NUR 170 Final Exam V2 | NUR 170 Medical-Surgical Nursing | Actual
Q&A with Rationale (NUR 170 Final Exam) | Galen
1. A 68-year-old male patient, Mr. Thompson, is admitted to the telemetry unit with a
diagnosis of acute heart failure exacerbation. He reports sudden onset of shortness of breath
and is coughing up pink, frothy sputum. Which action should the nurse prioritize first?
A. Obtain a 12-lead electrocardiogram (ECG).
B. Position the patient in high-Fowler’s with legs dependent.
C. Administer the prescribed dose of IV furosemide.
D. Auscultate the patient’s breath sounds for crackles.
Answer: B
Rationale: In acute pulmonary edema, immediate positioning is the first priority to
decrease venous return (preload) and improve respiratory excursion. High-Fowler’s
position allows for maximum chest expansion and reduces the work of breathing. While
diuretics and assessments are necessary, physical positioning provides the most immediate
relief for acute respiratory distress before pharmacological interventions take effect.
2. Mrs. Garcia is a 45-year-old post-operative patient who underwent a total thyroidectomy
12 hours ago. During the assessment, the nurse notes that the patient is complaining of
numbness and tingling in her fingers and around her mouth. Which medication should the
nurse ensure is readily available?
A. Potassium chloride
B. Sodium bicarbonate
C. Calcium gluconate
D. Magnesium sulfate
Answer: C
Rationale: Numbness and tingling (paresthesia) after a thyroidectomy are early signs of
hypocalcemia, which can occur if the parathyroid glands were accidentally removed or
damaged. If left untreated, this can progress to tetany and laryngospasm, which is a
medical emergency. Calcium gluconate is the standard treatment to rapidly restore serum
calcium levels and prevent life-threatening complications.
3. A 54-year-old patient with a history of Chronic Obstructive Pulmonary Disease (COPD) is
being discharged. The nurse is providing education regarding the use of a dry powder inhaler
(DPI). Which statement by the patient indicates a need for further teaching?
A. I should breathe in fast and deep when using this inhaler.
,B. I will rinse my mouth out with water after using the medicine.
C. I should shake the inhaler vigorously for 10 seconds before use.
D. I will hold my breath for about 10 seconds after inhaling.
Answer: C
Rationale: Unlike Metered Dose Inhalers (MDIs), Dry Powder Inhalers (DPIs) should not
be shaken as this may cause the pre-measured dose to be lost or spilled. The patient should
breathe in rapidly and deeply to ensure the powder reaches the lower airways. Rinsing the
mouth is essential to prevent oral candidiasis, especially if the DPI contains a
corticosteroid.
4. Mr. Roberts is a 62-year-old male hospitalized for a deep vein thrombosis (DVT) in his right
calf. He is currently receiving a continuous IV heparin infusion. The nurse notes the most
recent aPTT is 110 seconds (Control: 25-35 seconds). What is the nurse’s priority action?
A. Increase the infusion rate as per the heparin protocol.
B. Stop the heparin infusion and notify the healthcare provider.
C. Document the finding and continue to monitor for bleeding.
D. Administer Vitamin K as an antidote for heparin.
Answer: B
Rationale: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5
times the control value (approx. 45-70 seconds). An aPTT of 110 seconds is significantly
elevated, putting the patient at high risk for spontaneous hemorrhage. The nurse must stop
the infusion immediately to prevent further anticoagulation and contact the provider for
further orders; Protamine Sulfate, not Vitamin K, is the antidote for heparin.
5. A nurse is caring for a patient who is 2 days post-operative following an abdominal surgery.
The patient reports a ‘popping’ sensation after sneezing, and the nurse observes that the
surgical wound has opened, with loops of bowel visible. What is the immediate nursing
intervention?
A. Cover the protruding organs with sterile dressings soaked in normal saline.
B. Apply a dry, sterile pressure dressing to the site.
C. Attempt to gently push the organs back into the abdominal cavity.
D. Ask the patient to sit up to reduce abdominal pressure.
Answer: A
Rationale: Wound evisceration is a surgical emergency. The nurse must cover the exposed
abdominal contents with sterile gauze soaked in warm sterile normal saline to prevent the
tissue from drying out or becoming necrotic. The patient should be kept in a low-Fowler’s
, position with knees flexed to reduce tension on the abdominal wall, and the surgeon must
be notified immediately.
