NUR 170 Exam 3 V2 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 3) | Galen
1. A 68-year-old male patient, Mr. Miller, is admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). His arterial blood gas (ABG) results show pH 7.31,
PaCO2 52 mmHg, and HCO3 28 mEq/L. Which acid-base imbalance is Mr. Miller experiencing?
A. Respiratory acidosis, partially compensated
B. Metabolic acidosis, partially compensated
C. Respiratory alkalosis, uncompensated
D. Metabolic alkalosis, fully compensated
Answer: A
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The HCO3 is elevated above 26 mEq/L,
suggesting that the kidneys are attempting to compensate for the primary respiratory
issue. Because the pH has not yet returned to the normal range, the imbalance is
considered partially compensated.
2. A nurse is caring for Mrs. Jenkins, who is 24 hours post-abdominal surgery. Upon
assessment, the nurse notes that the patient’s abdominal dressing is saturated with
serosanguineous drainage and the patient reports a ‘popping’ sensation after coughing. What
is the nurse’s priority action?
A. Reinforce the dressing and document the findings.
B. Apply an abdominal binder tightly to prevent further drainage.
C. Place the patient in a low-Fowler’s position with knees bent.
D. Instruct the patient to perform deep breathing exercises immediately.
Answer: C
Rationale: The patient’s symptoms suggest wound dehiscence or potential evisceration
following surgery. Placing the patient in low-Fowler’s position with knees flexed minimizes
tension on the abdominal incision. The nurse should then cover the area with sterile,
saline-soaked dressings and notify the surgeon immediately.
3. Mr. Henderson is receiving a continuous intravenous infusion of heparin for the treatment
of a Deep Vein Thrombosis (DVT). Which laboratory value must the nurse monitor to evaluate
the effectiveness of this medication?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
,C. Platelet Count
D. Activated Partial Thromboplastin Time (aPTT)
Answer: D
Rationale: The aPTT is the standard laboratory test used to monitor the therapeutic effect
of unfractionated heparin. PT and INR are typically used to monitor warfarin therapy
rather than heparin. Monitoring the platelet count is also important to screen for heparin-
induced thrombocytopenia, but it does not measure the anticoagulant effectiveness of the
drug.
4. A nurse is preparing to administer 40 mg of Furosemide (Lasix) IV push to a patient with
Congestive Heart Failure. Which assessment finding should the nurse prioritize before
administration?
A. Serum potassium level
B. Blood pressure
C. Respiratory rate
D. Serum sodium level
Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of potassium, potentially
leading to hypokalemia. Administering this medication to a patient who is already
hypokalemic can cause dangerous cardiac arrhythmias. Therefore, checking the potassium
level is the highest safety priority before proceeding with the dose.
5. Mrs. Thompson is scheduled for an elective cholecystectomy. During the preoperative
assessment, she informs the nurse that she has a severe allergy to bananas and avocados.
What is the most critical action for the nurse to take?
A. Notify the surgical team to ensure a latex-free environment.
B. Document the food allergies in the nutritional assessment.
C. Request a dietary consult to modify the postoperative menu.
D. Ensure the patient receives an extra dose of antihistamines.
Answer: A
Rationale: There is a known cross-sensitivity between certain foods, such as bananas,
avocados, and kiwis, and latex. Patients with these food allergies are at a higher risk for
developing a latex allergy or anaphylaxis during surgery. Implementing latex-safe
precautions is essential to protect the patient’s safety throughout the perioperative period.
, 6. A 55-year-old patient with Type 2 Diabetes Mellitus is being treated for a foot ulcer. The
nurse notes the patient’s blood glucose is 450 mg/dL and there are ketones in the urine.
Which condition is the patient likely developing?
A. Hyperglycemic Hyperosmolar State (HHS)
B. Diabetes Insipidus
C. Diabetic Ketoacidosis (DKA)
D. Metabolic alkalosis
Answer: C
Rationale: While DKA is more common in Type 1 Diabetes, it can occur in Type 2 patients
under extreme stress or infection. The presence of significant hyperglycemia (450 mg/dL)
combined with ketonuria is diagnostic of DKA. HHS typically presents with much higher
glucose levels and an absence of ketones.
7. A nurse is teaching a patient who was recently diagnosed with Gastroesophageal Reflux
Disease (GERD). Which instruction should be included in the teaching plan?
A. Lie down for 30 minutes immediately after eating.
B. Eat three large meals a day to reduce stomach acid production.
C. Avoid caffeine, chocolate, and peppermint.
D. Wear tight-fitting clothing to support the abdominal muscles.
Answer: C
Rationale: Caffeine, chocolate, and peppermint are known to relax the lower esophageal
sphincter (LES), which allows gastric contents to reflux into the esophagus. Patients with
GERD should also be advised to eat small, frequent meals and avoid lying down for at least
2-3 hours after eating. Tight-fitting clothing should be avoided because it increases intra-
abdominal pressure, worsening the reflux.
8. A patient is admitted with suspected acute pancreatitis. Which laboratory result would the
nurse expect to see elevated?
