Medical Surgical Nursing II (NU 185) Exam 3
Advanced Study Set Exam 3 Practice Questions,
Exams of Nursing
1. A patient receiving heparin infusion for venous thromboembolism has an aPTT of 98
seconds (therapeutic range 60-80 seconds). Which action should the nurse take first?
A. Continue the infusion and recheck aPTT in 6 hours.
B. Stop the heparin infusion and prepare to administer protamine sulfate.
C. Hold the next dose and notify the provider; anticipate dose reduction.
D. Administer vitamin K (phytonadione) IV push.
Answer: C
Rationale: An aPTT of 98 seconds exceeds the therapeutic range, indicating supratherapeutic
anticoagulation; the infusion should be held and the provider notified for dose adjustment.
Protamine sulfate is reserved for serious bleeding or overdose with clinical instability, not
routine supratherapeutic aPTT. Vitamin K reverses warfarin, not heparin.
2. Which assessment finding most urgently requires intervention in a patient with a new
tracheostomy?
A. Copious thin secretions requiring suction every 2 hours
B. Faint whistling sound heard over the tracheostomy site
C. Circumoral pallor and absent breath sounds on the right
D. Mild serosanguineous drainage on the dressing
Answer: C
Rationale: Absent breath sounds with pallor suggests tracheostomy obstruction or
pneumothorax, an airway emergency requiring immediate intervention. Whistling may indicate
partial obstruction but is less urgent than absent breath sounds. Serosanguineous drainage and
need for suctioning are expected findings.
3. A patient with chronic kidney disease (CKD) stage 4 has a serum potassium of 6.4
mEq/L and peaked T waves on ECG. Which prescription should the nurse anticipate
implementing first?
A. Oral sodium polystyrene sulfonate 15 g
B. IV calcium gluconate 10%
C. Regular insulin 10 units IV with 25 g dextrose
D. IV furosemide 40 mg
Answer: B
Page 1
,Rationale: IV calcium gluconate is given first to stabilize the myocardium and prevent lethal arrhythmias when
hyperkalemia causes ECG changes. Insulin/dextrose and furosemide shift or eliminate potassium but do not immediately
protect the heart. Sodium polystyrene sulfonate has a delayed onset.
4. A patient with type 1 diabetes is admitted with nausea, vomiting, and a blood glucose of
480 mg/dL. ABG shows pH 7.22 and HCO3 12 mEq/L. Which intervention is the priority?
A. Administer sodium bicarbonate IV push
B. Initiate an IV insulin infusion per protocol
C. Give subcutaneous insulin glargine only
D. Restrict fluids to prevent cerebral edema
Answer: B
Rationale: The presentation indicates diabetic ketoacidosis; an IV insulin infusion is the priority
to halt ketogenesis and lower glucose. Bicarbonate is not routinely recommended and may
worsen hypokalemia. Subcutaneous glargine alone is insufficient for acute DKA management,
and fluid restriction is contraindicated.
5. Which finding in a patient 24 hours after a total thyroidectomy requires immediate
notification of the provider?
A. Hoarseness when speaking
B. Serum calcium 7.2 mg/dL with tingling in fingertips
C. Drain output of 30 mL serosanguineous fluid
D. Pain at the incision site rated 4/10
Answer: B
Rationale: Hypocalcemia after thyroidectomy may indicate parathyroid injury and can progress
to tetany, laryngospasm, and seizures; immediate notification is required. Hoarseness may be
transient from surgical manipulation. Drain output and incisional pain are expected
postoperative findings.
6. A patient with an acute ischemic stroke has a blood pressure of 210/120 mm Hg and is
not a candidate for thrombolytics. Which action should the nurse anticipate?
A. Rapidly lower BP to below 120/80 mm Hg with IV labetalol
B. Withhold all antihypertensives for 72 hours
C. Lower BP by approximately 15% in the first 24 hours
D. Administer aspirin 325 mg chewed immediately
Answer: C
Rationale: In ischemic stroke without thrombolysis, guidelines recommend lowering BP by about
15% in the first 24 hours to maintain cerebral perfusion. Rapid normalization can worsen
ischemia. Aspirin is typically delayed 24 hours after thrombolysis exclusion, and withholding all
antihypertensives is unsafe at this pressure.
