for the RN to delegate to an Unlicensed Assistive Personnel
(UAP)?
A. Feeding a patient who was admitted with an acute stroke 2 hours ago.
B. Measuring and recording the intake and output for a patient with heart failure.
C. Performing a sterile dressing change on a post-operative wound.
D. Assessing the lung sounds of a patient with a new chest tube.
Correct Answer: B
Rationale: Measuring intake and output is a routine, non-invasive task that falls within the
scope of practice for a UAP. Feeding a new stroke patient requires a swallow assessment,
which must be performed by an RN or speech therapist. Sterile dressing changes and
physical assessments require professional nursing judgment and licensure. Delegating
appropriately allows the RN to focus on complex clinical decisions. The nurse must always
verify that the UAP is competent in the delegated task.
7. A patient is receiving a Heparin infusion for a deep vein thrombosis (DVT). The aPTT is 110
seconds (Control: 30 seconds). What is the nurse’s priority action?
A. Continue the infusion as the value is within therapeutic range.
B. Increase the infusion rate to reach the target range.
C. Stop the infusion and prepare to administer Protamine Sulfate.
D. Draw a stat PT/INR level.
Correct Answer: C
Rationale: A therapeutic aPTT for Heparin is typically 1.5 to 2.5 times the control value,
which would be 45 to 75 seconds. An aPTT of 110 seconds is significantly elevated, placing
the patient at high risk for hemorrhage. The infusion must be stopped immediately to
prevent further anticoagulation. Protamine sulfate is the specific antidote for Heparin
overdose. Monitoring for signs of bleeding is a critical nursing responsibility during this
intervention.
8. A patient with a suspected Pulmonary Embolism (PE) presents with sudden chest pain and
shortness of breath. Which diagnostic test is considered the gold standard for confirmation?
A. CT Pulmonary Angiogram (CTPA).
B. D-dimer assay.
C. Chest X-ray.
D. Electrocardiogram (ECG).
Correct Answer: A
