PNR 206/PNR206 Final Exam V3 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who has Chronic Obstructive Pulmonary Disease (COPD) and is
receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client’s oxygen saturation
is 89%. Which of the following actions should the nurse take first?
A. Increase the oxygen flow rate to 4 L/min.
B. Assess the client’s respiratory rate and effort.
C. Administer a prescribed rescue inhaler.
D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: The first action in the nursing process is assessment to determine the
severity of the client’s condition. For clients with COPD, an oxygen saturation between 88%
and 92% is often within the expected range. Increasing oxygen too rapidly in a COPD
patient can suppress the hypoxic drive to breathe, leading to carbon dioxide retention.
2. A client with type 2 diabetes mellitus is scheduled for a computed tomography (CT) scan
with intravenous contrast. Which medication should the nurse expect to withhold for 48
hours after the procedure?
A. Glipizide
B. Metformin
,C. Pioglitazone
D. Lispro insulin
Correct Answer: B
Explanation: Metformin must be withheld prior to and for 48 hours after any procedure
involving iodine-based contrast media. This precaution is necessary to prevent the
development of lactic acidosis, especially if contrast-induced nephropathy occurs. The
nurse should monitor renal function tests before resuming the medication.
3. A nurse is assessing a client who is 4 hours postoperative following a subtotal
thyroidectomy. Which of the following findings is the highest priority?
A. Pain level of 5 on a scale of 0 to 10.
B. Numbness and tingling around the mouth.
C. Hoarseness when speaking.
D. Small amount of serosanguineous drainage on the dressing.
Correct Answer: B
Explanation: Numbness and tingling around the mouth (circumoral paresthesia) are early
signs of hypocalcemia, which can occur if the parathyroid glands are accidentally damaged
during surgery. If untreated, hypocalcemia can lead to tetany and laryngospasm, which are
life-threatening. The nurse should check for Chvostek’s and Trousseau’s signs and have
calcium gluconate available.
,4. A client is admitted with a diagnosis of acute pancreatitis. Which of the following
laboratory results should the nurse expect to be elevated?
A. Serum Calcium
B. Serum Potassium
C. Serum Amylase
D. Hemoglobin
Correct Answer: C
Explanation: Serum amylase and lipase levels typically rise significantly within 24 hours of
the onset of acute pancreatitis. Serum calcium levels actually tend to decrease in severe
pancreatitis due to fat necrosis and saponification. Monitoring these enzyme levels helps
clinicians track the progression and resolution of the inflammatory process.
5. Which clinical manifestation should a nurse anticipate when assessing a client with Right-
Sided Heart Failure?
A. Crackles in the lungs
B. Peripheral edema
C. Dyspnea on exertion
D. Orthopnea
Correct Answer: B
, Explanation: Right-sided heart failure leads to systemic venous congestion, which
manifests as peripheral edema, jugular venous distention, and hepatomegaly. Left-sided
heart failure primarily causes pulmonary symptoms like crackles, dyspnea, and orthopnea
due to backflow into the lungs. Understanding this distinction is critical for prioritizing
nursing assessments and interventions.
6. A nurse is teaching a client who has a new prescription for Alendronate for osteoporosis.
Which of the following instructions should be included?
A. Take the medication with a full glass of milk.
B. Lie down for 30 minutes after taking the medication.
C. Take the medication first thing in the morning on an empty stomach.
D. Take the medication immediately after eating breakfast.
Correct Answer: C
Explanation: Alendronate must be taken on an empty stomach with a full glass of plain
water to ensure proper absorption. The client must remain upright for at least 30 minutes
to prevent esophageal irritation or ulceration. Milk and food interfere significantly with the
medication’s bioavailability and should be avoided for at least 30 minutes post-dose.
7. A client with Chronic Kidney Disease (CKD) has a serum potassium level of 6.2 mEq/L.
Which of the following cardiac changes should the nurse monitor for on the EKG?
