NUR 201/NUR201 Exam 3 V2 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A nurse is caring for a patient diagnosed with Type 1 Diabetes Mellitus who is experiencing
shakiness, diaphoresis, and a heart rate of 110 bpm. What is the nurse’s priority action?
A. Check the patient’s blood glucose level.
B. Administer 15 grams of fast-acting carbohydrates.
C. Notify the healthcare provider immediately.
D. Administer the scheduled dose of insulin.
Correct Answer: A
Explanation: The patient’s symptoms of shakiness, diaphoresis, and tachycardia are
clinical indicators of hypoglycemia. The nurse must first confirm the blood glucose level to
provide appropriate treatment based on the facility protocol. Following confirmation, the
nurse would typically provide a carbohydrate source if the glucose is low.
2. A patient with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
statement by the patient indicates a need for further teaching regarding oxygen therapy?
A. “I will keep the oxygen tubing away from open flames.”
B. “I will report any increased shortness of breath to my doctor.”
C. “I should use oil-based lubricants for my nose if it feels dry.”
D. “I need to wear cotton clothing to prevent static electricity.”
,Correct Answer: C
Explanation: Oil-based or petroleum-based products are flammable and should not be
used when oxygen is in use. Patients should be taught to use water-soluble lubricants to
treat nasal dryness. Ensuring safety with oxygen equipment is a critical component of
home care education for COPD patients.
3. The nurse is assessing a patient with suspected Hypocalcemia. Which clinical finding would
support this diagnosis?
A. Polyuria and polydipsia.
B. Decreased deep tendon reflexes.
C. Positive Trousseau’s sign.
D. Constipation and muscle weakness.
Correct Answer: C
Explanation: A positive Trousseau’s sign, characterized by carpal spasm after inflating a
blood pressure cuff, is a classic indicator of hypocalcemia. This condition increases
neuromuscular excitability, leading to tetany and spasms. Other signs include Chvostek’s
sign and hyperactive reflexes.
4. A patient is 24 hours post-operative following an abdominal surgery. The nurse notes the
patient’s oxygen saturation is 90% on room air and breath sounds are diminished at the
bases. Which intervention should the nurse perform first?
A. Obtain a prescription for a chest X-ray.
, B. Administer prescribed PRN pain medication.
C. Increase the intravenous fluid rate.
D. Encourage the patient to use the incentive spirometer.
Correct Answer: D
Explanation: Diminished breath sounds and low oxygen saturation postoperatively often
indicate atelectasis. Using an incentive spirometer helps to expand the alveoli and improve
gas exchange. The nurse should also encourage deep breathing and coughing to prevent
further respiratory complications.
5. Which laboratory value is most indicative of a patient’s long-term glucose control over the
past 3 months?
A. Glycosylated hemoglobin (HbA1c).
B. Postprandial glucose level.
C. Fasting blood glucose level.
D. Serum creatinine level.
Correct Answer: A
Explanation: The HbA1c test measures the average blood glucose levels over the lifespan
of a red blood cell, which is approximately 120 days. It provides a more accurate picture of
long-term adherence to a diabetic treatment plan than a single glucose reading. A target for
most diabetic patients is typically below 7%.
Nursing I Q&A with Rationale | Fortis College
1. A nurse is caring for a patient diagnosed with Type 1 Diabetes Mellitus who is experiencing
shakiness, diaphoresis, and a heart rate of 110 bpm. What is the nurse’s priority action?
A. Check the patient’s blood glucose level.
B. Administer 15 grams of fast-acting carbohydrates.
C. Notify the healthcare provider immediately.
D. Administer the scheduled dose of insulin.
Correct Answer: A
Explanation: The patient’s symptoms of shakiness, diaphoresis, and tachycardia are
clinical indicators of hypoglycemia. The nurse must first confirm the blood glucose level to
provide appropriate treatment based on the facility protocol. Following confirmation, the
nurse would typically provide a carbohydrate source if the glucose is low.
2. A patient with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
statement by the patient indicates a need for further teaching regarding oxygen therapy?
A. “I will keep the oxygen tubing away from open flames.”
B. “I will report any increased shortness of breath to my doctor.”
C. “I should use oil-based lubricants for my nose if it feels dry.”
D. “I need to wear cotton clothing to prevent static electricity.”
,Correct Answer: C
Explanation: Oil-based or petroleum-based products are flammable and should not be
used when oxygen is in use. Patients should be taught to use water-soluble lubricants to
treat nasal dryness. Ensuring safety with oxygen equipment is a critical component of
home care education for COPD patients.
3. The nurse is assessing a patient with suspected Hypocalcemia. Which clinical finding would
support this diagnosis?
A. Polyuria and polydipsia.
B. Decreased deep tendon reflexes.
C. Positive Trousseau’s sign.
D. Constipation and muscle weakness.
Correct Answer: C
Explanation: A positive Trousseau’s sign, characterized by carpal spasm after inflating a
blood pressure cuff, is a classic indicator of hypocalcemia. This condition increases
neuromuscular excitability, leading to tetany and spasms. Other signs include Chvostek’s
sign and hyperactive reflexes.
4. A patient is 24 hours post-operative following an abdominal surgery. The nurse notes the
patient’s oxygen saturation is 90% on room air and breath sounds are diminished at the
bases. Which intervention should the nurse perform first?
A. Obtain a prescription for a chest X-ray.
, B. Administer prescribed PRN pain medication.
C. Increase the intravenous fluid rate.
D. Encourage the patient to use the incentive spirometer.
Correct Answer: D
Explanation: Diminished breath sounds and low oxygen saturation postoperatively often
indicate atelectasis. Using an incentive spirometer helps to expand the alveoli and improve
gas exchange. The nurse should also encourage deep breathing and coughing to prevent
further respiratory complications.
5. Which laboratory value is most indicative of a patient’s long-term glucose control over the
past 3 months?
A. Glycosylated hemoglobin (HbA1c).
B. Postprandial glucose level.
C. Fasting blood glucose level.
D. Serum creatinine level.
Correct Answer: A
Explanation: The HbA1c test measures the average blood glucose levels over the lifespan
of a red blood cell, which is approximately 120 days. It provides a more accurate picture of
long-term adherence to a diabetic treatment plan than a single glucose reading. A target for
most diabetic patients is typically below 7%.
