NUR 170 Exam 2 V2 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 2) | Galen
1. A 65-year-old patient, Mr. Thompson, is admitted with an exacerbation of heart failure. He
is prescribed Furosemide 40 mg IV daily. Which laboratory finding should the nurse prioritize
reporting to the healthcare provider?
A. Sodium level of 136 mEq/L
B. Potassium level of 3.2 mEq/L
C. Calcium level of 9.2 mg/dL
D. Magnesium level of 1.9 mEq/L
Answer: B
Rationale: Furosemide is a loop diuretic that causes the excretion of potassium, potentially
leading to hypokalemia. A potassium level of 3.2 mEq/L is below the normal range of 3.5 to
5.0 mEq/L and can cause life-threatening cardiac dysrhythmias. The nurse must monitor
electrolyte levels closely and advocate for potassium supplementation when levels fall
below normal limits.
2. Ms. Davis is a 48-year-old patient scheduled for an elective cholecystectomy. During the
preoperative assessment, she expresses anxiety about the procedure. Which nursing
intervention is most appropriate at this time?
A. Provide the patient with an opportunity to ask questions and express her feelings.
B. Explain the entire surgical procedure in detail to the patient.
C. Tell the patient that everything will be fine and there is no need to worry.
D. Administer the preoperative sedative immediately to reduce anxiety.
Answer: A
Rationale: Active listening and providing a safe space for the patient to express concerns is
the first step in addressing preoperative anxiety. Detailed technical explanations may
increase anxiety, while false reassurance is non-therapeutic and dismissive of the patient’s
feelings. The nurse should facilitate communication and then provide targeted education to
address specific fears.
3. A 72-year-old male, Mr. Garcia, is 24 hours postoperative following a total hip
replacement. He complains of sudden shortness of breath and pleuritic chest pain. His heart
rate is 112 beats/minute, and his oxygen saturation is 89% on room air. What is the nurse’s
priority action?
A. Elevate the head of the bed and apply supplemental oxygen.
,B. Instruct the patient to use the incentive spirometer 10 times.
C. Obtain a 12-lead electrocardiogram (ECG).
D. Administer the prescribed PRN dose of Morphine.
Answer: A
Rationale: Sudden shortness of breath and chest pain in a postoperative orthopedic
patient are hallmark signs of a pulmonary embolism. Elevating the head of the bed
improves chest expansion and oxygenation while applying oxygen addresses the
immediate hypoxia. These are priority nursing actions before proceeding with diagnostic
testing such as an ECG or imaging.
4. Mrs. Baker is receiving a blood transfusion for symptomatic anemia. Ten minutes into the
transfusion, she reports back pain, chills, and becomes tachycardic. What is the nurse’s first
action?
A. Stop the transfusion immediately and disconnect the tubing.
B. Slow the rate of the transfusion and notify the physician.
C. Administer Diphenhydramine (Benadryl) as per PRN orders.
D. Document the symptoms and continue to monitor vital signs.
Answer: A
Rationale: The patient is exhibiting signs of an acute hemolytic reaction, which is a life-
threatening emergency. The nurse must stop the infusion immediately to prevent further
exposure to the incompatible blood product and disconnect the tubing at the hub.
Maintaining the IV line with normal saline using new tubing is the next step to ensure
access for emergency medications.
5. A patient with Type 1 Diabetes Mellitus, Mr. Evans, is found unconscious and diaphoretic.
His fingerstick blood glucose is 42 mg/dL. Which action should the nurse take first?
A. Administer 4 ounces of orange juice.
B. Administer 15 grams of simple carbohydrates orally.
C. Administer Glucagon 1 mg intramuscularly (IM).
D. Check the patient’s hemoglobin A1c level.
Answer: C
Rationale: Because the patient is unconscious and unable to swallow, oral carbohydrates
are contraindicated due to the risk of aspiration. Glucagon is the appropriate emergency
treatment for severe hypoglycemia in a patient who cannot take anything by mouth. Once
the patient regains consciousness and can safely swallow, a snack containing
carbohydrates and protein should be provided to maintain blood glucose levels.
