NUR 209 MEDICAL SURGICAL NURSING
II EXAM 2 COMPREHENSIVE
QUESTIONS AND ANSWERS
1. A patient is admitted with an acute exacerbation of Heart Failure. Which clinical finding is
the most sensitive indicator of fluid volume status changes?
A. Serum sodium levels
B. Daily weight measurements
C. Presence of peripheral edema
D. 24-hour intake and output records
Answer: B
Conceptual Explanation: Daily weight is the most accurate and sensitive indicator of fluid
volume status. A weight gain of 2.2 lbs (1 kg) equals 1 liter of fluid retention.
2. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD). The
patient’s ABG results are: pH 7.31, PaCO2 52 mmHg, HCO3 28 mEq/L. How should the nurse
interpret these results?
A. Partially compensated respiratory acidosis
B. Uncompensated metabolic acidosis
,C. Fully compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Answer: A
Conceptual Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause),
and the HCO3 is elevated, indicating the kidneys are attempting to compensate but the pH
has not yet returned to normal.
3. When monitoring a patient receiving a blood transfusion, the nurse notes the patient is
experiencing chills, low back pain, and tachycardia. Which action should the nurse take first?
A. Notify the healthcare provider immediately
B. Slow the infusion rate to keep the vein open
C. Administer PRN diphenhydramine
D. Stop the transfusion and disconnect the tubing at the hub
Answer: D
Conceptual Explanation: These are signs of a hemolytic reaction. The priority is to stop
the transfusion immediately to prevent further exposure to the incompatible blood.
4. A patient with a history of Atrial Fibrillation is prescribed Warfarin. Which lab value should
the nurse prioritize when assessing for therapeutic effectiveness?
A. Activated partial thromboplastin time (aPTT)
B. Platelet count
, C. Prothrombin time (PT) and INR
D. Bleeding time
Answer: C
Conceptual Explanation: PT and INR are used to monitor the effectiveness of Warfarin
therapy. aPTT is used for heparin.
5. A patient presents with a potassium level of 6.2 mEq/L. Which EKG change is most
characteristic of this electrolyte imbalance?
A. ST segment depression
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged QT interval
Answer: C
Conceptual Explanation: Hyperkalemia typically causes tall, peaked T waves and
widening of the QRS complex. U waves are associated with hypokalemia.
6. A nurse is assessing a patient for Cushing’s Triad following a head injury. Which set of vital
signs indicates this condition?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypotension, and Cheyne-Stokes respirations
C. Bradycardia, hypertension with widening pulse pressure, and irregular respirations
II EXAM 2 COMPREHENSIVE
QUESTIONS AND ANSWERS
1. A patient is admitted with an acute exacerbation of Heart Failure. Which clinical finding is
the most sensitive indicator of fluid volume status changes?
A. Serum sodium levels
B. Daily weight measurements
C. Presence of peripheral edema
D. 24-hour intake and output records
Answer: B
Conceptual Explanation: Daily weight is the most accurate and sensitive indicator of fluid
volume status. A weight gain of 2.2 lbs (1 kg) equals 1 liter of fluid retention.
2. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD). The
patient’s ABG results are: pH 7.31, PaCO2 52 mmHg, HCO3 28 mEq/L. How should the nurse
interpret these results?
A. Partially compensated respiratory acidosis
B. Uncompensated metabolic acidosis
,C. Fully compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Answer: A
Conceptual Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause),
and the HCO3 is elevated, indicating the kidneys are attempting to compensate but the pH
has not yet returned to normal.
3. When monitoring a patient receiving a blood transfusion, the nurse notes the patient is
experiencing chills, low back pain, and tachycardia. Which action should the nurse take first?
A. Notify the healthcare provider immediately
B. Slow the infusion rate to keep the vein open
C. Administer PRN diphenhydramine
D. Stop the transfusion and disconnect the tubing at the hub
Answer: D
Conceptual Explanation: These are signs of a hemolytic reaction. The priority is to stop
the transfusion immediately to prevent further exposure to the incompatible blood.
4. A patient with a history of Atrial Fibrillation is prescribed Warfarin. Which lab value should
the nurse prioritize when assessing for therapeutic effectiveness?
A. Activated partial thromboplastin time (aPTT)
B. Platelet count
, C. Prothrombin time (PT) and INR
D. Bleeding time
Answer: C
Conceptual Explanation: PT and INR are used to monitor the effectiveness of Warfarin
therapy. aPTT is used for heparin.
5. A patient presents with a potassium level of 6.2 mEq/L. Which EKG change is most
characteristic of this electrolyte imbalance?
A. ST segment depression
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged QT interval
Answer: C
Conceptual Explanation: Hyperkalemia typically causes tall, peaked T waves and
widening of the QRS complex. U waves are associated with hypokalemia.
6. A nurse is assessing a patient for Cushing’s Triad following a head injury. Which set of vital
signs indicates this condition?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypotension, and Cheyne-Stokes respirations
C. Bradycardia, hypertension with widening pulse pressure, and irregular respirations