Page 2
,7. A patient with a new colostomy has a stoma that is dark purple and dry. Which action
should the nurse take?
A. Document as a normal finding and continue care
B. Apply a moist gauze dressing and reassess in 24 hours
C. Notify the surgeon immediately
D. Increase oral fluid intake and reassess
Answer: C
Rationale: A dark purple, dry stoma indicates ischemia/necrosis and requires immediate surgical
evaluation; a healthy stoma is pink to red and moist. Moist dressings and increased fluids do not
address compromised perfusion. Documenting as normal delays necessary intervention.
8. Which laboratory value is most important for the nurse to monitor in a patient receiving
continuous bladder irrigation after transurethral resection of the prostate (TURP)?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Answer: A
Rationale: TURP syndrome results from absorption of hypotonic irrigation fluid, causing
dilutional hyponatremia; serum sodium is the priority monitoring parameter. Potassium,
calcium, and magnesium are not the primary electrolytes affected by TURP syndrome.
9. A patient receiving chemotherapy has an absolute neutrophil count (ANC) of 400/mm³.
Which instruction is most important for the nurse to include in discharge teaching?
A. Avoid crowded places and report a temperature of 100.4°F (38°C) or higher immediately
B. Increase intake of fresh fruits and vegetables
C. Use a soft toothbrush and avoid flossing
D. Take acetaminophen for any fever
Answer: A
Rationale: Severe neutropenia (ANC < 500) increases risk for life-threatening infection; avoiding
crowds and reporting fever promptly is critical. Fresh fruits/vegetables may harbor pathogens
and are often restricted. Soft toothbrush use prevents bleeding but addresses thrombocytopenia,
and acetaminophen can mask fever.
10. A patient with acute decompensated heart failure is started on IV furosemide. Which
assessment finding best indicates the medication is producing the intended therapeutic
effect?
A. Serum potassium rises from 3.2 to 4.0 mEq/L
B. Urine output increases to 100 mL/hr with a 1.5 kg weight loss
C. Heart rate decreases from 110 to 88 beats/min
Page 3
, D. Bilateral crackles clear after a single dose
Answer: B
Rationale: Loop diuretics work by promoting diuresis, so increased urine output with
corresponding weight loss reflects effective decongestion. Potassium typically falls, not rises,
with furosemide. Heart rate and crackle changes are secondary and not the primary indicator of
diuretic efficacy.
11. A patient with chronic kidney disease has a serum potassium of 6.4 mEq/L and peaked
T waves on ECG. Which prescription should the nurse anticipate administering first?
A. Oral sodium polystyrene sulfonate
B. IV calcium gluconate
C. IV regular insulin with dextrose
D. IV furosemide
Answer: B
Rationale: IV calcium gluconate is given first to stabilize the myocardium and prevent lethal
dysrhythmias from hyperkalemia, acting within minutes without lowering potassium.
Insulin/dextrose and furosemide shift or eliminate potassium but take longer. Sodium polystyrene
sulfonate works slowly in the gut.
12. Which finding in a patient receiving a blood transfusion should prompt the nurse to
stop the transfusion immediately?
A. Temperature rise of 0.5°C (0.9°F) at 30 minutes
B. Mild urticaria at the IV site
C. Flank pain and dark urine
D. Complaint of feeling cold
Answer: C
Rationale: Flank pain and hemoglobinuria suggest acute hemolytic transfusion reaction,
requiring immediate cessation and emergency management. A low-grade fever may be a febrile
nonhemolytic reaction managed per protocol. Mild urticaria indicates a mild allergic reaction.
Feeling cold alone is nonspecific.
13. A patient is prescribed enoxaparin for DVT prophylaxis. Which laboratory value is
most important to monitor before administration?
A. International normalized ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Bleeding time
Answer: C
Rationale: Heparin-induced thrombocytopenia is a serious risk with low-molecular-weight
heparin, so platelet counts must be monitored. INR and aPTT are not used to monitor
enoxaparin. Bleeding time is not a standard monitoring test for LMWH therapy.
Page 4
Advanced Study Set Exam 3 Practice Questions,
Exams of Nursing
1. A patient receiving heparin infusion for venous thromboembolism has an aPTT of 98
seconds (therapeutic range 60-80 seconds). Which action should the nurse take first?
