NUR242 MEDICAL-SURGICAL NURSING
EXAM QUESTIONS AND ANSWERS
1. A client is admitted with a suspected tension pneumothorax. Which clinical finding should
the nurse prioritize as an emergency?
A. Bilateral wheezing
B. Tracheal deviation to the unaffected side
C. Increased tactile fremitus
D. Dullness on percussion
Answer: B
Conceptual Explanation: Tracheal deviation is a late and life-threatening sign of tension
pneumothorax, indicating a significant shift in mediastinal structures that can compress the
heart and great vessels.
2. Which arterial blood gas (ABG) result is most indicative of a patient in early stage
respiratory failure?
A. pH 7.35, PaCO2 45, HCO3 24
B. pH 7.30, PaCO2 35, HCO3 18
,C. pH 7.25, PaCO2 60, HCO3 28
D. pH 7.48, PaCO2 30, PaO2 55
Answer: D
Conceptual Explanation: Early respiratory failure often manifests as respiratory alkalosis
due to hyperventilation (low PaCO2) and hypoxemia (low PaO2).
3. A nurse is caring for a patient with Cushing’s Triad. Which set of vital signs aligns with this
condition?
A. BP 180/60, Pulse 50, Respiration 10
B. BP 140/90, Pulse 80, Respiration 18
C. BP 90/60, Pulse 120, Respiration 24
D. BP 120/80, Pulse 70, Respiration 16
Answer: A
Conceptual Explanation: Cushing’s Triad consists of bradycardia, hypertension with a
widening pulse pressure, and irregular/slow respirations, signifying increased intracranial
pressure.
4. A patient with heart failure is prescribed Digoxin. Which electrolyte imbalance should the
nurse monitor most closely to prevent toxicity?
A. Hypernatremia
B. Hypercalcemia
, C. Hypokalemia
D. Hypomagnesemia
Answer: C
Conceptual Explanation: Hypokalemia increases the risk of Digoxin toxicity because
potassium and digoxin compete for binding sites on the sodium-potassium ATPase pump.
5. The nurse is assessing a patient with a chest tube. Which finding requires immediate
intervention?
A. Fluctuation of the water level with inspiration
B. Intermittent bubbling in the water-seal chamber during coughing
C. Continuous bubbling in the water-seal chamber
D. 100 mL of serosanguinous drainage in 2 hours
Answer: C
Conceptual Explanation: Continuous bubbling in the water-seal chamber indicates a large
air leak in the system or the patient’s pleural space, requiring immediate attention.
6. A patient with Type 1 Diabetes presents with deep, rapid respirations and a fruity breath
odor. What is the priority nursing action?
A. Starting a rapid infusion of Normal Saline
B. Administering oral glucose gel
C. Administering subcutaneous Glucagon
EXAM QUESTIONS AND ANSWERS
1. A client is admitted with a suspected tension pneumothorax. Which clinical finding should
the nurse prioritize as an emergency?
A. Bilateral wheezing
B. Tracheal deviation to the unaffected side
C. Increased tactile fremitus
D. Dullness on percussion
Answer: B
Conceptual Explanation: Tracheal deviation is a late and life-threatening sign of tension
pneumothorax, indicating a significant shift in mediastinal structures that can compress the
heart and great vessels.
2. Which arterial blood gas (ABG) result is most indicative of a patient in early stage
respiratory failure?
A. pH 7.35, PaCO2 45, HCO3 24
B. pH 7.30, PaCO2 35, HCO3 18
,C. pH 7.25, PaCO2 60, HCO3 28
D. pH 7.48, PaCO2 30, PaO2 55
Answer: D
Conceptual Explanation: Early respiratory failure often manifests as respiratory alkalosis
due to hyperventilation (low PaCO2) and hypoxemia (low PaO2).
3. A nurse is caring for a patient with Cushing’s Triad. Which set of vital signs aligns with this
condition?
A. BP 180/60, Pulse 50, Respiration 10
B. BP 140/90, Pulse 80, Respiration 18
C. BP 90/60, Pulse 120, Respiration 24
D. BP 120/80, Pulse 70, Respiration 16
Answer: A
Conceptual Explanation: Cushing’s Triad consists of bradycardia, hypertension with a
widening pulse pressure, and irregular/slow respirations, signifying increased intracranial
pressure.
4. A patient with heart failure is prescribed Digoxin. Which electrolyte imbalance should the
nurse monitor most closely to prevent toxicity?
A. Hypernatremia
B. Hypercalcemia
, C. Hypokalemia
D. Hypomagnesemia
Answer: C
Conceptual Explanation: Hypokalemia increases the risk of Digoxin toxicity because
potassium and digoxin compete for binding sites on the sodium-potassium ATPase pump.
5. The nurse is assessing a patient with a chest tube. Which finding requires immediate
intervention?
A. Fluctuation of the water level with inspiration
B. Intermittent bubbling in the water-seal chamber during coughing
C. Continuous bubbling in the water-seal chamber
D. 100 mL of serosanguinous drainage in 2 hours
Answer: C
Conceptual Explanation: Continuous bubbling in the water-seal chamber indicates a large
air leak in the system or the patient’s pleural space, requiring immediate attention.
6. A patient with Type 1 Diabetes presents with deep, rapid respirations and a fruity breath
odor. What is the priority nursing action?
A. Starting a rapid infusion of Normal Saline
B. Administering oral glucose gel
C. Administering subcutaneous Glucagon