6. Ms. Baker, a 30-year-old female, is admitted for a suspected exacerbation of Systemic
Lupus Erythematosus (SLE). Which clinical manifestation is most characteristic of this
autoimmune disorder?
A. A scaly, red rash over the extensor surfaces of the elbows.
B. Painless, small white nodules on the ear pinnae.
C. A butterfly-shaped rash across the bridge of the nose and cheeks.
D. Thickened, hardened skin on the fingers and hands.
Answer: C
Rationale: A malar or ‘butterfly’ rash is a classic diagnostic sign of Systemic Lupus
Erythematosus. This rash is often triggered or exacerbated by exposure to sunlight
(photosensitivity). While SLE can affect many organ systems, the facial rash is a hallmark
skin manifestation that distinguishes it from other connective tissue diseases like
scleroderma or psoriasis.
7. A patient with Type 1 Diabetes Mellitus is found unconscious in the hallway. The nurse is
unable to obtain a capillary blood glucose reading immediately. Which action is most
appropriate?
A. Administer 1 mg of Glucagon intramuscularly (IM).
B. Administer 15 grams of simple carbohydrates orally.
C. Wait for the lab to perform a stat venipuncture.
D. Start a bolus of 0.9% Normal Saline.
Answer: A
Rationale: If a diabetic patient is unconscious and hypoglycemia is suspected, the nurse
should treat for hypoglycemia immediately, as it is more acutely life-threatening than
hyperglycemia. Since the patient is unconscious and cannot safely swallow, oral
carbohydrates are contraindicated due to aspiration risk. Glucagon IM or IV Dextrose (D50)
are the treatments of choice to rapidly elevate blood glucose levels in an emergency.
8. Mr. Lee is a 72-year-old male with a history of Benign Prostatic Hyperplasia (BPH) who is 4
hours post-operative following a Transurethral Resection of the Prostate (TURP). He has a
three-way urinary catheter with continuous bladder irrigation (CBI). The nurse notices the
drainage has become bright red with numerous large clots. Which action should the nurse
take?
A. Decrease the rate of the continuous bladder irrigation.
B. Increase the flow rate of the irrigation fluid.
Q&A with Rationale (NUR 170 Final Exam) | Galen
1. A 68-year-old male patient, Mr. Thompson, is admitted to the telemetry unit with a
diagnosis of acute heart failure exacerbation. He reports sudden onset of shortness of breath
and is coughing up pink, frothy sputum. Which action should the nurse prioritize first?
A. Obtain a 12-lead electrocardiogram (ECG).
B. Position the patient in high-Fowler’s with legs dependent.
C. Administer the prescribed dose of IV furosemide.
D. Auscultate the patient’s breath sounds for crackles.
Answer: B
Rationale: In acute pulmonary edema, immediate positioning is the first priority to
decrease venous return (preload) and improve respiratory excursion. High-Fowler’s
position allows for maximum chest expansion and reduces the work of breathing. While
diuretics and assessments are necessary, physical positioning provides the most immediate
relief for acute respiratory distress before pharmacological interventions take effect.
2. Mrs. Garcia is a 45-year-old post-operative patient who underwent a total thyroidectomy
12 hours ago. During the assessment, the nurse notes that the patient is complaining of
numbness and tingling in her fingers and around her mouth. Which medication should the
nurse ensure is readily available?
A. Potassium chloride
B. Sodium bicarbonate
C. Calcium gluconate
D. Magnesium sulfate
Answer: C
Rationale: Numbness and tingling (paresthesia) after a thyroidectomy are early signs of
hypocalcemia, which can occur if the parathyroid glands were accidentally removed or
damaged. If left untreated, this can progress to tetany and laryngospasm, which is a
medical emergency. Calcium gluconate is the standard treatment to rapidly restore serum
calcium levels and prevent life-threatening complications.
3. A 54-year-old patient with a history of Chronic Obstructive Pulmonary Disease (COPD) is
being discharged. The nurse is providing education regarding the use of a dry powder inhaler
(DPI). Which statement by the patient indicates a need for further teaching?
A. I should breathe in fast and deep when using this inhaler.
,B. I will rinse my mouth out with water after using the medicine.
