NUR 170 Final Exam V2 | NUR 170
Concepts of Medical-Surgical Nursing |
Q&A with Rationale (NUR170 Final Exam) |
Galen College of Nursing
1. A nurse is caring for a patient with a serum potassium level of 6.5 mEq/L. Which of the
following priority nursing interventions should be implemented?
A. Administer an oral potassium supplement.
B. Prepare to administer intravenous calcium gluconate.
C. Encourage the intake of orange juice and bananas.
D. Assess the patient for a positive Trousseau sign.
Answer: B
Rationale: Hyperkalemia is defined as a serum potassium level exceeding 5.0 mEq/L and
poses a significant risk for cardiac dysrhythmias. Intravenous calcium gluconate is
administered to stabilize the myocardial cell membrane and prevent life-threatening
arrhythmias. The nurse must prioritize cardiac protection before utilizing methods to
lower the potassium level itself.
2. A patient is admitted with a pH of 7.25, a PaCO2 of 50 mmHg, and a HCO3 of 24 mEq/L.
Which acid-base imbalance is the patient experiencing?
A. Metabolic Acidosis
,B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The patient’s pH is below the normal range of 7.35 to 7.45, indicating acidosis.
The PaCO2 is elevated above the normal range of 35 to 45 mmHg, which points to a
respiratory cause. Since the bicarbonate level is within the normal range, the imbalance is
categorized as uncompensated respiratory acidosis.
3. During the preoperative assessment, a patient reports an allergy to avocados and bananas.
Which action should the nurse take next?
A. Document the allergy and continue with the assessment.
B. Notify the surgical team of a possible latex allergy.
C. Request a prescription for an antihistamine.
D. Tell the patient that these allergies are irrelevant to surgery.
Answer: B
Rationale: There is a high correlation between allergies to certain fruits, such as bananas,
avocados, and kiwi, and latex sensitivity. The nurse must alert the surgical team to ensure a
latex-free environment to prevent an anaphylactic reaction during the procedure. This
cross-reactivity is a critical component of a thorough preoperative safety screening.
, 4. A nurse is monitoring a patient postoperatively who had abdominal surgery. The patient
suddenly reports a popping sensation and the nurse observes a loop of bowel protruding
through the incision. What is the immediate priority action?
A. Attempt to push the bowel back into the abdominal cavity.
B. Place the patient in a high-Fowler’s position.
C. Apply a sterile, non-adherent dressing soaked in warm saline.
D. Check the patient’s blood pressure and pulse immediately.
Answer: C
Rationale: The protrusion of internal organs through a wound is known as evisceration
and is a medical emergency. The nurse must cover the exposed bowel with sterile, saline-
soaked dressings to keep the tissue moist and prevent infection. It is crucial not to attempt
reinsertion and to keep the patient in a low-Fowler’s position with knees slightly flexed to
reduce abdominal tension.
5. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. What is the
nurse’s first action?
A. Administer 15 grams of simple carbohydrates orally.
B. Contact the healthcare provider for an insulin order.
C. Administer intramuscular glucagon as prescribed.
D. Perform a bedside capillary blood glucose check.
Concepts of Medical-Surgical Nursing |
Q&A with Rationale (NUR170 Final Exam) |
Galen College of Nursing
1. A nurse is caring for a patient with a serum potassium level of 6.5 mEq/L. Which of the
following priority nursing interventions should be implemented?
A. Administer an oral potassium supplement.
B. Prepare to administer intravenous calcium gluconate.
C. Encourage the intake of orange juice and bananas.
D. Assess the patient for a positive Trousseau sign.
Answer: B
Rationale: Hyperkalemia is defined as a serum potassium level exceeding 5.0 mEq/L and
poses a significant risk for cardiac dysrhythmias. Intravenous calcium gluconate is
administered to stabilize the myocardial cell membrane and prevent life-threatening
arrhythmias. The nurse must prioritize cardiac protection before utilizing methods to
lower the potassium level itself.
2. A patient is admitted with a pH of 7.25, a PaCO2 of 50 mmHg, and a HCO3 of 24 mEq/L.
Which acid-base imbalance is the patient experiencing?
A. Metabolic Acidosis
,B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The patient’s pH is below the normal range of 7.35 to 7.45, indicating acidosis.
The PaCO2 is elevated above the normal range of 35 to 45 mmHg, which points to a
respiratory cause. Since the bicarbonate level is within the normal range, the imbalance is
categorized as uncompensated respiratory acidosis.
3. During the preoperative assessment, a patient reports an allergy to avocados and bananas.
Which action should the nurse take next?
A. Document the allergy and continue with the assessment.
B. Notify the surgical team of a possible latex allergy.
C. Request a prescription for an antihistamine.
D. Tell the patient that these allergies are irrelevant to surgery.
Answer: B
Rationale: There is a high correlation between allergies to certain fruits, such as bananas,
avocados, and kiwi, and latex sensitivity. The nurse must alert the surgical team to ensure a
latex-free environment to prevent an anaphylactic reaction during the procedure. This
cross-reactivity is a critical component of a thorough preoperative safety screening.
, 4. A nurse is monitoring a patient postoperatively who had abdominal surgery. The patient
suddenly reports a popping sensation and the nurse observes a loop of bowel protruding
through the incision. What is the immediate priority action?
A. Attempt to push the bowel back into the abdominal cavity.
B. Place the patient in a high-Fowler’s position.
C. Apply a sterile, non-adherent dressing soaked in warm saline.
D. Check the patient’s blood pressure and pulse immediately.
Answer: C
Rationale: The protrusion of internal organs through a wound is known as evisceration
and is a medical emergency. The nurse must cover the exposed bowel with sterile, saline-
soaked dressings to keep the tissue moist and prevent infection. It is crucial not to attempt
reinsertion and to keep the patient in a low-Fowler’s position with knees slightly flexed to
reduce abdominal tension.
5. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. What is the
nurse’s first action?
A. Administer 15 grams of simple carbohydrates orally.
B. Contact the healthcare provider for an insulin order.
C. Administer intramuscular glucagon as prescribed.
D. Perform a bedside capillary blood glucose check.
