NURS 211L | NURS211L Exam 3: Med Surg 2 - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient with increased intracranial pressure (ICP). Which of the
following nursing interventions is appropriate to help decrease ICP?
A. Keep the head of the bed elevated at 30 to 45 degrees
B. Place the patient in the Trendelenburg position
C. Encourage the patient to perform isometric exercises
D. Perform vigorous suctioning every hour
Correct Answer: A
Rationale: Elevating the head of the bed to 30 to 45 degrees promotes venous drainage
from the brain. This intervention is a standard practice to reduce intracranial pressure in
neurological patients. The nurse must also ensure the patient’s head remains in a neutral,
midline position. Avoiding hip flexion is equally important to prevent increases in intra-
abdominal pressure. Consistent monitoring of the patient’s neurological status is required
to evaluate the effectiveness of this positioning.
2. A patient with a history of seizures is admitted to the medical-surgical unit. Which of the
following items should the nurse ensure is available at the bedside?
A. Padded tongue blades
B. Soft wrist restraints
C. An oral airway
D. Suction equipment and oxygen
Correct Answer: D
Rationale: Maintaining a patent airway and providing oxygen are the highest priorities
during and after a seizure. Suction equipment must be ready to clear secretions or vomitus
to prevent aspiration. The nurse should also ensure that the side rails are padded to protect
the patient from injury. Padded tongue blades should never be used as they can cause
dental damage or airway obstruction. These safety precautions create a controlled
environment for a patient at risk for seizure activity.
3. A nurse is assessing a patient with a spinal cord injury at the T6 level who reports a severe,
pounding headache. The nurse notes the patient is diaphoretic and has a blood pressure of
190/100 mmHg. What is the priority nursing action?
A. Administer an analgesic for the headache
,B. Lower the head of the bed to a flat position
C. Check the patient for bladder distention
D. Assess the patient’s pupillary response
Correct Answer: C
Rationale: These symptoms are classic indicators of autonomic dysreflexia, a life-
threatening emergency in spinal cord injuries. The most common cause is a noxious
stimulus, such as a distended bladder or fecal impaction. The nurse should immediately sit
the patient upright to help lower the blood pressure. After sitting the patient up, the nurse
must quickly identify and remove the triggering stimulus. Failure to treat this condition
promptly can result in a stroke or seizure.
4. A patient is diagnosed with Parkinson’s disease. Which of the following clinical
manifestations should the nurse expect to observe?
A. Spasticity and hyperreflexia
B. Bradykinesia and mask-like facial expression
C. Ascending paralysis and loss of sensation
D. Extreme muscle weakness and ptosis
Correct Answer: B
Rationale: Parkinson’s disease is characterized by a triad of symptoms including tremors,
rigidity, and bradykinesia. A mask-like facial expression is a common sign of the motor
slowing associated with the disease. Patients often exhibit a shuffling gait and difficulty
initiating movements. These symptoms result from a deficiency of dopamine in the basal
ganglia. The nurse focuses on improving mobility and safety during the progression of the
illness.
5. A nurse is evaluating a patient with Chronic Kidney Disease (CKD) for signs of fluid volume
overload. Which of the following findings is most indicative of this condition?
A. Flattened neck veins
B. Increased urine output
C. Crackles in the lungs on auscultation
D. Weight loss of 2 pounds in 24 hours
Correct Answer: C
Rationale: Fluid volume overload in CKD patients often leads to pulmonary edema, which
manifests as crackles. The kidneys’ inability to excrete excess water and sodium results in
systemic fluid accumulation. The nurse should also look for peripheral edema and
distended jugular veins. Frequent weight checks are the most accurate way to monitor fluid
, status changes. Interventions typically include fluid restriction and the administration of
diuretics if the kidneys are still functional.
6. Which laboratory value should the nurse monitor most closely for a patient receiving
hemodialysis?
A. Serum potassium levels
B. Serum glucose levels
C. Hemoglobin A1c
D. White blood cell count
Correct Answer: A
Rationale: Hyperkalemia is a significant risk for patients with renal failure and can cause
life-threatening cardiac dysrhythmias. Hemodialysis is used to remove excess potassium
that the kidneys can no longer filter. The nurse must monitor electrolyte levels before and
after dialysis treatments. Dietary education regarding low-potassium foods is a vital
component of patient care. Significant elevations in potassium require immediate medical
intervention to stabilize the heart.
7. A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to low
intermittent suction. What is the primary rationale for this intervention?
A. To decrease pancreatic enzyme stimulation
B. To prevent the development of a paralytic ileus
C. To provide a route for nutritional support
D. To drain infected fluid from the pancreas
Correct Answer: A
Rationale: The primary goal of NPO status and NG suction in acute pancreatitis is to rest
the pancreas. By minimizing gastric acid secretion, the stimulation of pancreatic enzymes is
significantly reduced. This helps decrease the autodigestion of the pancreas and alleviates
severe abdominal pain. The nurse must provide meticulous oral care while the patient is
NPO. Fluid and electrolyte balance must be monitored closely during this period of gastric
decompression.
8. A nurse is caring for a patient with cirrhosis who has developed ascites. Which of the
following medications should the nurse anticipate administering?