A. Serum amylase
B. Serum calcium
C. Hemoglobin
D. Serum potassium
Answer: A
Rationale: Serum amylase and lipase are the hallmark enzymes that rise significantly
during acute pancreatitis. Calcium levels actually tend to decrease in severe pancreatitis
with Rationale (NUR 170 Exam 3) | Galen
1. A 68-year-old male patient, Mr. Miller, is admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). His arterial blood gas (ABG) results show pH 7.31,
PaCO2 52 mmHg, and HCO3 28 mEq/L. Which acid-base imbalance is Mr. Miller experiencing?
A. Respiratory acidosis, partially compensated
B. Metabolic acidosis, partially compensated
C. Respiratory alkalosis, uncompensated
D. Metabolic alkalosis, fully compensated
Answer: A
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The HCO3 is elevated above 26 mEq/L,
suggesting that the kidneys are attempting to compensate for the primary respiratory
issue. Because the pH has not yet returned to the normal range, the imbalance is
considered partially compensated.
2. A nurse is caring for Mrs. Jenkins, who is 24 hours post-abdominal surgery. Upon
assessment, the nurse notes that the patient’s abdominal dressing is saturated with
serosanguineous drainage and the patient reports a ‘popping’ sensation after coughing. What
is the nurse’s priority action?
A. Reinforce the dressing and document the findings.
B. Apply an abdominal binder tightly to prevent further drainage.
C. Place the patient in a low-Fowler’s position with knees bent.
D. Instruct the patient to perform deep breathing exercises immediately.
Answer: C
Rationale: The patient’s symptoms suggest wound dehiscence or potential evisceration
following surgery. Placing the patient in low-Fowler’s position with knees flexed minimizes
tension on the abdominal incision. The nurse should then cover the area with sterile,
saline-soaked dressings and notify the surgeon immediately.
3. Mr. Henderson is receiving a continuous intravenous infusion of heparin for the treatment
of a Deep Vein Thrombosis (DVT). Which laboratory value must the nurse monitor to evaluate
the effectiveness of this medication?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
,C. Platelet Count
D. Activated Partial Thromboplastin Time (aPTT)
Answer: D
Rationale: The aPTT is the standard laboratory test used to monitor the therapeutic effect
of unfractionated heparin. PT and INR are typically used to monitor warfarin therapy
rather than heparin. Monitoring the platelet count is also important to screen for heparin-
induced thrombocytopenia, but it does not measure the anticoagulant effectiveness of the
drug.
4. A nurse is preparing to administer 40 mg of Furosemide (Lasix) IV push to a patient with
Congestive Heart Failure. Which assessment finding should the nurse prioritize before
administration?
A. Serum potassium level
B. Blood pressure
C. Respiratory rate
D. Serum sodium level
Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of potassium, potentially
leading to hypokalemia. Administering this medication to a patient who is already
hypokalemic can cause dangerous cardiac arrhythmias. Therefore, checking the potassium
level is the highest safety priority before proceeding with the dose.
5. Mrs. Thompson is scheduled for an elective cholecystectomy. During the preoperative
assessment, she informs the nurse that she has a severe allergy to bananas and avocados.
What is the most critical action for the nurse to take?
A. Notify the surgical team to ensure a latex-free environment.
B. Document the food allergies in the nutritional assessment.
C. Request a dietary consult to modify the postoperative menu.
D. Ensure the patient receives an extra dose of antihistamines.
Answer: A
Rationale: There is a known cross-sensitivity between certain foods, such as bananas,
avocados, and kiwis, and latex. Patients with these food allergies are at a higher risk for
developing a latex allergy or anaphylaxis during surgery. Implementing latex-safe
precautions is essential to protect the patient’s safety throughout the perioperative period.
, 6. A 55-year-old patient with Type 2 Diabetes Mellitus is being treated for a foot ulcer. The
nurse notes the patient’s blood glucose is 450 mg/dL and there are ketones in the urine.
Which condition is the patient likely developing?
A. Hyperglycemic Hyperosmolar State (HHS)
B. Diabetes Insipidus
C. Diabetic Ketoacidosis (DKA)
D. Metabolic alkalosis
Answer: C
Rationale: While DKA is more common in Type 1 Diabetes, it can occur in Type 2 patients
under extreme stress or infection. The presence of significant hyperglycemia (450 mg/dL)
combined with ketonuria is diagnostic of DKA. HHS typically presents with much higher
glucose levels and an absence of ketones.
7. A nurse is teaching a patient who was recently diagnosed with Gastroesophageal Reflux
Disease (GERD). Which instruction should be included in the teaching plan?
A. Lie down for 30 minutes immediately after eating.
B. Eat three large meals a day to reduce stomach acid production.
C. Avoid caffeine, chocolate, and peppermint.
D. Wear tight-fitting clothing to support the abdominal muscles.
Answer: C
Rationale: Caffeine, chocolate, and peppermint are known to relax the lower esophageal
sphincter (LES), which allows gastric contents to reflux into the esophagus. Patients with
GERD should also be advised to eat small, frequent meals and avoid lying down for at least
2-3 hours after eating. Tight-fitting clothing should be avoided because it increases intra-
abdominal pressure, worsening the reflux.
8. A patient is admitted with suspected acute pancreatitis. Which laboratory result would the
nurse expect to see elevated?
A. Serum amylase
B. Serum calcium
C. Hemoglobin
D. Serum potassium
Answer: A
Rationale: Serum amylase and lipase are the hallmark enzymes that rise significantly
during acute pancreatitis. Calcium levels actually tend to decrease in severe pancreatitis
