NUR 201/NUR201 Final Exam V1 | Medical-
Surgical Nursing I Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who is 24 hours postoperative following an abdominal
surgery. The patient refuses to use the incentive spirometer because it ‘hurts too much.’
What is the nurse’s priority action?
A. Document the patient’s refusal in the electronic health record.
B. Explain the risk of developing pneumonia if the device is not used.
C. Notify the provider that the patient is being non-compliant.
D. Administer prescribed analgesic medication and return in 30 minutes.
Correct Answer: D
Explanation: Pain is a significant barrier to effective postoperative pulmonary hygiene and
deep breathing exercises. By administering analgesics first, the nurse addresses the
physical barrier to using the incentive spirometer. This intervention promotes patient
comfort and increases compliance with essential respiratory care to prevent atelectasis.
2. A patient presents to the emergency department with a potassium level of 6.2 mEq/L.
Which of the following ECG changes should the nurse anticipate?
A. Tall, peaked T waves
B. ST-segment depression
,C. Presence of U waves
D. Shortened PR interval
Correct Answer: A
Explanation: Hyperkalemia is characterized by potassium levels greater than 5.0 mEq/L
and can lead to life-threatening cardiac arrhythmias. Tall, peaked T waves are one of the
earliest signs of potassium’s effect on cardiac repolarization. The nurse must monitor the
patient closely for further progression to widened QRS complexes or cardiac arrest.
3. A nurse is providing discharge instructions to a client with a new diagnosis of Type 2
Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
A. ‘I will check my blood sugar before I exercise.’
B. ‘I will wear well-fitting shoes and inspect my feet daily.’
C. ‘I will carry a source of fast-acting glucose with me at all times.’
D. ‘I will use a heating pad on my feet if they feel cold at night.’
Correct Answer: D
Explanation: Patients with diabetes often suffer from peripheral neuropathy, which
reduces their ability to sense temperature extremes. Using a heating pad increases the risk
of severe burns because the patient may not feel the heat until tissue damage occurs. The
nurse should reinforce the importance of avoiding external heat sources and using socks
for warmth instead.
,4. Which clinical manifestation should a nurse prioritize when assessing a patient for a
suspected systemic inflammatory response syndrome (SIRS)?
A. Hyperthermia and leukocytosis
B. Hypotension and bradycardia
C. Localized redness and swelling
D. Polyuria and increased appetite
Correct Answer: A
Explanation: SIRS criteria include clinical findings such as a temperature greater than
38°C (100.4°F) or less than 36°C (96.8°F). It also involves a white blood cell count greater
than 12,000/mm³ or less than 4,000/mm³. Identifying these systemic markers is crucial for
early intervention in potentially septic patients.
5. A patient with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula. The nurse notes the patient’s oxygen saturation is 89% and the patient appears
comfortable. What is the most appropriate action?
A. Increase the oxygen flow rate to 6 L/min immediately.
B. Maintain the current flow rate as this is an acceptable range for COPD.
C. Call a Rapid Response Team for impending respiratory failure.
D. Switch the patient to a non-rebreather mask at 15 L/min.
Correct Answer: B
, Explanation: For patients with COPD, a target oxygen saturation between 88% and 92% is
often clinically acceptable to prevent the suppression of the hypoxic drive. Providing
excessive oxygen can lead to CO2 retention and respiratory acidosis in this population. The
nurse should continue to monitor the patient’s respiratory effort and mental status rather
than aggressively increasing oxygen.
6. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). Which of the
following actions is the highest priority?
A. Obtain the patient’s baseline vital signs.
B. Verify the blood type and patient identity with another RN.
C. Ensure the patient has a patent 20-gauge or larger IV line.
D. Check the expiration date on the blood bag.
Correct Answer: B
Explanation: Verification of the blood product and patient identity is the most critical step
to prevent a fatal hemolytic transfusion reaction. This process must be performed by two
qualified healthcare professionals at the bedside. While vital signs and IV access are
important, the prevention of an incompatible transfusion takes precedence in safety
protocols.
7. A client who is scheduled for a cholecystectomy expresses anxiety and asks the nurse,
‘What if I don’t wake up from the anesthesia?’ Which response is most therapeutic?