A. Lactulose
B. Warfarin
C. Spironolactone
D. Neomycin
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient with increased intracranial pressure (ICP). Which of the
following nursing interventions is appropriate to help decrease ICP?
A. Keep the head of the bed elevated at 30 to 45 degrees
B. Place the patient in the Trendelenburg position
C. Encourage the patient to perform isometric exercises
D. Perform vigorous suctioning every hour
Correct Answer: A
Rationale: Elevating the head of the bed to 30 to 45 degrees promotes venous drainage
from the brain. This intervention is a standard practice to reduce intracranial pressure in
neurological patients. The nurse must also ensure the patient’s head remains in a neutral,
midline position. Avoiding hip flexion is equally important to prevent increases in intra-
abdominal pressure. Consistent monitoring of the patient’s neurological status is required
to evaluate the effectiveness of this positioning.
2. A patient with a history of seizures is admitted to the medical-surgical unit. Which of the
following items should the nurse ensure is available at the bedside?
A. Padded tongue blades
B. Soft wrist restraints
C. An oral airway
D. Suction equipment and oxygen
Correct Answer: D
Rationale: Maintaining a patent airway and providing oxygen are the highest priorities
during and after a seizure. Suction equipment must be ready to clear secretions or vomitus
to prevent aspiration. The nurse should also ensure that the side rails are padded to protect
the patient from injury. Padded tongue blades should never be used as they can cause
dental damage or airway obstruction. These safety precautions create a controlled
environment for a patient at risk for seizure activity.
3. A nurse is assessing a patient with a spinal cord injury at the T6 level who reports a severe,
pounding headache. The nurse notes the patient is diaphoretic and has a blood pressure of
190/100 mmHg. What is the priority nursing action?
A. Administer an analgesic for the headache
,B. Lower the head of the bed to a flat position
C. Check the patient for bladder distention
D. Assess the patient’s pupillary response
Correct Answer: C
Rationale: These symptoms are classic indicators of autonomic dysreflexia, a life-
threatening emergency in spinal cord injuries. The most common cause is a noxious
stimulus, such as a distended bladder or fecal impaction. The nurse should immediately sit
the patient upright to help lower the blood pressure. After sitting the patient up, the nurse
must quickly identify and remove the triggering stimulus. Failure to treat this condition
promptly can result in a stroke or seizure.
4. A patient is diagnosed with Parkinson’s disease. Which of the following clinical
manifestations should the nurse expect to observe?
A. Spasticity and hyperreflexia
B. Bradykinesia and mask-like facial expression
C. Ascending paralysis and loss of sensation
D. Extreme muscle weakness and ptosis
Correct Answer: B
Rationale: Parkinson’s disease is characterized by a triad of symptoms including tremors,
rigidity, and bradykinesia. A mask-like facial expression is a common sign of the motor
slowing associated with the disease. Patients often exhibit a shuffling gait and difficulty
initiating movements. These symptoms result from a deficiency of dopamine in the basal
ganglia. The nurse focuses on improving mobility and safety during the progression of the
illness.
5. A nurse is evaluating a patient with Chronic Kidney Disease (CKD) for signs of fluid volume
overload. Which of the following findings is most indicative of this condition?
A. Flattened neck veins
B. Increased urine output
C. Crackles in the lungs on auscultation
D. Weight loss of 2 pounds in 24 hours
Correct Answer: C
Rationale: Fluid volume overload in CKD patients often leads to pulmonary edema, which
manifests as crackles. The kidneys’ inability to excrete excess water and sodium results in
systemic fluid accumulation. The nurse should also look for peripheral edema and
distended jugular veins. Frequent weight checks are the most accurate way to monitor fluid
, status changes. Interventions typically include fluid restriction and the administration of
diuretics if the kidneys are still functional.
6. Which laboratory value should the nurse monitor most closely for a patient receiving
hemodialysis?
A. Serum potassium levels
B. Serum glucose levels
C. Hemoglobin A1c
D. White blood cell count
Correct Answer: A
Rationale: Hyperkalemia is a significant risk for patients with renal failure and can cause
life-threatening cardiac dysrhythmias. Hemodialysis is used to remove excess potassium
that the kidneys can no longer filter. The nurse must monitor electrolyte levels before and
after dialysis treatments. Dietary education regarding low-potassium foods is a vital
component of patient care. Significant elevations in potassium require immediate medical
intervention to stabilize the heart.
7. A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to low
intermittent suction. What is the primary rationale for this intervention?
A. To decrease pancreatic enzyme stimulation
B. To prevent the development of a paralytic ileus
C. To provide a route for nutritional support
D. To drain infected fluid from the pancreas
Correct Answer: A
Rationale: The primary goal of NPO status and NG suction in acute pancreatitis is to rest
the pancreas. By minimizing gastric acid secretion, the stimulation of pancreatic enzymes is
significantly reduced. This helps decrease the autodigestion of the pancreas and alleviates
severe abdominal pain. The nurse must provide meticulous oral care while the patient is
NPO. Fluid and electrolyte balance must be monitored closely during this period of gastric
decompression.
8. A nurse is caring for a patient with cirrhosis who has developed ascites. Which of the
following medications should the nurse anticipate administering?
A. Lactulose
B. Warfarin
C. Spironolactone
D. Neomycin
