NU 185 Medical Surgical Nursing II Exam 4
Comprehensive Assessment Exam 4 Practice Questi,
Exams of Nursing
1. A patient with chronic heart failure is prescribed sacubitril/valsartan. Which assessment
finding requires immediate follow-up before the first dose?
A. Serum potassium 4.2 mEq/L
B. History of angioedema with lisinopril
C. Blood pressure 118/72 mm Hg
D. Current digoxin therapy
Answer: B
Rationale: Sacubitril/valsartan is contraindicated in patients with a history of angioedema
related to ACE inhibitors due to the risk of serious angioedema. Potassium, blood pressure, and
digoxin use do not absolutely contraindicate initiation, though monitoring is required.
2. Which arterial blood gas value is most consistent with uncompensated respiratory
alkalosis?
A. pH 7.48, PaCO2 30 mm Hg, HCO3- 24 mEq/L
B. pH 7.32, PaCO2 50 mm Hg, HCO3- 26 mEq/L
C. pH 7.44, PaCO2 40 mm Hg, HCO3- 30 mEq/L
D. pH 7.30, PaCO2 34 mm Hg, HCO3- 18 mEq/L
Answer: A
Rationale: Uncompensated respiratory alkalosis presents with an elevated pH, decreased
PaCO2, and normal bicarbonate. Option B reflects respiratory acidosis, C reflects metabolic
alkalosis, and D reflects metabolic acidosis.
3. Following a motor vehicle crash, a patient has absent breath sounds on the right,
tracheal deviation to the left, and distended neck veins. Which intervention is the priority?
A. Prepare for immediate chest tube insertion
B. Administer a bolus of intravenous fluids
C. Obtain a stat portable chest x-ray
D. Assist with needle decompression of the right chest
Answer: D
Rationale: These findings indicate a tension pneumothorax, a life-threatening emergency
requiring immediate needle decompression before chest tube insertion or imaging. Fluid bolus
and x-ray would delay definitive treatment.
Page 1
,4. A patient with acute kidney injury has a serum potassium of 6.8 mEq/L and peaked T
waves on ECG. Which prescription should the nurse implement first?
A. Administer sodium polystyrene sulfonate orally
B. Initiate an insulin infusion with dextrose
C. Give calcium gluconate intravenously
D. Prepare for emergent hemodialysis
Answer: C
Rationale: Calcium gluconate is administered first to stabilize the myocardium and counteract
the cardiac effects of hyperkalemia. Insulin/dextrose and polystyrene shift or eliminate
potassium but do not immediately protect the heart; dialysis is definitive but not the first
immediate action.
5. Which finding in a patient receiving levothyroxine for hypothyroidism indicates the need
for dosage adjustment?
A. Heart rate 88 beats/min and blood pressure 122/78 mm Hg
B. Weight loss of 2 kg over 2 weeks with insomnia and palpitations
C. TSH level within the reference range
D. Report of mild fatigue in the afternoon
Answer: B
Rationale: Weight loss, insomnia, and palpitations suggest excessive thyroid hormone
replacement (thyrotoxicosis), requiring dosage reduction. Normal vital signs, therapeutic TSH,
and mild fatigue do not indicate over-replacement.
6. A patient with a new colostomy has a stoma that is dark purple and dry. Which action
should the nurse take?
A. Apply a moist gauze dressing and reassess in 24 hours
B. Document the finding as normal and continue routine care
C. Notify the surgeon immediately
D. Increase oral fluid intake and monitor output
Answer: C
Rationale: A dark purple, dry stoma indicates ischemia or necrosis and requires immediate
surgical evaluation. A healthy stoma is pink to red and moist. Moist dressings, documentation as
normal, or fluid increase would delay necessary intervention.
7. Which laboratory value is most important to monitor in a patient receiving continuous
heparin infusion?
