NRSG 201 Final Exam V3 | NRSG 201 Med
Surg 1 | Actual Q&A with Rationale
(NRSG201 Final Exam) | Ivy Tech
1. A nurse is caring for a patient who is 4 hours postoperative following abdominal surgery.
The patient reports sudden shortness of breath and chest pain. Which of the following
actions should the nurse take first?
A. Check the patient’s surgical dressing for hemorrhage.
B. Administer the prescribed PRN analgesic.
C. Request a stat chest X-ray from the provider.
D. Elevate the head of the bed to a high-Fowler’s position.
Correct Answer: D
Elevating the head of the bed is the priority action to facilitate maximum lung expansion
and alleviate respiratory distress. This action aligns with the airway-breathing-circulation
(ABC) priority framework. Following this, the nurse should assess oxygen saturation and
notify the rapid response team if necessary.
2. A nurse is reviewing the laboratory results of a patient receiving a loop diuretic for heart
failure. Which of the following results should the nurse report to the provider immediately?
A. Sodium 136 mEq/L
B. Magnesium 1.9 mEq/L
,C. Calcium 9.2 mg/dL
D. Potassium 2.8 mEq/L
Correct Answer: D
A potassium level of 2.8 mEq/L indicates severe hypokalemia, which can lead to life-
threatening cardiac arrhythmias. Loop diuretics are potassium-wasting and require close
monitoring of electrolyte levels. The nurse must report this value immediately to obtain an
order for potassium supplementation.
3. A patient with Type 1 Diabetes Mellitus is found unresponsive and clammy. What should
be the nurse’s first intervention?
A. Administer 10 units of regular insulin subcutaneously.
B. Administer Glucagon IM or IV glucose as per protocol.
C. Obtain a venous blood sample for glucose testing.
D. Provide 4 ounces of orange juice orally.
Correct Answer: B
An unresponsive patient who is clammy most likely suffers from severe hypoglycemia and
cannot safely swallow oral fluids. Administering glucagon or IV dextrose is the emergency
standard of care to rapidly raise blood glucose levels. The nurse must prioritize immediate
glucose replacement over further diagnostic testing in an emergency.
, 4. A nurse is preparing to administer a blood transfusion. Which of the following is the most
critical safety step before starting the infusion?
A. Warming the blood to room temperature for 30 minutes.
B. Verifying the patient’s identity and blood unit with another RN.
C. Assessing the patient’s temperature only after the first hour.
D. Using a 24-gauge IV catheter for the infusion.
Correct Answer: B
Dual verification of the blood product and patient identity by two licensed nurses is
required to prevent life-threatening hemolytic reactions. This process involves checking
the donor’s blood group, Rh type, and the recipient’s unique identification number. This
safety check is the most critical nursing intervention in the transfusion process.
5. Which clinical manifestation should a nurse expect to find in a patient diagnosed with
right-sided heart failure?
A. Crackles in the lung bases
B. Pulmonary edema
C. Dependent peripheral edema and jugular vein distention.
D. Shortness of breath with exertion
Correct Answer: C
Surg 1 | Actual Q&A with Rationale
(NRSG201 Final Exam) | Ivy Tech
1. A nurse is caring for a patient who is 4 hours postoperative following abdominal surgery.
The patient reports sudden shortness of breath and chest pain. Which of the following
actions should the nurse take first?
A. Check the patient’s surgical dressing for hemorrhage.
B. Administer the prescribed PRN analgesic.
C. Request a stat chest X-ray from the provider.
D. Elevate the head of the bed to a high-Fowler’s position.
Correct Answer: D
Elevating the head of the bed is the priority action to facilitate maximum lung expansion
and alleviate respiratory distress. This action aligns with the airway-breathing-circulation
(ABC) priority framework. Following this, the nurse should assess oxygen saturation and
notify the rapid response team if necessary.
2. A nurse is reviewing the laboratory results of a patient receiving a loop diuretic for heart
failure. Which of the following results should the nurse report to the provider immediately?
A. Sodium 136 mEq/L
B. Magnesium 1.9 mEq/L
,C. Calcium 9.2 mg/dL
D. Potassium 2.8 mEq/L
Correct Answer: D
A potassium level of 2.8 mEq/L indicates severe hypokalemia, which can lead to life-
threatening cardiac arrhythmias. Loop diuretics are potassium-wasting and require close
monitoring of electrolyte levels. The nurse must report this value immediately to obtain an
order for potassium supplementation.
3. A patient with Type 1 Diabetes Mellitus is found unresponsive and clammy. What should
be the nurse’s first intervention?
A. Administer 10 units of regular insulin subcutaneously.
B. Administer Glucagon IM or IV glucose as per protocol.
C. Obtain a venous blood sample for glucose testing.
D. Provide 4 ounces of orange juice orally.
Correct Answer: B
An unresponsive patient who is clammy most likely suffers from severe hypoglycemia and
cannot safely swallow oral fluids. Administering glucagon or IV dextrose is the emergency
standard of care to rapidly raise blood glucose levels. The nurse must prioritize immediate
glucose replacement over further diagnostic testing in an emergency.
, 4. A nurse is preparing to administer a blood transfusion. Which of the following is the most
critical safety step before starting the infusion?
A. Warming the blood to room temperature for 30 minutes.
B. Verifying the patient’s identity and blood unit with another RN.
C. Assessing the patient’s temperature only after the first hour.
D. Using a 24-gauge IV catheter for the infusion.
Correct Answer: B
Dual verification of the blood product and patient identity by two licensed nurses is
required to prevent life-threatening hemolytic reactions. This process involves checking
the donor’s blood group, Rh type, and the recipient’s unique identification number. This
safety check is the most critical nursing intervention in the transfusion process.
5. Which clinical manifestation should a nurse expect to find in a patient diagnosed with
right-sided heart failure?
A. Crackles in the lung bases
B. Pulmonary edema
C. Dependent peripheral edema and jugular vein distention.
D. Shortness of breath with exertion
Correct Answer: C
