NUR 201 Exam 3 Latest 2026/2027
Exam Fortis Institute 100% Verified
Medical Surgical Nursing I Questions
with Rationale (All Chapters Covered)
UPDATED
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will
the nurse implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees.
ANS: C
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to
suppress the gag and cough reflexes during bronchoscopy, the nurse should monitor for the return of
these reflexes before allowing the patient to take oral fluids or food. The patient does not need to be on
bed rest, and the head of the bed does not need to be in the high-Fowler's position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. Which
sounds would the nurse most likely hear on auscultation?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous,
high-pitched sounds of short duration heard on inspiration. Course crackles are a series of long-duration,
discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical
sounds on inspiration and expiration.
The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to
88% while ambulating. What is the priority action of the nurse?
a. Notify the health care provider.
,b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity.
ANS: B
The drop in SpO2to 85% indicates that the patient is hypoxemic and needs supplemental O2when
exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient
indicates teaching was effective? a. "I should use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
c. "I will inhale deeply and blow out hard during the test."
d. "My blood pressure and pulse will be checked every 15 minutes."
ANS: C
For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other
actions are not needed. The administration of inhaled bronchodilators should be avoided 6 hours before
the procedure.
The nurse observes a student who is listening to a patient's lungs. Which action by the student indicates
a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth.
ANS: B
Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At
each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During
chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the
mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the
chest, unless the patient is in respiratory distress or will tire easily.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for
increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for
discharge, which action by the nurse will be most effective in improving compliance with discharge
teaching?
a. Have the patient repeat the instructions immediately after teaching.
b. Accomplish the patient teaching just before the scheduled discharge.
c. Arrange for the patient’s caregiver to be present during the teaching.
,d. Start giving the patient discharge teaching during the admission process.
ANS: C
Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's
caregiver present will increase the likelihood that discharge instructions will be followed. Having the
patient repeat the instructions will indicate that the information is understood at the time, but it does
not guarantee retention of the information. Because the patient is likely to be distracted just before
discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be
anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge
should be postponed.
A patient admitted to the emergency department with a sudden onset of shortness of breath is
diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic
testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to expect to inspire deeply and exhale forcefully.
ANS: B
Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli
and contrast media may be given IV. Bronchoscopy is used to detect changes in the bronchial tree, not
to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure.
Positron emission tomography scans are most useful in determining the presence of cancer and a
radioactive glucose preparation is used. For spirometry, the patient is asked to inhale deeply and exhale
as long, hard, and fast as possible.
The nurse admits a patient who has a diagnosis of acute asthma. Which statement indicates that the
patient may need teaching regarding medication use?
a. "I have not had any acute asthma attacks during the past year."
b. "I became short of breath an hour before coming to the hospital."
c. "I've been taking acetaminophen every 6 hours for chest wall pain."
d. "I've been using my albuterol inhaler frequently over the last 4 days."
ANS: D
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may
be imminent and that a change in therapy may be needed. The patient should be taught to contact a
health care provider if this occurs. The other data do not indicate any need for additional teaching.
, A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take
during the initial assessment of the patient?
a. Ask the patient to lie down for complete a full physical assessment.
b. Complete the health history and check for allergies before treatment.
c. Briefly ask specific questions about this episode of respiratory distress.
d. Delay the physical assessment to first complete pulmonary function tests.
ANS: C
When a patient has severe respiratory distress, only information pertinent to the current episode is
obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health
history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning
and a focused physical assessment should be done rapidly to help determine the cause of the distress
and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the
entire admission database at this time. The initial respiratory assessment must be completed before any
diagnostic tests or interventions can be ordered.
The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How should the
nurse position the patient? a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung
bases, and expands the intercostal space so that access to the pleural space is easier. The other
positions would increase the work of breathing for the patient and make it more difficult for the health
care provider performing the thoracentesis.
A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg;
HCO3?2- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2pressure
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low
pH and low bicarbonate result indicate metabolic acidosis. Acidosis does not cause intercostal
retractions, a low oxygen saturation rate, and a decrease in venous O2pressure.
