Exam 3: NUR201 / NUR 201 (Latest 2026
/ 2027 Update) Medical-Surgical Nursing
I | Questions and Verified Answers 100%
Correct | Grade A – Fortis College
Question 1
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 to complete a full physical assessment
B. Briefly ask specific questions about this episode of respiratory distress
C. Complete the admission database to check for allergies before treatment
D. Delay the physical assessment to first complete pulmonary function tests
Correct Answer: B. Briefly ask specific questions about this episode of respiratory
distress
Rationale: In a patient with acute respiratory distress, the initial assessment should
focus on the immediate episode while ensuring the airway is patent. A full physical
assessment, admission database, and pulmonary function tests can be delayed until the
patient is stable.
Question 2
The nurse prepares a patient with 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 overbed table
Correct Answer: D. Sitting upright with the arms supported on an overbed table
,Rationale: For thoracentesis, the patient should be positioned sitting upright with the
arms supported on an overbed table. This position allows for optimal access to the
pleural space and promotes patient stability during the procedure.
Question 3
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many
patients who have immigrated to the United States. Which question is important
for the nurse to ask before the skin test?
A. "Do you take any over-the-counter (OTC) medications?"
B. "Do you have any family members with a history of TB?"
C. "How long has it been since you moved to the United States?"
D. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
Correct Answer: D. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
Rationale: Patients who have received the BCG vaccine will have a positive Mantoux
test. Another screening method (e.g., chest x-ray) will need to be used to determine if
the patient has a TB infection. The other information is less pertinent to the decision
about TB skin testing.
Question 4
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg;
PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
A. Intercostal retractions
B. Kussmaul respirations
C. Low oxygen saturation (SpO2)
D. Decreased venous O2 pressure
Correct Answer: B. Kussmaul respirations
Rationale: The ABG results show metabolic acidosis (low pH and low HCO3-). Kussmaul
respirations (deep, rapid breathing) are a compensatory mechanism for metabolic
acidosis, often seen in diabetic ketoacidosis.
,Question 5
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds
during inhalation in the lower third of both lungs. How should the nurse
document this finding?
A. Inspiratory crackles at the bases
B. Expiratory wheezes in both lungs
C. Abnormal lung sounds in the apices of both lungs
D. Pleural friction rub in the right and left lower lobes
Correct Answer: A. Inspiratory crackles at the bases
Rationale: Low-pitched, bubbling sounds heard during inspiration in the lower lung
fields are characteristic of crackles (rales), often associated with fluid in the alveoli.
Crackles at the bases are commonly heard in heart failure or pneumonia.
Question 6
The nurse teaches a patient about pulmonary spirometry testing. Which
statement, if made 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."
Correct Answer: C. "I will inhale deeply and blow out hard during the test."
Rationale: Spirometry testing requires the patient to inhale deeply and then exhale
forcefully and completely into the device. This measures lung volumes and airflow.
Bronchodilators are usually held before testing, and fasting is not required.
Question 7
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 listens to the posterior lung fields first
Correct Answer: B. The student listens during the inspiratory phase, then moves the
stethoscope
Rationale: Proper auscultation requires listening to the full respiratory cycle (both
inspiration and expiration) at each location before moving the stethoscope. Listening
only during inspiration can miss important expiratory findings such as wheezes or
prolonged expiration.
Question 8
A patient is admitted to the emergency department with an open stab wound to
the left chest. What action should the nurse take?
A. Keep the head of the patient's bed positioned flat
B. Cover the wound tightly with an occlusive dressing
C. Position the patient so that the left chest is dependent
D. Tape a nonporous dressing on three sides over the wound
Correct Answer: D. Tape a nonporous dressing on three sides over the wound
Rationale: The dressing taped on three sides will allow air to escape when intrapleural
pressure increases during expiration but will prevent air from moving into the pleural
space during inspiration (creating a one-way valve effect). Placing the patient on the left
side or covering the wound with an occlusive dressing can cause a tension
pneumothorax.
Question 9
The nurse notes that a patient has incisional pain, a poor cough effort, and
scattered coarse crackles after a thoracotomy. Which action should the nurse take
first?
