Exam 1: NUR 201 Medical-Surgical Nursing I
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1. A 71-year-old male is admitted with dehydration secondary to vomiting and diarrhea for 3
days. His laboratory results reveal a serum sodium of 152 mEq/L. Which clinical manifestation
would the nurse expect to find during the physical assessment?
A. Bounding peripheral pulses and moist mucous membranes
B. Dry mucous membranes and decreased skin turgor
C. Muscle twitching and paresthesias
D. Flattened T-waves and prominent U-waves on ECG
Correct Answer: B
Rationale: This patient's presentation is consistent with hypernatremia (serum sodium >145
mEq/L), which occurs from dehydration and excessive water loss through vomiting and diarrhea.
Dry mucous membranes and decreased skin turgor are hallmark clinical manifestations of
hypernatremia resulting from intracellular fluid shifting out of cells to compensate for the
hyperosmolar extracellular environment. The priority nursing action is to administer IV fluids
such as 0.9% NS or hypotonic fluids while closely monitoring neurological status, as severe
hypernatremia can progress to seizures and coma.
Q2. A nurse is caring for a postoperative patient on postoperative day 2 who has a temperature
of 100.8°F, decreased breath sounds in the left lower lobe, and mild tachycardia. The patient has
been reluctant to use the incentive spirometer. Which complication is the nurse most concerned
about?
A. Surgical site infection
B. Deep vein thrombosis
C. Pulmonary embolism
D. Atelectasis
Correct Answer: D
,Rationale: In post-operative care, atelectasis is the most common cause of low-grade fever
within the first 24-48 hours, resulting from collapsed alveoli due to decreased lung expansion
from anesthesia, pain, immobility, and opioid use. This patient's presentation of low-grade fever,
decreased breath sounds, and reluctance to use incentive spirometry is classic for atelectasis.
The priority nursing action is to encourage incentive spirometry (10-15 breaths per hour while
awake), promote early ambulation, and ensure adequate pain control to facilitate deep
breathing and coughing.
Q3. A nurse is preparing a 72-year-old patient for an elective total knee replacement scheduled
for tomorrow morning. Which action by the nurse demonstrates proper understanding of the
informed consent process?
A. The nurse witnesses the patient's signature after the surgeon explains the procedure, risks,
and alternatives
B. The nurse obtains the informed consent from the patient after explaining the surgical
procedure
C. The nurse asks the patient to sign the consent form without the surgeon present
D. The nurse explains the risks and benefits of anesthesia to the patient
Correct Answer: A
Rationale: Correct because informed consent is a legally required process that must be
obtained by the physician (surgeon), and the nurse's role is to witness the patient's signature
and verify the patient's understanding through teach-back methods. The nurse ensures there is
no coercion and that the patient has had adequate opportunity to ask questions before signing.
It is outside the nurse's scope of practice to obtain informed consent for surgical procedures, as
this responsibility belongs to the operating surgeon who will perform the procedure.
Q4. A patient with chronic kidney disease presents with perioral paresthesias, muscle cramps,
and a positive Chvostek's sign. The nurse reviews the laboratory results and anticipates which
electrolyte imbalance?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypernatremia
Correct Answer: C
, Rationale: This patient's presentation is consistent with hypocalcemia (calcium <8.5 mg/dL), as
evidenced by the positive Chvostek's sign (facial muscle twitching when tapping the facial
nerve), perioral paresthesias, and muscle cramps. Chronic kidney disease is a primary cause of
hypocalcemia because impaired renal function reduces the activation of vitamin D, which is
essential for calcium absorption. The priority nursing interventions include administering IV
calcium gluconate for severe hypocalcemia, implementing seizure precautions, and monitoring
for signs of laryngospasm and tetany.
Q5. A patient returns to the PACU following an abdominal hysterectomy. The nurse notes that
the patient is difficult to arouse, has a respiratory rate of 8 breaths/minute, and an oxygen
saturation of 88%. Which is the priority nursing action?
A. Administer ondansetron for nausea
B. Check the surgical dressing for bleeding
C. Assess the patient's pain level
D. Apply supplemental oxygen and stimulate respirations
Correct Answer: D
Rationale: The priority nursing action is to address the patient's compromised airway and
breathing, as the ABCs (airway, breathing, circulation) always take precedence in postoperative
care. This patient's respiratory rate of 8 breaths/minute and oxygen saturation of 88% indicate
significant respiratory depression, likely secondary to opioid analgesia administered during or
after surgery. The nurse must immediately apply supplemental oxygen, stimulate respirations,
prepare to administer naloxone if ordered, and remain at the bedside while notifying the
anesthesia provider.
Q6. A nurse is caring for a patient on postoperative day 5 after colon resection. The patient
reports sudden onset of dyspnea, chest pain that worsens with inspiration, and mild
hemoptysis. Vital signs show tachycardia (HR 118) and tachypnea (RR 28). Which complication
should the nurse suspect?
