PNR 206/PNR206 Exam 3 V2 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is 24 hours post-thyroidectomy. Which of the following
findings should the nurse prioritize as the most immediate concern?
A. Sore throat when swallowing
B. Tingling in the toes and fingers
C. Hoarseness of the voice
D. Pain at the incision site
Correct Answer: B
Explanation: Tingling in the extremities is a clinical sign of hypocalcemia, which can occur
if the parathyroid glands are accidentally damaged or removed during a thyroidectomy.
The nurse should assess for Chvostek’s and Trousseau’s signs to verify this condition
immediately. If left untreated, hypocalcemia can lead to tetany and respiratory distress,
making it a higher priority than expected post-operative pain or mild hoarseness.
2. A client with Type 1 Diabetes Mellitus is found unresponsive and clammy. What should be
the nurse’s first action according to the facility protocol for suspected hypoglycemia?
A. Prepare to administer Glucagon IM or SQ
B. Administer 15g of simple carbohydrates orally
C. Call the provider to request a STAT blood glucose test
,D. Check the client’s HbA1c levels
Correct Answer: A
Explanation: When a diabetic client is unresponsive, oral carbohydrates are
contraindicated due to the high risk of aspiration. Glucagon is the standard emergency
treatment for severe hypoglycemia in an unconscious patient to stimulate the liver to
release stored glucose. The nurse must prioritize restoring glucose levels rapidly to
prevent permanent neurological damage.
3. Which lab value would the nurse expect to see in a client diagnosed with Cushing’s
Syndrome?
A. WBC count 4,000/mm3
B. Serum Glucose 75 mg/dL
C. Serum Sodium 128 mEq/L
D. Serum Potassium 3.2 mEq/L
Correct Answer: D
Explanation: Cushing’s Syndrome involves an overproduction of cortisol, which leads to
sodium retention and potassium excretion. A potassium level of 3.2 mEq/L reflects
hypokalemia, which is a common metabolic disturbance in these patients. Other typical
findings include hyperglycemia and hypernatremia, rather than the low levels listed in the
other options.
, 4. A client is admitted with suspected Acute Pancreatitis. Which of the following laboratory
results is most diagnostic of this condition?
A. Decreased Serum Bilirubin
B. Elevated Serum Lipase
C. Elevated Serum Calcium
D. Decreased WBC count
Correct Answer: B
Explanation: Serum lipase is the most specific enzyme for diagnosing acute pancreatitis
because it stays elevated longer than amylase. Pancreatitis usually causes hypocalcemia
rather than hypercalcemia due to fat necrosis and calcium binding. Elevated white blood
cell counts are also expected due to the inflammatory nature of the disease, making choice
A the most definitive diagnostic indicator.
5. The nurse is providing discharge education to a client with Addison’s disease. Which
instruction is most critical for the client’s safety?
A. Limit sodium intake to 2 grams per day
B. Stop taking steroids once symptoms improve
C. Exercise vigorously to reduce stress
D. Carry an emergency kit with injectable hydrocortisone
Correct Answer: D
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is 24 hours post-thyroidectomy. Which of the following
findings should the nurse prioritize as the most immediate concern?
A. Sore throat when swallowing
B. Tingling in the toes and fingers
C. Hoarseness of the voice
D. Pain at the incision site
Correct Answer: B
Explanation: Tingling in the extremities is a clinical sign of hypocalcemia, which can occur
if the parathyroid glands are accidentally damaged or removed during a thyroidectomy.
The nurse should assess for Chvostek’s and Trousseau’s signs to verify this condition
immediately. If left untreated, hypocalcemia can lead to tetany and respiratory distress,
making it a higher priority than expected post-operative pain or mild hoarseness.
2. A client with Type 1 Diabetes Mellitus is found unresponsive and clammy. What should be
the nurse’s first action according to the facility protocol for suspected hypoglycemia?
A. Prepare to administer Glucagon IM or SQ
B. Administer 15g of simple carbohydrates orally
C. Call the provider to request a STAT blood glucose test
,D. Check the client’s HbA1c levels
Correct Answer: A
Explanation: When a diabetic client is unresponsive, oral carbohydrates are
contraindicated due to the high risk of aspiration. Glucagon is the standard emergency
treatment for severe hypoglycemia in an unconscious patient to stimulate the liver to
release stored glucose. The nurse must prioritize restoring glucose levels rapidly to
prevent permanent neurological damage.
3. Which lab value would the nurse expect to see in a client diagnosed with Cushing’s
Syndrome?
A. WBC count 4,000/mm3
B. Serum Glucose 75 mg/dL
C. Serum Sodium 128 mEq/L
D. Serum Potassium 3.2 mEq/L
Correct Answer: D
Explanation: Cushing’s Syndrome involves an overproduction of cortisol, which leads to
sodium retention and potassium excretion. A potassium level of 3.2 mEq/L reflects
hypokalemia, which is a common metabolic disturbance in these patients. Other typical
findings include hyperglycemia and hypernatremia, rather than the low levels listed in the
other options.
, 4. A client is admitted with suspected Acute Pancreatitis. Which of the following laboratory
results is most diagnostic of this condition?
A. Decreased Serum Bilirubin
B. Elevated Serum Lipase
C. Elevated Serum Calcium
D. Decreased WBC count
Correct Answer: B
Explanation: Serum lipase is the most specific enzyme for diagnosing acute pancreatitis
because it stays elevated longer than amylase. Pancreatitis usually causes hypocalcemia
rather than hypercalcemia due to fat necrosis and calcium binding. Elevated white blood
cell counts are also expected due to the inflammatory nature of the disease, making choice
A the most definitive diagnostic indicator.
5. The nurse is providing discharge education to a client with Addison’s disease. Which
instruction is most critical for the client’s safety?
A. Limit sodium intake to 2 grams per day
B. Stop taking steroids once symptoms improve
C. Exercise vigorously to reduce stress
D. Carry an emergency kit with injectable hydrocortisone
Correct Answer: D
