Exam 2: 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 72-year-old patient with dark skin is admitted with suspected liver disease. The nurse
knows that jaundice is best assessed in which location for this patient?
A. Nail beds and lips
B. Palms and soles
C. Sclera and hard palate
D. Buccal mucosa and conjunctiva
Correct Answer: C
Rationale: Correct because the sclera and hard palate are the most reliable sites for assessing
jaundice in patients with dark skin, as these areas contain less melanin and will show yellow
discoloration from elevated bilirubin more accurately. Nail beds and lips are unreliable due to
greater pigmentation variance and potential for confusion with normal skin tones. According to
evidence-based nursing assessment, the hard palate and sclera provide consistent visualization
across all skin types regardless of melanin content.
Q2: A 45-year-old male trauma patient arrives in the ICU with oozing from multiple IV sites,
petechiae, and hypotension. His platelet count is 45,000/mm³, PT is 28 seconds, and D-dimer is
elevated. Which condition is most likely, and what is the priority intervention?
A. Thrombocytopenia; administer platelet transfusion
B. Disseminated intravascular coagulation; treat underlying cause and provide supportive care
C. Hemophilia A; administer factor VIII replacement
D. Heparin-induced thrombocytopenia; discontinue all heparin
Correct Answer: B
,Rationale: Correct because this presentation of widespread bleeding, low platelets, prolonged
PT, and elevated D-dimer in a trauma patient is classic for disseminated intravascular
coagulation, a consumption coagulopathy triggered by massive tissue injury and inflammation.
The priority intervention is treating the underlying trauma while providing supportive care with
blood product replacement as needed. Thrombocytopenia alone does not explain the prolonged
PT and elevated D-dimer; hemophilia A would not present acutely in adulthood with this pattern;
and HIT requires prior heparin exposure.
Q3: A patient receiving a unit of packed red blood cells develops chills, fever of 38.5°C, and
lower back pain 15 minutes into the transfusion. What is the nurse's immediate priority action?
A. Slow the transfusion rate and administer diphenhydramine
B. Stop the transfusion immediately and maintain IV access with normal saline
C. Continue the transfusion and notify the provider at the end of the unit
D. Draw a blood culture and wait for provider orders
Correct Answer: B
Rationale: Correct because fever, chills, and lower back pain during transfusion are hallmark
signs of acute hemolytic transfusion reaction, the most dangerous type of transfusion reaction
requiring immediate cessation of the blood product. The nurse must stop the transfusion
immediately, keep the IV line open with normal saline using new tubing, assess vital signs, and
notify the provider urgently. Slowing the transfusion or continuing it risks massive hemolysis,
renal failure, and disseminated intravascular coagulation.
Q4: A patient taking furosemide and digoxin has a serum potassium of 2.9 mEq/L. The nurse
notes the patient has nausea, bradycardia, and reports seeing yellow halos around lights. Which
action is most appropriate?
A. Administer the scheduled digoxin dose and encourage potassium-rich foods
B. Hold the digoxin, notify the provider, and prepare for potassium replacement
C. Increase the furosemide dose to enhance diuresis
D. Administer IV calcium gluconate for cardiac protection
Correct Answer: B
Rationale: Correct because hypokalemia intensifies digoxin binding to the Na-K-ATPase pump,
increasing the risk of lethal toxicity even at therapeutic serum digoxin levels; the presence of
nausea, bradycardia, and visual disturbances confirms digoxin toxicity. The nurse must hold the
digoxin dose, notify the provider immediately, and initiate potassium replacement as ordered to
, reduce digoxin binding affinity. Increasing furosemide would worsen hypokalemia; calcium
gluconate is indicated for hyperkalemia, not hypokalemia with digoxin toxicity.
Q5: A patient with suspected active tuberculosis is admitted to the emergency department. Which
isolation precautions are required, and what is the essential room feature? (Select all that apply.)
A. Droplet precautions with a private room
B. Airborne precautions with a negative-pressure room
C. Contact precautions with dedicated equipment
D. N95 respirator for healthcare workers entering the room
Correct Answer: B, D
Rationale: Correct because Mycobacterium tuberculosis is transmitted via airborne droplet
nuclei, requiring airborne precautions in a negative-pressure room where air is exhausted outside
or through HEPA filtration, with the door closed at all times. Healthcare workers must wear fit-
tested N95 respirators with seal checks before every entry; patients wear surgical masks only
during transport through hallways. Droplet precautions are insufficient for TB; contact
precautions are unnecessary unless there is copious drainage, though standard precautions apply
to all patients.
Q6: A 19-year-old with sickle cell disease presents with severe chest pain, fever, cough, and
hypoxia. Chest X-ray shows bilateral infiltrates. Which three interventions are the nurse's priority
actions? (Select all that apply.)
A. Administer oxygen to maintain SpO2 greater than 95%
B. Initiate aggressive IV fluid hydration
C. Apply cold compresses to painful areas
D. Implement IV opioid pain management
Correct Answer: A, B, D
Rationale: Correct because this presentation indicates acute chest syndrome, a life-threatening
pulmonary complication of sickle cell disease characterized by vaso-occlusion in the lungs;
priority interventions include oxygen administration to prevent further sickling, aggressive IV
hydration to reduce blood viscosity, and robust IV opioid analgesia for severe pain. Cold
compresses are contraindicated as cold triggers sickling by causing vasoconstriction; warm
compresses promote vasodilation and are preferred. According to evidence-based sickle cell
crisis management, these three interventions must be implemented simultaneously without delay.