, 6. A 55-year-old patient is admitted with a diagnosis of Chronic Obstructive Pulmonary
Disease (COPD) exacerbation. The patient’s arterial blood gas (ABG) results are: pH 7.31,
PaCO2 58 mmHg, and HCO3 26 mEq/L. The nurse interprets these results as representing
which condition?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH of 7.31 indicates acidosis, and the elevated PaCO2 of 58 mmHg confirms
that the cause is respiratory in origin, typical for COPD patients who retain CO2. The HCO3
is within the normal range, indicating that compensation has not yet occurred or is
incomplete. The nurse should prioritize interventions that improve ventilation and gas
exchange to normalize these values.
7. Ms. Wilson is post-operative Day 2 after an abdominal surgery. The nurse notes that the
patient’s incision has partially opened, and a loop of bowel is visible. What is the priority
nursing intervention?
A. Push the bowel back into the abdominal cavity gently.
B. Cover the exposed organ with sterile dressings soaked in sterile normal saline.
C. Place the patient in a high-Fowler’s position immediately.
D. Ask the patient to cough to check for further protrusion.
Answer: B
Rationale: Evisceration is a surgical emergency that requires immediate action to prevent
the bowel from drying out or becoming necrotic. The nurse should cover the site with
sterile saline-soaked gauze and notify the surgical team immediately. The patient should be
kept in a low-Fowler’s position with knees slightly flexed to reduce abdominal pressure
and remain NPO for potential emergency surgery.
8. A nurse is caring for a patient who is 4 hours postoperative from a thyroidectomy. The
patient reports a tingling sensation in the fingers and around the mouth. Which assessment
should the nurse perform next?
A. Assess for a positive Homan’s sign.
B. Check the patient’s blood pressure using a cuff to observe for Trousseau’s sign.
C. Evaluate the patient’s deep tendon reflexes for hyperreflexia.
D. Assess the surgical site for signs of hemorrhage or hematoma.
with Rationale (NUR 170 Exam 2) | Galen
1. A 65-year-old patient, Mr. Thompson, is admitted with an exacerbation of heart failure. He
is prescribed Furosemide 40 mg IV daily. Which laboratory finding should the nurse prioritize
reporting to the healthcare provider?
A. Sodium level of 136 mEq/L
B. Potassium level of 3.2 mEq/L
C. Calcium level of 9.2 mg/dL
D. Magnesium level of 1.9 mEq/L
Answer: B
Rationale: Furosemide is a loop diuretic that causes the excretion of potassium, potentially
leading to hypokalemia. A potassium level of 3.2 mEq/L is below the normal range of 3.5 to
5.0 mEq/L and can cause life-threatening cardiac dysrhythmias. The nurse must monitor
electrolyte levels closely and advocate for potassium supplementation when levels fall
below normal limits.
2. Ms. Davis is a 48-year-old patient scheduled for an elective cholecystectomy. During the
preoperative assessment, she expresses anxiety about the procedure. Which nursing
intervention is most appropriate at this time?
A. Provide the patient with an opportunity to ask questions and express her feelings.
B. Explain the entire surgical procedure in detail to the patient.
C. Tell the patient that everything will be fine and there is no need to worry.
D. Administer the preoperative sedative immediately to reduce anxiety.
Answer: A
Rationale: Active listening and providing a safe space for the patient to express concerns is
the first step in addressing preoperative anxiety. Detailed technical explanations may
increase anxiety, while false reassurance is non-therapeutic and dismissive of the patient’s
feelings. The nurse should facilitate communication and then provide targeted education to
address specific fears.
3. A 72-year-old male, Mr. Garcia, is 24 hours postoperative following a total hip
replacement. He complains of sudden shortness of breath and pleuritic chest pain. His heart
rate is 112 beats/minute, and his oxygen saturation is 89% on room air. What is the nurse’s
priority action?
A. Elevate the head of the bed and apply supplemental oxygen.
,B. Instruct the patient to use the incentive spirometer 10 times.