A. International normalized ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Prothrombin time (PT)
Page 2
, Answer: B
Rationale: aPTT is the standard test to monitor unfractionated heparin therapy and guide dose
titration. INR and PT monitor warfarin, while platelet count is monitored for heparin-induced
thrombocytopenia but does not guide infusion rate.
8. A patient with acute pancreatitis is prescribed enteral feedings. Which intervention is
most appropriate to promote tolerance?
A. Administer feedings into the stomach at a rapid rate
B. Place a nasogastric tube for gastric decompression
C. Initiate feedings via nasojejunal tube at a low rate
D. Withhold feedings until lipase levels normalize
Answer: C
Rationale: Nasojejunal feeding bypasses pancreatic stimulation and is better tolerated in acute
pancreatitis. Gastric feeding may exacerbate symptoms, decompression does not promote
tolerance, and feedings should not be withheld solely based on lipase levels.
9. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 7. Which
nursing intervention is the priority?
A. Perform oral care every 4 hours
B. Maintain head of bed at 30 degrees and monitor airway
C. Encourage family to stimulate the patient frequently
D. Administer prescribed osmotic diuretic
Answer: B
Rationale: A GCS of 7 indicates severe neurologic impairment and risk for airway compromise;
maintaining head elevation and airway patency is the priority. Oral care, family stimulation,
and diuretic administration are important but secondary to airway and perfusion.
10. Which assessment finding in a patient with syndrome of inappropriate antidiuretic
hormone (SIADH) requires immediate intervention?
A. Serum sodium 122 mEq/L with confusion
B. Urine specific gravity 1.030
C. Serum osmolality 275 mOsm/kg
D. Weight gain of 0.5 kg over 24 hours
Answer: A
Rationale: Severe hyponatremia with neurologic symptoms (confusion) indicates cerebral edema
risk and requires immediate intervention, often with hypertonic saline. The other findings are
consistent with SIADH but do not necessitate emergency action alone.
11. A patient with acute decompensated heart failure is prescribed IV furosemide. Which
assessment finding best indicates a therapeutic response to this therapy?
Page 3
Comprehensive Assessment Exam 4 Practice Questi,
Exams of Nursing
1. A patient with chronic heart failure is prescribed sacubitril/valsartan. Which assessment
finding requires immediate follow-up before the first dose?
A. Serum potassium 4.2 mEq/L
B. History of angioedema with lisinopril
C. Blood pressure 118/72 mm Hg
D. Current digoxin therapy
Answer: B
Rationale: Sacubitril/valsartan is contraindicated in patients with a history of angioedema
related to ACE inhibitors due to the risk of serious angioedema. Potassium, blood pressure, and
digoxin use do not absolutely contraindicate initiation, though monitoring is required.
2. Which arterial blood gas value is most consistent with uncompensated respiratory
alkalosis?
A. pH 7.48, PaCO2 30 mm Hg, HCO3- 24 mEq/L
B. pH 7.32, PaCO2 50 mm Hg, HCO3- 26 mEq/L
C. pH 7.44, PaCO2 40 mm Hg, HCO3- 30 mEq/L
D. pH 7.30, PaCO2 34 mm Hg, HCO3- 18 mEq/L
Answer: A
Rationale: Uncompensated respiratory alkalosis presents with an elevated pH, decreased
PaCO2, and normal bicarbonate. Option B reflects respiratory acidosis, C reflects metabolic
alkalosis, and D reflects metabolic acidosis.
3. Following a motor vehicle crash, a patient has absent breath sounds on the right,
tracheal deviation to the left, and distended neck veins. Which intervention is the priority?
A. Prepare for immediate chest tube insertion
B. Administer a bolus of intravenous fluids
C. Obtain a stat portable chest x-ray
D. Assist with needle decompression of the right chest
Answer: D
Rationale: These findings indicate a tension pneumothorax, a life-threatening emergency
requiring immediate needle decompression before chest tube insertion or imaging. Fluid bolus
and x-ray would delay definitive treatment.