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1: A 72-year-old patient with dark skin is admitted with suspected liver disease. The nurse
knows that jaundice is best assessed in which location for this patient?
A. Nail beds and lips
B. Palms and soles
C. Sclera and hard palate
D. Buccal mucosa and conjunctiva
Correct Answer: C
Rationale: Correct because the sclera and hard palate are the most reliable sites for assessing
jaundice in patients with dark skin, as these areas contain less melanin and will show yellow
discoloration from elevated bilirubin more accurately. Nail beds and lips are unreliable due to
greater pigmentation variance and potential for confusion with normal skin tones. According to
evidence-based nursing assessment, the hard palate and sclera provide consistent visualization
across all skin types regardless of melanin content.
Q2: A 45-year-old male trauma patient arrives in the ICU with oozing from multiple IV sites,
petechiae, and hypotension. His platelet count is 45,000/mm³, PT is 28 seconds, and D-dimer is
elevated. Which condition is most likely, and what is the priority intervention?
A. Thrombocytopenia; administer platelet transfusion
B. Disseminated intravascular coagulation; treat underlying cause and provide supportive care
C. Hemophilia A; administer factor VIII replacement
D. Heparin-induced thrombocytopenia; discontinue all heparin
Correct Answer: B
,Rationale: Correct because this presentation of widespread bleeding, low platelets, prolonged
PT, and elevated D-dimer in a trauma patient is classic for disseminated intravascular
coagulation, a consumption coagulopathy triggered by massive tissue injury and inflammation.
The priority intervention is treating the underlying trauma while providing supportive care with
blood product replacement as needed. Thrombocytopenia alone does not explain the prolonged
PT and elevated D-dimer; hemophilia A would not present acutely in adulthood with this pattern;
and HIT requires prior heparin exposure.
Q3: A patient receiving a unit of packed red blood cells develops chills, fever of 38.5°C, and
lower back pain 15 minutes into the transfusion. What is the nurse's immediate priority action?
A. Slow the transfusion rate and administer diphenhydramine
B. Stop the transfusion immediately and maintain IV access with normal saline
C. Continue the transfusion and notify the provider at the end of the unit
D. Draw a blood culture and wait for provider orders
Correct Answer: B
Rationale: Correct because fever, chills, and lower back pain during transfusion are hallmark
signs of acute hemolytic transfusion reaction, the most dangerous type of transfusion reaction
requiring immediate cessation of the blood product. The nurse must stop the transfusion
immediately, keep the IV line open with normal saline using new tubing, assess vital signs, and
notify the provider urgently. Slowing the transfusion or continuing it risks massive hemolysis,
renal failure, and disseminated intravascular coagulation.
Q4: A patient taking furosemide and digoxin has a serum potassium of 2.9 mEq/L. The nurse
notes the patient has nausea, bradycardia, and reports seeing yellow halos around lights. Which
action is most appropriate?
A. Administer the scheduled digoxin dose and encourage potassium-rich foods
B. Hold the digoxin, notify the provider, and prepare for potassium replacement
C. Increase the furosemide dose to enhance diuresis
D. Administer IV calcium gluconate for cardiac protection
Correct Answer: B
Rationale: Correct because hypokalemia intensifies digoxin binding to the Na-K-ATPase pump,
increasing the risk of lethal toxicity even at therapeutic serum digoxin levels; the presence of
nausea, bradycardia, and visual disturbances confirms digoxin toxicity. The nurse must hold the
digoxin dose, notify the provider immediately, and initiate potassium replacement as ordered to
, reduce digoxin binding affinity. Increasing furosemide would worsen hypokalemia; calcium
gluconate is indicated for hyperkalemia, not hypokalemia with digoxin toxicity.
Q5: A patient with suspected active tuberculosis is admitted to the emergency department. Which
isolation precautions are required, and what is the essential room feature? (Select all that apply.)
A. Droplet precautions with a private room
B. Airborne precautions with a negative-pressure room
C. Contact precautions with dedicated equipment
D. N95 respirator for healthcare workers entering the room
Correct Answer: B, D
Rationale: Correct because Mycobacterium tuberculosis is transmitted via airborne droplet
nuclei, requiring airborne precautions in a negative-pressure room where air is exhausted outside
or through HEPA filtration, with the door closed at all times. Healthcare workers must wear fit-
tested N95 respirators with seal checks before every entry; patients wear surgical masks only
during transport through hallways. Droplet precautions are insufficient for TB; contact
precautions are unnecessary unless there is copious drainage, though standard precautions apply
to all patients.
Q6: A 19-year-old with sickle cell disease presents with severe chest pain, fever, cough, and
hypoxia. Chest X-ray shows bilateral infiltrates. Which three interventions are the nurse's priority
actions? (Select all that apply.)
A. Administer oxygen to maintain SpO2 greater than 95%
B. Initiate aggressive IV fluid hydration
C. Apply cold compresses to painful areas
D. Implement IV opioid pain management
Correct Answer: A, B, D
Rationale: Correct because this presentation indicates acute chest syndrome, a life-threatening
pulmonary complication of sickle cell disease characterized by vaso-occlusion in the lungs;
priority interventions include oxygen administration to prevent further sickling, aggressive IV
hydration to reduce blood viscosity, and robust IV opioid analgesia for severe pain. Cold
compresses are contraindicated as cold triggers sickling by causing vasoconstriction; warm
compresses promote vasodilation and are preferred. According to evidence-based sickle cell
crisis management, these three interventions must be implemented simultaneously without delay.