A. Tall, peaked T waves
B. Prominent ST-segment elevation
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who has Chronic Obstructive Pulmonary Disease (COPD) and is
receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client’s oxygen saturation
is 89%. Which of the following actions should the nurse take first?
A. Increase the oxygen flow rate to 4 L/min.
B. Assess the client’s respiratory rate and effort.
C. Administer a prescribed rescue inhaler.
D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: The first action in the nursing process is assessment to determine the
severity of the client’s condition. For clients with COPD, an oxygen saturation between 88%
and 92% is often within the expected range. Increasing oxygen too rapidly in a COPD
patient can suppress the hypoxic drive to breathe, leading to carbon dioxide retention.
2. A client with type 2 diabetes mellitus is scheduled for a computed tomography (CT) scan
with intravenous contrast. Which medication should the nurse expect to withhold for 48
hours after the procedure?
A. Glipizide
B. Metformin
,C. Pioglitazone
D. Lispro insulin
Correct Answer: B
Explanation: Metformin must be withheld prior to and for 48 hours after any procedure
involving iodine-based contrast media. This precaution is necessary to prevent the
development of lactic acidosis, especially if contrast-induced nephropathy occurs. The
nurse should monitor renal function tests before resuming the medication.
3. A nurse is assessing a client who is 4 hours postoperative following a subtotal
thyroidectomy. Which of the following findings is the highest priority?
A. Pain level of 5 on a scale of 0 to 10.
B. Numbness and tingling around the mouth.
C. Hoarseness when speaking.
D. Small amount of serosanguineous drainage on the dressing.
Correct Answer: B
Explanation: Numbness and tingling around the mouth (circumoral paresthesia) are early
signs of hypocalcemia, which can occur if the parathyroid glands are accidentally damaged
during surgery. If untreated, hypocalcemia can lead to tetany and laryngospasm, which are
life-threatening. The nurse should check for Chvostek’s and Trousseau’s signs and have
calcium gluconate available.
,4. A client is admitted with a diagnosis of acute pancreatitis. Which of the following
laboratory results should the nurse expect to be elevated?
A. Serum Calcium
B. Serum Potassium
C. Serum Amylase
D. Hemoglobin
Correct Answer: C
Explanation: Serum amylase and lipase levels typically rise significantly within 24 hours of
the onset of acute pancreatitis. Serum calcium levels actually tend to decrease in severe
pancreatitis due to fat necrosis and saponification. Monitoring these enzyme levels helps
clinicians track the progression and resolution of the inflammatory process.
5. Which clinical manifestation should a nurse anticipate when assessing a client with Right-
Sided Heart Failure?
A. Crackles in the lungs
B. Peripheral edema
C. Dyspnea on exertion
D. Orthopnea
Correct Answer: B
, Explanation: Right-sided heart failure leads to systemic venous congestion, which
manifests as peripheral edema, jugular venous distention, and hepatomegaly. Left-sided
heart failure primarily causes pulmonary symptoms like crackles, dyspnea, and orthopnea
due to backflow into the lungs. Understanding this distinction is critical for prioritizing
nursing assessments and interventions.
6. A nurse is teaching a client who has a new prescription for Alendronate for osteoporosis.
Which of the following instructions should be included?
A. Take the medication with a full glass of milk.
B. Lie down for 30 minutes after taking the medication.
C. Take the medication first thing in the morning on an empty stomach.
D. Take the medication immediately after eating breakfast.
Correct Answer: C
Explanation: Alendronate must be taken on an empty stomach with a full glass of plain
water to ensure proper absorption. The client must remain upright for at least 30 minutes
to prevent esophageal irritation or ulceration. Milk and food interfere significantly with the
medication’s bioavailability and should be avoided for at least 30 minutes post-dose.
7. A client with Chronic Kidney Disease (CKD) has a serum potassium level of 6.2 mEq/L.
Which of the following cardiac changes should the nurse monitor for on the EKG?
A. Tall, peaked T waves
B. Prominent ST-segment elevation