C. I should shake the inhaler vigorously for 10 seconds before use.
D. I will hold my breath for about 10 seconds after inhaling.
Answer: C
Rationale: Unlike Metered Dose Inhalers (MDIs), Dry Powder Inhalers (DPIs) should not
be shaken as this may cause the pre-measured dose to be lost or spilled. The patient should
breathe in rapidly and deeply to ensure the powder reaches the lower airways. Rinsing the
mouth is essential to prevent oral candidiasis, especially if the DPI contains a
corticosteroid.
4. Mr. Roberts is a 62-year-old male hospitalized for a deep vein thrombosis (DVT) in his right
calf. He is currently receiving a continuous IV heparin infusion. The nurse notes the most
recent aPTT is 110 seconds (Control: 25-35 seconds). What is the nurse’s priority action?
A. Increase the infusion rate as per the heparin protocol.
B. Stop the heparin infusion and notify the healthcare provider.
C. Document the finding and continue to monitor for bleeding.
D. Administer Vitamin K as an antidote for heparin.
Answer: B
Rationale: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5
times the control value (approx. 45-70 seconds). An aPTT of 110 seconds is significantly
elevated, putting the patient at high risk for spontaneous hemorrhage. The nurse must stop
the infusion immediately to prevent further anticoagulation and contact the provider for
further orders; Protamine Sulfate, not Vitamin K, is the antidote for heparin.
5. A nurse is caring for a patient who is 2 days post-operative following an abdominal surgery.
The patient reports a ‘popping’ sensation after sneezing, and the nurse observes that the
surgical wound has opened, with loops of bowel visible. What is the immediate nursing
intervention?
A. Cover the protruding organs with sterile dressings soaked in normal saline.
B. Apply a dry, sterile pressure dressing to the site.
C. Attempt to gently push the organs back into the abdominal cavity.
D. Ask the patient to sit up to reduce abdominal pressure.
Answer: A
Rationale: Wound evisceration is a surgical emergency. The nurse must cover the exposed
abdominal contents with sterile gauze soaked in warm sterile normal saline to prevent the
tissue from drying out or becoming necrotic. The patient should be kept in a low-Fowler’s
, position with knees flexed to reduce tension on the abdominal wall, and the surgeon must
be notified immediately.
6. Ms. Baker, a 30-year-old female, is admitted for a suspected exacerbation of Systemic
Lupus Erythematosus (SLE). Which clinical manifestation is most characteristic of this
autoimmune disorder?
A. A scaly, red rash over the extensor surfaces of the elbows.
B. Painless, small white nodules on the ear pinnae.
C. A butterfly-shaped rash across the bridge of the nose and cheeks.
D. Thickened, hardened skin on the fingers and hands.
Answer: C
Rationale: A malar or ‘butterfly’ rash is a classic diagnostic sign of Systemic Lupus
Erythematosus. This rash is often triggered or exacerbated by exposure to sunlight
(photosensitivity). While SLE can affect many organ systems, the facial rash is a hallmark
skin manifestation that distinguishes it from other connective tissue diseases like
scleroderma or psoriasis.
7. A patient with Type 1 Diabetes Mellitus is found unconscious in the hallway. The nurse is
unable to obtain a capillary blood glucose reading immediately. Which action is most
appropriate?
A. Administer 1 mg of Glucagon intramuscularly (IM).
B. Administer 15 grams of simple carbohydrates orally.
C. Wait for the lab to perform a stat venipuncture.
D. Start a bolus of 0.9% Normal Saline.
Answer: A
Rationale: If a diabetic patient is unconscious and hypoglycemia is suspected, the nurse
should treat for hypoglycemia immediately, as it is more acutely life-threatening than
hyperglycemia. Since the patient is unconscious and cannot safely swallow, oral
carbohydrates are contraindicated due to aspiration risk. Glucagon IM or IV Dextrose (D50)
are the treatments of choice to rapidly elevate blood glucose levels in an emergency.
8. Mr. Lee is a 72-year-old male with a history of Benign Prostatic Hyperplasia (BPH) who is 4
hours post-operative following a Transurethral Resection of the Prostate (TURP). He has a
three-way urinary catheter with continuous bladder irrigation (CBI). The nurse notices the
drainage has become bright red with numerous large clots. Which action should the nurse
take?
A. Decrease the rate of the continuous bladder irrigation.
B. Increase the flow rate of the irrigation fluid.
