NUR 170 Exam 2 V2 | NUR 170 Medical-Surgical
Nursing | Actual Q&A with Rationale (NUR 170
Exam 2) | Galen
1. A 68-year-old male patient, Mr. Miller, is admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). He is currently receiving oxygen at 2 L/min via nasal
cannula. His SpO2 is 89%, and he appears restless with a respiratory rate of 28 breaths/min.
Which action should the nurse take first?
A. Assist the patient into a high-Fowler’s or tripod position.
B. Increase the oxygen flow rate to 6 L/min via simple mask.
C. Administer a PRN dose of intravenous methylprednisolone.
D. Perform a rapid arterial blood gas (ABG) analysis.
Correct Answer: A
Explanation: Assisting the patient into a tripod or high-Fowler’s position promotes
maximal chest expansion and reduces the work of breathing, which is the immediate non-
invasive priority for a patient in respiratory distress. While oxygen titration is important in
COPD, increasing it too high can suppress the hypoxic drive, so positioning should come
first. The nurse should also reassess the patient’s status after positioning before escalating
pharmacological or invasive interventions.
,2. Mrs. Bennett, a 54-year-old patient with a history of heart failure, presents to the clinic
complaining of increased shortness of breath and a persistent cough that produces frothy,
pink-tinged sputum. Upon auscultation, the nurse notes crackles in the lung bases. Which
condition does the nurse suspect?
A. Left-sided heart failure leading to pulmonary edema.
B. Pulmonary embolism resulting from deep vein thrombosis.
C. Right-sided heart failure causing systemic congestion.
D. Bacterial pneumonia with associated pleuritic pain.
Correct Answer: A
Explanation: Pink, frothy sputum is a classic clinical manifestation of acute pulmonary
edema, which results from left-sided heart failure causing fluid to back up into the
pulmonary circulation. The presence of crackles in the lung bases further supports the
diagnosis of fluid accumulation in the alveoli. The nurse must prioritize oxygenation and
prepare for diuretic administration to reduce preload and pulmonary congestion.
3. Mr. Harrison, a 72-year-old patient diagnosed with Stage 4 Chronic Kidney Disease (CKD),
has a serum potassium level of 6.4 mEq/L. The nurse observes peaked T-waves on the cardiac
monitor. Which medication should the nurse anticipate administering first to protect the
heart?
A. Sodium polystyrene sulfonate orally.
B. Regular insulin and D50W intravenously.
,C. Intravenous Calcium Gluconate.
D. Furosemide intravenously.
Correct Answer: C
Explanation: In the presence of hyperkalemia with EKG changes like peaked T-waves, the
immediate priority is to stabilize the myocardial cell membrane to prevent lethal
arrhythmias. Calcium gluconate does not lower potassium levels but protects the heart
while other treatments are initiated to shift or remove potassium. After stabilization,
medications like insulin/Dextrose or Kayexalate can be used to actually lower the serum
potassium concentration.
4. A patient, Sarah, is 24 hours post-operative following a total hip arthroplasty. The nurse is
assessing for potential complications. Which finding would most strongly suggest the
development of a Deep Vein Thrombosis (DVT)?
A. Bilateral 1+ pitting edema in the lower extremities.
B. Unilateral calf warmth, redness, and tenderness.
C. Diminished pedal pulses in the affected extremity.
D. Muscle cramping related to prolonged immobility.
Correct Answer: B
Explanation: Unilateral symptoms such as swelling, warmth, and tenderness in one calf
are hallmark signs of a DVT in a post-operative patient. Bilateral edema is more often
associated with systemic issues like heart failure or fluid overload rather than a localized
, clot. The nurse should immediately notify the provider and avoid massaging the area to
prevent the clot from dislodging and becoming a pulmonary embolism.
5. Mr. Thompson is admitted with Acute Pancreatitis. He reports severe epigastric pain
radiating to his back, rated at 9/10. Which nursing intervention is the highest priority during
the acute phase of this illness?
A. Encouraging a high-protein, low-fat diet to promote healing.
B. Maintaining strict NPO status to rest the pancreas.
C. Administering oral pancreatic enzymes with every meal.
D. Teaching the patient about the importance of alcohol cessation.
Correct Answer: B
Explanation: During the acute phase of pancreatitis, keeping the patient NPO (nothing by
mouth) is essential to minimize pancreatic stimulation and the secretion of digestive
enzymes that cause self-digestion of the organ. This intervention helps reduce pain and
allows the inflammation to subside. Once the acute phase resolves and pain decreases, the
patient can gradually reintroduce clear liquids and low-fat foods.
6. A 45-year-old female patient is being treated for Grave’s Disease. She underwent a
subtotal thyroidectomy this morning. During the evening assessment, she complains of
numbness and tingling around her mouth and in her fingertips. What is the nurse’s first
action?
