NURS 201 Quiz 3 V3 | NURS 201 Medical
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 3) | West Coast
University
1. A nurse is caring for a client with COPD who is receiving oxygen therapy. Which finding
best indicates that the oxygen therapy is effective for this specific client?
A. Oxygen saturation (SpO2) of 90%
B. Respiratory rate of 24 breaths per minute
C. Arterial blood gas showing a PaCO2 of 55 mmHg
D. Clear breath sounds upon auscultation
Answer: A
Rationale: For clients with COPD, the therapeutic goal for oxygen saturation is typically
between 88% and 92% to maintain the hypoxic drive. A saturation of 90% indicates that
the oxygen delivery is sufficient without causing respiratory depression from oxygen-
induced hypercapnia. The nurse must monitor the client closely for signs of oxygen toxicity
while ensuring adequate tissue perfusion.
2. A client with type 1 diabetes mellitus is found confused and diaphoretic. What is the
priority nursing action?
A. Check the client’s capillary blood glucose level
,B. Administer 15 grams of fast-acting carbohydrates
C. Call the healthcare provider immediately
D. Administer the scheduled dose of regular insulin
Answer: A
Rationale: Confusion and diaphoresis are hallmark signs of hypoglycemia, but the nurse
must first confirm the blood glucose level before intervention. Following the assessment,
the nurse should implement the ‘Rule of 15’ if the glucose is below 70 mg/dL. Safety is the
priority, as untreated hypoglycemia can lead to seizures or loss of consciousness.
3. The nurse is providing discharge instructions to a client with heart failure. Which
instruction is most critical for the nurse to include?
A. Maintain a high-protein diet for muscle strength
B. Limit physical activity to bedrest only
C. Weigh yourself daily and report a gain of 3 lbs in 2 days
D. Increase fluid intake to at least 3 liters per day
Answer: C
Rationale: Daily weights are the most sensitive indicator of fluid volume status in clients
with heart failure. A rapid weight gain suggests fluid retention and worsening heart failure,
requiring immediate medical adjustment. Teaching the client to recognize these changes is
essential for preventing hospital readmission.
, 4. A client is scheduled for an elective surgery. Who is legally responsible for obtaining the
informed consent?
A. The surgeon performing the procedure
B. The nurse manager of the unit
C. The anesthesiologist
D. The preoperative nurse
Answer: A
Rationale: The surgeon has the legal responsibility to explain the risks, benefits, and
alternatives of the procedure to the client. The nurse’s role is to witness the client’s
signature and verify that the client understands the information provided. If the client has
questions about the surgery itself, the nurse must contact the surgeon to return and
provide further clarification.
5. A client’s potassium level is 3.2 mEq/L. Which clinical manifestation should the nurse
expect to assess?
A. Hyperactive bowel sounds and diarrhea
B. Tall, peaked T-waves on the EKG
C. Muscle weakness and leg cramps
D. Hyperreflexia and positive Chvostek’s sign
Answer: C
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 3) | West Coast
University
1. A nurse is caring for a client with COPD who is receiving oxygen therapy. Which finding
best indicates that the oxygen therapy is effective for this specific client?
A. Oxygen saturation (SpO2) of 90%
B. Respiratory rate of 24 breaths per minute
C. Arterial blood gas showing a PaCO2 of 55 mmHg
D. Clear breath sounds upon auscultation
Answer: A
Rationale: For clients with COPD, the therapeutic goal for oxygen saturation is typically
between 88% and 92% to maintain the hypoxic drive. A saturation of 90% indicates that
the oxygen delivery is sufficient without causing respiratory depression from oxygen-
induced hypercapnia. The nurse must monitor the client closely for signs of oxygen toxicity
while ensuring adequate tissue perfusion.
2. A client with type 1 diabetes mellitus is found confused and diaphoretic. What is the
priority nursing action?
A. Check the client’s capillary blood glucose level
,B. Administer 15 grams of fast-acting carbohydrates
C. Call the healthcare provider immediately
D. Administer the scheduled dose of regular insulin
Answer: A
Rationale: Confusion and diaphoresis are hallmark signs of hypoglycemia, but the nurse
must first confirm the blood glucose level before intervention. Following the assessment,
the nurse should implement the ‘Rule of 15’ if the glucose is below 70 mg/dL. Safety is the
priority, as untreated hypoglycemia can lead to seizures or loss of consciousness.
3. The nurse is providing discharge instructions to a client with heart failure. Which
instruction is most critical for the nurse to include?
A. Maintain a high-protein diet for muscle strength
B. Limit physical activity to bedrest only
C. Weigh yourself daily and report a gain of 3 lbs in 2 days
D. Increase fluid intake to at least 3 liters per day
Answer: C
Rationale: Daily weights are the most sensitive indicator of fluid volume status in clients
with heart failure. A rapid weight gain suggests fluid retention and worsening heart failure,
requiring immediate medical adjustment. Teaching the client to recognize these changes is
essential for preventing hospital readmission.
, 4. A client is scheduled for an elective surgery. Who is legally responsible for obtaining the
informed consent?
A. The surgeon performing the procedure
B. The nurse manager of the unit
C. The anesthesiologist
D. The preoperative nurse
Answer: A
Rationale: The surgeon has the legal responsibility to explain the risks, benefits, and
alternatives of the procedure to the client. The nurse’s role is to witness the client’s
signature and verify that the client understands the information provided. If the client has
questions about the surgery itself, the nurse must contact the surgeon to return and
provide further clarification.
5. A client’s potassium level is 3.2 mEq/L. Which clinical manifestation should the nurse
expect to assess?
A. Hyperactive bowel sounds and diarrhea
B. Tall, peaked T-waves on the EKG
C. Muscle weakness and leg cramps
D. Hyperreflexia and positive Chvostek’s sign
Answer: C
