NUR 201/NUR201 Final Exam V3 | Medical-
Surgical Nursing I Q&A with Rationale | Fortis
College
1. A patient is admitted with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Increased muscle tone and tetany
C. Cardiac dysrhythmias and U-waves
D. Peaked T-waves on the ECG
Correct Answer: C
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, significantly
affects cardiac electrical conduction and can lead to dangerous arrhythmias. The presence
of U-waves is a characteristic ECG change associated with low potassium levels. The nurse
must prioritize cardiac monitoring to prevent potential cardiac arrest in this patient.
2. Which nursing intervention is most appropriate for a patient experiencing an acute asthma
exacerbation?
A. Administering a short-acting beta-agonist (SABA) via nebulizer
B. Encouraging the patient to perform pursed-lip breathing
C. Administering a long-acting beta-agonist (LABA)
,D. Starting the patient on a high-protein diet
Correct Answer: A
Explanation: Short-acting beta-agonists like Albuterol are the first-line treatment for acute
bronchoconstriction as they provide rapid relief. Pursed-lip breathing is helpful for chronic
management but is not the priority during an acute attack where airway patency is
compromised. The nurse must ensure immediate delivery of bronchodilators to improve
ventilation and oxygenation.
3. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 550 mg/dL, fruity-
smelling breath, and Kussmaul respirations. What is the nurse’s priority action?
A. Administer subcutaneous glargine insulin
B. Request a referral for a diabetic educator
C. Offer the patient 15 grams of simple carbohydrates
D. Initiate intravenous fluid resuscitation with Normal Saline
Correct Answer: D
Explanation: The patient is exhibiting classic signs of Diabetic Ketoacidosis (DKA), which
is a medical emergency requiring rapid intervention. Fluid resuscitation is the initial
priority to address severe dehydration and restore circulatory volume before starting
insulin drips. Continuous monitoring of electrolyte levels, especially potassium, is also
essential during the treatment of DKA.
, 4. A nurse is caring for a patient who is 24 hours postoperative following abdominal surgery.
The patient reports sudden chest pain and shortness of breath. What should the nurse
suspect?
A. Hypovolemic shock
B. Pulmonary embolism
C. Wound evisceration
D. Paralytic ileus
Correct Answer: B
Explanation: Sudden onset of dyspnea and chest pain in a postoperative patient are
hallmark signs of a pulmonary embolism. Patients are at high risk for venous
thromboembolism due to immobility and the surgical procedure itself. Immediate nursing
actions include applying oxygen and notifying the Rapid Response Team or the physician.
5. When assessing a patient with right-sided heart failure, which finding does the nurse
expect to observe?
A. Pulmonary crackles and wheezing
B. Jugular venous distention (JVD) and peripheral edema
C. Orthopnea and paroxysmal nocturnal dyspnea
D. Pink frothy sputum
Correct Answer: B
Surgical Nursing I Q&A with Rationale | Fortis
College
1. A patient is admitted with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Increased muscle tone and tetany
C. Cardiac dysrhythmias and U-waves
D. Peaked T-waves on the ECG
Correct Answer: C
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, significantly
affects cardiac electrical conduction and can lead to dangerous arrhythmias. The presence
of U-waves is a characteristic ECG change associated with low potassium levels. The nurse
must prioritize cardiac monitoring to prevent potential cardiac arrest in this patient.
2. Which nursing intervention is most appropriate for a patient experiencing an acute asthma
exacerbation?
A. Administering a short-acting beta-agonist (SABA) via nebulizer
B. Encouraging the patient to perform pursed-lip breathing
C. Administering a long-acting beta-agonist (LABA)
,D. Starting the patient on a high-protein diet
Correct Answer: A
Explanation: Short-acting beta-agonists like Albuterol are the first-line treatment for acute
bronchoconstriction as they provide rapid relief. Pursed-lip breathing is helpful for chronic
management but is not the priority during an acute attack where airway patency is
compromised. The nurse must ensure immediate delivery of bronchodilators to improve
ventilation and oxygenation.
3. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 550 mg/dL, fruity-
smelling breath, and Kussmaul respirations. What is the nurse’s priority action?
A. Administer subcutaneous glargine insulin
B. Request a referral for a diabetic educator
C. Offer the patient 15 grams of simple carbohydrates
D. Initiate intravenous fluid resuscitation with Normal Saline
Correct Answer: D
Explanation: The patient is exhibiting classic signs of Diabetic Ketoacidosis (DKA), which
is a medical emergency requiring rapid intervention. Fluid resuscitation is the initial
priority to address severe dehydration and restore circulatory volume before starting
insulin drips. Continuous monitoring of electrolyte levels, especially potassium, is also
essential during the treatment of DKA.
, 4. A nurse is caring for a patient who is 24 hours postoperative following abdominal surgery.
The patient reports sudden chest pain and shortness of breath. What should the nurse
suspect?
A. Hypovolemic shock
B. Pulmonary embolism
C. Wound evisceration
D. Paralytic ileus
Correct Answer: B
Explanation: Sudden onset of dyspnea and chest pain in a postoperative patient are
hallmark signs of a pulmonary embolism. Patients are at high risk for venous
thromboembolism due to immobility and the surgical procedure itself. Immediate nursing
actions include applying oxygen and notifying the Rapid Response Team or the physician.
5. When assessing a patient with right-sided heart failure, which finding does the nurse
expect to observe?
A. Pulmonary crackles and wheezing
B. Jugular venous distention (JVD) and peripheral edema
C. Orthopnea and paroxysmal nocturnal dyspnea
D. Pink frothy sputum
Correct Answer: B