C. Obtain a 12-lead electrocardiogram (ECG).
D. Administer the prescribed PRN dose of Morphine.
Answer: A
Rationale: Sudden shortness of breath and chest pain in a postoperative orthopedic
patient are hallmark signs of a pulmonary embolism. Elevating the head of the bed
improves chest expansion and oxygenation while applying oxygen addresses the
immediate hypoxia. These are priority nursing actions before proceeding with diagnostic
testing such as an ECG or imaging.
4. Mrs. Baker is receiving a blood transfusion for symptomatic anemia. Ten minutes into the
transfusion, she reports back pain, chills, and becomes tachycardic. What is the nurse’s first
action?
A. Stop the transfusion immediately and disconnect the tubing.
B. Slow the rate of the transfusion and notify the physician.
C. Administer Diphenhydramine (Benadryl) as per PRN orders.
D. Document the symptoms and continue to monitor vital signs.
Answer: A
Rationale: The patient is exhibiting signs of an acute hemolytic reaction, which is a life-
threatening emergency. The nurse must stop the infusion immediately to prevent further
exposure to the incompatible blood product and disconnect the tubing at the hub.
Maintaining the IV line with normal saline using new tubing is the next step to ensure
access for emergency medications.
5. A patient with Type 1 Diabetes Mellitus, Mr. Evans, is found unconscious and diaphoretic.
His fingerstick blood glucose is 42 mg/dL. Which action should the nurse take first?
A. Administer 4 ounces of orange juice.
B. Administer 15 grams of simple carbohydrates orally.
C. Administer Glucagon 1 mg intramuscularly (IM).
D. Check the patient’s hemoglobin A1c level.
Answer: C
Rationale: Because the patient is unconscious and unable to swallow, oral carbohydrates
are contraindicated due to the risk of aspiration. Glucagon is the appropriate emergency
treatment for severe hypoglycemia in a patient who cannot take anything by mouth. Once
the patient regains consciousness and can safely swallow, a snack containing
carbohydrates and protein should be provided to maintain blood glucose levels.
, 6. A 55-year-old patient is admitted with a diagnosis of Chronic Obstructive Pulmonary
Disease (COPD) exacerbation. The patient’s arterial blood gas (ABG) results are: pH 7.31,
PaCO2 58 mmHg, and HCO3 26 mEq/L. The nurse interprets these results as representing
which condition?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH of 7.31 indicates acidosis, and the elevated PaCO2 of 58 mmHg confirms
that the cause is respiratory in origin, typical for COPD patients who retain CO2. The HCO3
is within the normal range, indicating that compensation has not yet occurred or is
incomplete. The nurse should prioritize interventions that improve ventilation and gas
exchange to normalize these values.
7. Ms. Wilson is post-operative Day 2 after an abdominal surgery. The nurse notes that the
patient’s incision has partially opened, and a loop of bowel is visible. What is the priority
nursing intervention?
A. Push the bowel back into the abdominal cavity gently.
B. Cover the exposed organ with sterile dressings soaked in sterile normal saline.
C. Place the patient in a high-Fowler’s position immediately.
D. Ask the patient to cough to check for further protrusion.
Answer: B
Rationale: Evisceration is a surgical emergency that requires immediate action to prevent
the bowel from drying out or becoming necrotic. The nurse should cover the site with
sterile saline-soaked gauze and notify the surgical team immediately. The patient should be
kept in a low-Fowler’s position with knees slightly flexed to reduce abdominal pressure
and remain NPO for potential emergency surgery.
8. A nurse is caring for a patient who is 4 hours postoperative from a thyroidectomy. The
patient reports a tingling sensation in the fingers and around the mouth. Which assessment
should the nurse perform next?
A. Assess for a positive Homan’s sign.
B. Check the patient’s blood pressure using a cuff to observe for Trousseau’s sign.
C. Evaluate the patient’s deep tendon reflexes for hyperreflexia.
D. Assess the surgical site for signs of hemorrhage or hematoma.