Page 1
,4. A patient with acute kidney injury has a serum potassium of 6.8 mEq/L and peaked T
waves on ECG. Which prescription should the nurse implement first?
A. Administer sodium polystyrene sulfonate orally
B. Initiate an insulin infusion with dextrose
C. Give calcium gluconate intravenously
D. Prepare for emergent hemodialysis
Answer: C
Rationale: Calcium gluconate is administered first to stabilize the myocardium and counteract
the cardiac effects of hyperkalemia. Insulin/dextrose and polystyrene shift or eliminate
potassium but do not immediately protect the heart; dialysis is definitive but not the first
immediate action.
5. Which finding in a patient receiving levothyroxine for hypothyroidism indicates the need
for dosage adjustment?
A. Heart rate 88 beats/min and blood pressure 122/78 mm Hg
B. Weight loss of 2 kg over 2 weeks with insomnia and palpitations
C. TSH level within the reference range
D. Report of mild fatigue in the afternoon
Answer: B
Rationale: Weight loss, insomnia, and palpitations suggest excessive thyroid hormone
replacement (thyrotoxicosis), requiring dosage reduction. Normal vital signs, therapeutic TSH,
and mild fatigue do not indicate over-replacement.
6. A patient with a new colostomy has a stoma that is dark purple and dry. Which action
should the nurse take?
A. Apply a moist gauze dressing and reassess in 24 hours
B. Document the finding as normal and continue routine care
C. Notify the surgeon immediately
D. Increase oral fluid intake and monitor output
Answer: C
Rationale: A dark purple, dry stoma indicates ischemia or necrosis and requires immediate
surgical evaluation. A healthy stoma is pink to red and moist. Moist dressings, documentation as
normal, or fluid increase would delay necessary intervention.
7. Which laboratory value is most important to monitor in a patient receiving continuous
heparin infusion?
A. International normalized ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Prothrombin time (PT)
Page 2
, Answer: B
Rationale: aPTT is the standard test to monitor unfractionated heparin therapy and guide dose
titration. INR and PT monitor warfarin, while platelet count is monitored for heparin-induced
thrombocytopenia but does not guide infusion rate.
8. A patient with acute pancreatitis is prescribed enteral feedings. Which intervention is
most appropriate to promote tolerance?
A. Administer feedings into the stomach at a rapid rate
B. Place a nasogastric tube for gastric decompression
C. Initiate feedings via nasojejunal tube at a low rate
D. Withhold feedings until lipase levels normalize
Answer: C
Rationale: Nasojejunal feeding bypasses pancreatic stimulation and is better tolerated in acute
pancreatitis. Gastric feeding may exacerbate symptoms, decompression does not promote
tolerance, and feedings should not be withheld solely based on lipase levels.
9. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 7. Which
nursing intervention is the priority?
A. Perform oral care every 4 hours
B. Maintain head of bed at 30 degrees and monitor airway
C. Encourage family to stimulate the patient frequently
D. Administer prescribed osmotic diuretic
Answer: B
Rationale: A GCS of 7 indicates severe neurologic impairment and risk for airway compromise;
maintaining head elevation and airway patency is the priority. Oral care, family stimulation,
and diuretic administration are important but secondary to airway and perfusion.
10. Which assessment finding in a patient with syndrome of inappropriate antidiuretic
hormone (SIADH) requires immediate intervention?
A. Serum sodium 122 mEq/L with confusion
B. Urine specific gravity 1.030
C. Serum osmolality 275 mOsm/kg
D. Weight gain of 0.5 kg over 24 hours
Answer: A
Rationale: Severe hyponatremia with neurologic symptoms (confusion) indicates cerebral edema
risk and requires immediate intervention, often with hypertonic saline. The other findings are
consistent with SIADH but do not necessitate emergency action alone.
11. A patient with acute decompensated heart failure is prescribed IV furosemide. Which
assessment finding best indicates a therapeutic response to this therapy?
Page 3