Exam Fortis Institute 100% Verified
Medical Surgical Nursing I Questions
with Rationale (All Chapters Covered)
UPDATED
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will
the nurse implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees.
ANS: C
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to
suppress the gag and cough reflexes during bronchoscopy, the nurse should monitor for the return of
these reflexes before allowing the patient to take oral fluids or food. The patient does not need to be on
bed rest, and the head of the bed does not need to be in the high-Fowler's position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. Which
sounds would the nurse most likely hear on auscultation?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous,
high-pitched sounds of short duration heard on inspiration. Course crackles are a series of long-duration,
discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical
sounds on inspiration and expiration.
The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to
88% while ambulating. What is the priority action of the nurse?
a. Notify the health care provider.
,b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity.
ANS: B
The drop in SpO2to 85% indicates that the patient is hypoxemic and needs supplemental O2when
exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient
indicates teaching was effective? a. "I should use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
c. "I will inhale deeply and blow out hard during the test."
d. "My blood pressure and pulse will be checked every 15 minutes."
ANS: C
For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other
actions are not needed. The administration of inhaled bronchodilators should be avoided 6 hours before
the procedure.
The nurse observes a student who is listening to a patient's lungs. Which action by the student indicates
a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth.
ANS: B
Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At
each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During
chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the
mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the
chest, unless the patient is in respiratory distress or will tire easily.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for
increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for
discharge, which action by the nurse will be most effective in improving compliance with discharge
teaching?
a. Have the patient repeat the instructions immediately after teaching.
b. Accomplish the patient teaching just before the scheduled discharge.
c. Arrange for the patient’s caregiver to be present during the teaching.
,d. Start giving the patient discharge teaching during the admission process.
ANS: C
Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's
caregiver present will increase the likelihood that discharge instructions will be followed. Having the
patient repeat the instructions will indicate that the information is understood at the time, but it does
not guarantee retention of the information. Because the patient is likely to be distracted just before
discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be
anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge
should be postponed.
A patient admitted to the emergency department with a sudden onset of shortness of breath is
diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic
testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to expect to inspire deeply and exhale forcefully.
ANS: B
Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli
and contrast media may be given IV. Bronchoscopy is used to detect changes in the bronchial tree, not
to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure.
Positron emission tomography scans are most useful in determining the presence of cancer and a
radioactive glucose preparation is used. For spirometry, the patient is asked to inhale deeply and exhale
as long, hard, and fast as possible.
The nurse admits a patient who has a diagnosis of acute asthma. Which statement indicates that the
patient may need teaching regarding medication use?
a. "I have not had any acute asthma attacks during the past year."
b. "I became short of breath an hour before coming to the hospital."
c. "I've been taking acetaminophen every 6 hours for chest wall pain."
d. "I've been using my albuterol inhaler frequently over the last 4 days."
ANS: D
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may
be imminent and that a change in therapy may be needed. The patient should be taught to contact a
health care provider if this occurs. The other data do not indicate any need for additional teaching.
, A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take
during the initial assessment of the patient?
a. Ask the patient to lie down for complete a full physical assessment.
b. Complete the health history and check for allergies before treatment.
c. Briefly ask specific questions about this episode of respiratory distress.
d. Delay the physical assessment to first complete pulmonary function tests.
ANS: C
When a patient has severe respiratory distress, only information pertinent to the current episode is
obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health
history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning
and a focused physical assessment should be done rapidly to help determine the cause of the distress
and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the
entire admission database at this time. The initial respiratory assessment must be completed before any
diagnostic tests or interventions can be ordered.
The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How should the
nurse position the patient? a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung
bases, and expands the intercostal space so that access to the pleural space is easier. The other
positions would increase the work of breathing for the patient and make it more difficult for the health
care provider performing the thoracentesis.
A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg;
HCO3?2- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2pressure
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low
pH and low bicarbonate result indicate metabolic acidosis. Acidosis does not cause intercostal
retractions, a low oxygen saturation rate, and a decrease in venous O2pressure.