/ 2027 Update) Medical-Surgical Nursing
I | Questions and Verified Answers 100%
Correct | Grade A – Fortis College
Question 1
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 to complete a full physical assessment
B. Briefly ask specific questions about this episode of respiratory distress
C. Complete the admission database to check for allergies before treatment
D. Delay the physical assessment to first complete pulmonary function tests
Correct Answer: B. Briefly ask specific questions about this episode of respiratory
distress
Rationale: In a patient with acute respiratory distress, the initial assessment should
focus on the immediate episode while ensuring the airway is patent. A full physical
assessment, admission database, and pulmonary function tests can be delayed until the
patient is stable.
Question 2
The nurse prepares a patient with 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 overbed table
Correct Answer: D. Sitting upright with the arms supported on an overbed table
,Rationale: For thoracentesis, the patient should be positioned sitting upright with the
arms supported on an overbed table. This position allows for optimal access to the
pleural space and promotes patient stability during the procedure.
Question 3
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many
patients who have immigrated to the United States. Which question is important
for the nurse to ask before the skin test?
A. "Do you take any over-the-counter (OTC) medications?"
B. "Do you have any family members with a history of TB?"
C. "How long has it been since you moved to the United States?"
D. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
Correct Answer: D. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
Rationale: Patients who have received the BCG vaccine will have a positive Mantoux
test. Another screening method (e.g., chest x-ray) will need to be used to determine if
the patient has a TB infection. The other information is less pertinent to the decision
about TB skin testing.
Question 4
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg;
PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
A. Intercostal retractions
B. Kussmaul respirations
C. Low oxygen saturation (SpO2)
D. Decreased venous O2 pressure
Correct Answer: B. Kussmaul respirations
Rationale: The ABG results show metabolic acidosis (low pH and low HCO3-). Kussmaul
respirations (deep, rapid breathing) are a compensatory mechanism for metabolic
acidosis, often seen in diabetic ketoacidosis.
,Question 5
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds
during inhalation in the lower third of both lungs. How should the nurse
document this finding?
A. Inspiratory crackles at the bases
B. Expiratory wheezes in both lungs
C. Abnormal lung sounds in the apices of both lungs
D. Pleural friction rub in the right and left lower lobes
Correct Answer: A. Inspiratory crackles at the bases
Rationale: Low-pitched, bubbling sounds heard during inspiration in the lower lung
fields are characteristic of crackles (rales), often associated with fluid in the alveoli.
Crackles at the bases are commonly heard in heart failure or pneumonia.
Question 6
The nurse teaches a patient about pulmonary spirometry testing. Which
statement, if made 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."
Correct Answer: C. "I will inhale deeply and blow out hard during the test."
Rationale: Spirometry testing requires the patient to inhale deeply and then exhale
forcefully and completely into the device. This measures lung volumes and airflow.
Bronchodilators are usually held before testing, and fasting is not required.
Question 7
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 listens to the posterior lung fields first
Correct Answer: B. The student listens during the inspiratory phase, then moves the
stethoscope
Rationale: Proper auscultation requires listening to the full respiratory cycle (both
inspiration and expiration) at each location before moving the stethoscope. Listening
only during inspiration can miss important expiratory findings such as wheezes or
prolonged expiration.
Question 8
A patient is admitted to the emergency department with an open stab wound to
the left chest. What action should the nurse take?
A. Keep the head of the patient's bed positioned flat
B. Cover the wound tightly with an occlusive dressing
C. Position the patient so that the left chest is dependent
D. Tape a nonporous dressing on three sides over the wound
Correct Answer: D. Tape a nonporous dressing on three sides over the wound
Rationale: The dressing taped on three sides will allow air to escape when intrapleural
pressure increases during expiration but will prevent air from moving into the pleural
space during inspiration (creating a one-way valve effect). Placing the patient on the left
side or covering the wound with an occlusive dressing can cause a tension
pneumothorax.
Question 9
The nurse notes that a patient has incisional pain, a poor cough effort, and
scattered coarse crackles after a thoracotomy. Which action should the nurse take
first?