A. Pulmonary embolism
B. Pneumonia
C. Atelectasis
D. Surgical site infection
Correct Answer: A
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1. A 71-year-old male is admitted with dehydration secondary to vomiting and diarrhea for 3
days. His laboratory results reveal a serum sodium of 152 mEq/L. Which clinical manifestation
would the nurse expect to find during the physical assessment?
A. Bounding peripheral pulses and moist mucous membranes
B. Dry mucous membranes and decreased skin turgor
C. Muscle twitching and paresthesias
D. Flattened T-waves and prominent U-waves on ECG
Correct Answer: B
Rationale: This patient's presentation is consistent with hypernatremia (serum sodium >145
mEq/L), which occurs from dehydration and excessive water loss through vomiting and diarrhea.
Dry mucous membranes and decreased skin turgor are hallmark clinical manifestations of
hypernatremia resulting from intracellular fluid shifting out of cells to compensate for the
hyperosmolar extracellular environment. The priority nursing action is to administer IV fluids
such as 0.9% NS or hypotonic fluids while closely monitoring neurological status, as severe
hypernatremia can progress to seizures and coma.
Q2. A nurse is caring for a postoperative patient on postoperative day 2 who has a temperature
of 100.8°F, decreased breath sounds in the left lower lobe, and mild tachycardia. The patient has
been reluctant to use the incentive spirometer. Which complication is the nurse most concerned
about?
A. Surgical site infection
B. Deep vein thrombosis
C. Pulmonary embolism
D. Atelectasis
Correct Answer: D
,Rationale: In post-operative care, atelectasis is the most common cause of low-grade fever
within the first 24-48 hours, resulting from collapsed alveoli due to decreased lung expansion
from anesthesia, pain, immobility, and opioid use. This patient's presentation of low-grade fever,
decreased breath sounds, and reluctance to use incentive spirometry is classic for atelectasis.
The priority nursing action is to encourage incentive spirometry (10-15 breaths per hour while
awake), promote early ambulation, and ensure adequate pain control to facilitate deep
breathing and coughing.
Q3. A nurse is preparing a 72-year-old patient for an elective total knee replacement scheduled
for tomorrow morning. Which action by the nurse demonstrates proper understanding of the
informed consent process?
A. The nurse witnesses the patient's signature after the surgeon explains the procedure, risks,
and alternatives
B. The nurse obtains the informed consent from the patient after explaining the surgical
procedure
C. The nurse asks the patient to sign the consent form without the surgeon present
D. The nurse explains the risks and benefits of anesthesia to the patient
Correct Answer: A
Rationale: Correct because informed consent is a legally required process that must be
obtained by the physician (surgeon), and the nurse's role is to witness the patient's signature
and verify the patient's understanding through teach-back methods. The nurse ensures there is
no coercion and that the patient has had adequate opportunity to ask questions before signing.
It is outside the nurse's scope of practice to obtain informed consent for surgical procedures, as
this responsibility belongs to the operating surgeon who will perform the procedure.
Q4. A patient with chronic kidney disease presents with perioral paresthesias, muscle cramps,
and a positive Chvostek's sign. The nurse reviews the laboratory results and anticipates which
electrolyte imbalance?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypernatremia
Correct Answer: C
, Rationale: This patient's presentation is consistent with hypocalcemia (calcium <8.5 mg/dL), as
evidenced by the positive Chvostek's sign (facial muscle twitching when tapping the facial
nerve), perioral paresthesias, and muscle cramps. Chronic kidney disease is a primary cause of
hypocalcemia because impaired renal function reduces the activation of vitamin D, which is
essential for calcium absorption. The priority nursing interventions include administering IV
calcium gluconate for severe hypocalcemia, implementing seizure precautions, and monitoring
for signs of laryngospasm and tetany.
Q5. A patient returns to the PACU following an abdominal hysterectomy. The nurse notes that
the patient is difficult to arouse, has a respiratory rate of 8 breaths/minute, and an oxygen
saturation of 88%. Which is the priority nursing action?
A. Administer ondansetron for nausea
B. Check the surgical dressing for bleeding
C. Assess the patient's pain level
D. Apply supplemental oxygen and stimulate respirations
Correct Answer: D
Rationale: The priority nursing action is to address the patient's compromised airway and
breathing, as the ABCs (airway, breathing, circulation) always take precedence in postoperative
care. This patient's respiratory rate of 8 breaths/minute and oxygen saturation of 88% indicate
significant respiratory depression, likely secondary to opioid analgesia administered during or
after surgery. The nurse must immediately apply supplemental oxygen, stimulate respirations,
prepare to administer naloxone if ordered, and remain at the bedside while notifying the
anesthesia provider.
Q6. A nurse is caring for a patient on postoperative day 5 after colon resection. The patient
reports sudden onset of dyspnea, chest pain that worsens with inspiration, and mild
hemoptysis. Vital signs show tachycardia (HR 118) and tachypnea (RR 28). Which complication
should the nurse suspect?
A. Pulmonary embolism
B. Pneumonia
C. Atelectasis
D. Surgical site infection
Correct Answer: A