A. ‘Don’t worry, we have very skilled anesthesiologists here.’
Surgical Nursing I Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who is 24 hours postoperative following an abdominal
surgery. The patient refuses to use the incentive spirometer because it ‘hurts too much.’
What is the nurse’s priority action?
A. Document the patient’s refusal in the electronic health record.
B. Explain the risk of developing pneumonia if the device is not used.
C. Notify the provider that the patient is being non-compliant.
D. Administer prescribed analgesic medication and return in 30 minutes.
Correct Answer: D
Explanation: Pain is a significant barrier to effective postoperative pulmonary hygiene and
deep breathing exercises. By administering analgesics first, the nurse addresses the
physical barrier to using the incentive spirometer. This intervention promotes patient
comfort and increases compliance with essential respiratory care to prevent atelectasis.
2. A patient presents to the emergency department with a potassium level of 6.2 mEq/L.
Which of the following ECG changes should the nurse anticipate?
A. Tall, peaked T waves
B. ST-segment depression
,C. Presence of U waves
D. Shortened PR interval
Correct Answer: A
Explanation: Hyperkalemia is characterized by potassium levels greater than 5.0 mEq/L
and can lead to life-threatening cardiac arrhythmias. Tall, peaked T waves are one of the
earliest signs of potassium’s effect on cardiac repolarization. The nurse must monitor the
patient closely for further progression to widened QRS complexes or cardiac arrest.
3. A nurse is providing discharge instructions to a client with a new diagnosis of Type 2
Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
A. ‘I will check my blood sugar before I exercise.’
B. ‘I will wear well-fitting shoes and inspect my feet daily.’
C. ‘I will carry a source of fast-acting glucose with me at all times.’
D. ‘I will use a heating pad on my feet if they feel cold at night.’
Correct Answer: D
Explanation: Patients with diabetes often suffer from peripheral neuropathy, which
reduces their ability to sense temperature extremes. Using a heating pad increases the risk
of severe burns because the patient may not feel the heat until tissue damage occurs. The
nurse should reinforce the importance of avoiding external heat sources and using socks
for warmth instead.
,4. Which clinical manifestation should a nurse prioritize when assessing a patient for a
suspected systemic inflammatory response syndrome (SIRS)?
A. Hyperthermia and leukocytosis
B. Hypotension and bradycardia
C. Localized redness and swelling
D. Polyuria and increased appetite
Correct Answer: A
Explanation: SIRS criteria include clinical findings such as a temperature greater than
38°C (100.4°F) or less than 36°C (96.8°F). It also involves a white blood cell count greater
than 12,000/mm³ or less than 4,000/mm³. Identifying these systemic markers is crucial for
early intervention in potentially septic patients.
5. A patient with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula. The nurse notes the patient’s oxygen saturation is 89% and the patient appears
comfortable. What is the most appropriate action?
A. Increase the oxygen flow rate to 6 L/min immediately.
B. Maintain the current flow rate as this is an acceptable range for COPD.
C. Call a Rapid Response Team for impending respiratory failure.
D. Switch the patient to a non-rebreather mask at 15 L/min.
Correct Answer: B
, Explanation: For patients with COPD, a target oxygen saturation between 88% and 92% is
often clinically acceptable to prevent the suppression of the hypoxic drive. Providing
excessive oxygen can lead to CO2 retention and respiratory acidosis in this population. The
nurse should continue to monitor the patient’s respiratory effort and mental status rather
than aggressively increasing oxygen.
6. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). Which of the
following actions is the highest priority?
A. Obtain the patient’s baseline vital signs.
B. Verify the blood type and patient identity with another RN.
C. Ensure the patient has a patent 20-gauge or larger IV line.
D. Check the expiration date on the blood bag.
Correct Answer: B
Explanation: Verification of the blood product and patient identity is the most critical step
to prevent a fatal hemolytic transfusion reaction. This process must be performed by two
qualified healthcare professionals at the bedside. While vital signs and IV access are
important, the prevention of an incompatible transfusion takes precedence in safety
protocols.
7. A client who is scheduled for a cholecystectomy expresses anxiety and asks the nurse,
‘What if I don’t wake up from the anesthesia?’ Which response is most therapeutic?
A. ‘Don’t worry, we have very skilled anesthesiologists here.’