A. Check the patient’s temperature for signs of thyroid storm.
Nursing | Actual Q&A with Rationale (NUR 170
Exam 2) | Galen
1. A 68-year-old male patient, Mr. Miller, is admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). He is currently receiving oxygen at 2 L/min via nasal
cannula. His SpO2 is 89%, and he appears restless with a respiratory rate of 28 breaths/min.
Which action should the nurse take first?
A. Assist the patient into a high-Fowler’s or tripod position.
B. Increase the oxygen flow rate to 6 L/min via simple mask.
C. Administer a PRN dose of intravenous methylprednisolone.
D. Perform a rapid arterial blood gas (ABG) analysis.
Correct Answer: A
Explanation: Assisting the patient into a tripod or high-Fowler’s position promotes
maximal chest expansion and reduces the work of breathing, which is the immediate non-
invasive priority for a patient in respiratory distress. While oxygen titration is important in
COPD, increasing it too high can suppress the hypoxic drive, so positioning should come
first. The nurse should also reassess the patient’s status after positioning before escalating
pharmacological or invasive interventions.
,2. Mrs. Bennett, a 54-year-old patient with a history of heart failure, presents to the clinic
complaining of increased shortness of breath and a persistent cough that produces frothy,
pink-tinged sputum. Upon auscultation, the nurse notes crackles in the lung bases. Which
condition does the nurse suspect?
A. Left-sided heart failure leading to pulmonary edema.
B. Pulmonary embolism resulting from deep vein thrombosis.
C. Right-sided heart failure causing systemic congestion.
D. Bacterial pneumonia with associated pleuritic pain.
Correct Answer: A
Explanation: Pink, frothy sputum is a classic clinical manifestation of acute pulmonary
edema, which results from left-sided heart failure causing fluid to back up into the
pulmonary circulation. The presence of crackles in the lung bases further supports the
diagnosis of fluid accumulation in the alveoli. The nurse must prioritize oxygenation and
prepare for diuretic administration to reduce preload and pulmonary congestion.
3. Mr. Harrison, a 72-year-old patient diagnosed with Stage 4 Chronic Kidney Disease (CKD),
has a serum potassium level of 6.4 mEq/L. The nurse observes peaked T-waves on the cardiac
monitor. Which medication should the nurse anticipate administering first to protect the
heart?
A. Sodium polystyrene sulfonate orally.
B. Regular insulin and D50W intravenously.
,C. Intravenous Calcium Gluconate.
D. Furosemide intravenously.
Correct Answer: C
Explanation: In the presence of hyperkalemia with EKG changes like peaked T-waves, the
immediate priority is to stabilize the myocardial cell membrane to prevent lethal
arrhythmias. Calcium gluconate does not lower potassium levels but protects the heart
while other treatments are initiated to shift or remove potassium. After stabilization,
medications like insulin/Dextrose or Kayexalate can be used to actually lower the serum
potassium concentration.
4. A patient, Sarah, is 24 hours post-operative following a total hip arthroplasty. The nurse is
assessing for potential complications. Which finding would most strongly suggest the
development of a Deep Vein Thrombosis (DVT)?
A. Bilateral 1+ pitting edema in the lower extremities.
B. Unilateral calf warmth, redness, and tenderness.
C. Diminished pedal pulses in the affected extremity.
D. Muscle cramping related to prolonged immobility.
Correct Answer: B
Explanation: Unilateral symptoms such as swelling, warmth, and tenderness in one calf
are hallmark signs of a DVT in a post-operative patient. Bilateral edema is more often
associated with systemic issues like heart failure or fluid overload rather than a localized
, clot. The nurse should immediately notify the provider and avoid massaging the area to
prevent the clot from dislodging and becoming a pulmonary embolism.
5. Mr. Thompson is admitted with Acute Pancreatitis. He reports severe epigastric pain
radiating to his back, rated at 9/10. Which nursing intervention is the highest priority during
the acute phase of this illness?
A. Encouraging a high-protein, low-fat diet to promote healing.
B. Maintaining strict NPO status to rest the pancreas.
C. Administering oral pancreatic enzymes with every meal.
D. Teaching the patient about the importance of alcohol cessation.
Correct Answer: B
Explanation: During the acute phase of pancreatitis, keeping the patient NPO (nothing by
mouth) is essential to minimize pancreatic stimulation and the secretion of digestive
enzymes that cause self-digestion of the organ. This intervention helps reduce pain and
allows the inflammation to subside. Once the acute phase resolves and pain decreases, the
patient can gradually reintroduce clear liquids and low-fat foods.
6. A 45-year-old female patient is being treated for Grave’s Disease. She underwent a
subtotal thyroidectomy this morning. During the evening assessment, she complains of
numbness and tingling around her mouth and in her fingertips. What is the nurse’s first
action?
A. Check the patient’s temperature for signs of thyroid storm.