A. Continue the infusion and recheck aPTT in 6 hours.
B. Stop the heparin infusion and prepare to administer protamine sulfate.
C. Hold the next dose and notify the provider; anticipate dose reduction.
D. Administer vitamin K (phytonadione) IV push.
Answer: C
Rationale: An aPTT of 98 seconds exceeds the therapeutic range, indicating supratherapeutic
anticoagulation; the infusion should be held and the provider notified for dose adjustment.
Protamine sulfate is reserved for serious bleeding or overdose with clinical instability, not
routine supratherapeutic aPTT. Vitamin K reverses warfarin, not heparin.
2. Which assessment finding most urgently requires intervention in a patient with a new
tracheostomy?
A. Copious thin secretions requiring suction every 2 hours
B. Faint whistling sound heard over the tracheostomy site
C. Circumoral pallor and absent breath sounds on the right
D. Mild serosanguineous drainage on the dressing
Answer: C
Rationale: Absent breath sounds with pallor suggests tracheostomy obstruction or
pneumothorax, an airway emergency requiring immediate intervention. Whistling may indicate
partial obstruction but is less urgent than absent breath sounds. Serosanguineous drainage and
need for suctioning are expected findings.
3. A patient with chronic kidney disease (CKD) stage 4 has a serum potassium of 6.4
mEq/L and peaked T waves on ECG. Which prescription should the nurse anticipate
implementing first?
A. Oral sodium polystyrene sulfonate 15 g
B. IV calcium gluconate 10%
C. Regular insulin 10 units IV with 25 g dextrose
D. IV furosemide 40 mg
Answer: B
Page 1
,Rationale: IV calcium gluconate is given first to stabilize the myocardium and prevent lethal arrhythmias when
hyperkalemia causes ECG changes. Insulin/dextrose and furosemide shift or eliminate potassium but do not immediately
protect the heart. Sodium polystyrene sulfonate has a delayed onset.
4. A patient with type 1 diabetes is admitted with nausea, vomiting, and a blood glucose of
480 mg/dL. ABG shows pH 7.22 and HCO3 12 mEq/L. Which intervention is the priority?
A. Administer sodium bicarbonate IV push
B. Initiate an IV insulin infusion per protocol
C. Give subcutaneous insulin glargine only
D. Restrict fluids to prevent cerebral edema
Answer: B
Rationale: The presentation indicates diabetic ketoacidosis; an IV insulin infusion is the priority
to halt ketogenesis and lower glucose. Bicarbonate is not routinely recommended and may
worsen hypokalemia. Subcutaneous glargine alone is insufficient for acute DKA management,
and fluid restriction is contraindicated.
5. Which finding in a patient 24 hours after a total thyroidectomy requires immediate
notification of the provider?
A. Hoarseness when speaking
B. Serum calcium 7.2 mg/dL with tingling in fingertips
C. Drain output of 30 mL serosanguineous fluid
D. Pain at the incision site rated 4/10
Answer: B
Rationale: Hypocalcemia after thyroidectomy may indicate parathyroid injury and can progress
to tetany, laryngospasm, and seizures; immediate notification is required. Hoarseness may be
transient from surgical manipulation. Drain output and incisional pain are expected
postoperative findings.
6. A patient with an acute ischemic stroke has a blood pressure of 210/120 mm Hg and is
not a candidate for thrombolytics. Which action should the nurse anticipate?
A. Rapidly lower BP to below 120/80 mm Hg with IV labetalol
B. Withhold all antihypertensives for 72 hours
C. Lower BP by approximately 15% in the first 24 hours
D. Administer aspirin 325 mg chewed immediately
Answer: C
Rationale: In ischemic stroke without thrombolysis, guidelines recommend lowering BP by about
15% in the first 24 hours to maintain cerebral perfusion. Rapid normalization can worsen
ischemia. Aspirin is typically delayed 24 hours after thrombolysis exclusion, and withholding all
antihypertensives is unsafe at this pressure.
Page 2
,7. A patient with a new colostomy has a stoma that is dark purple and dry. Which action
should the nurse take?
A. Document as a normal finding and continue care
B. Apply a moist gauze dressing and reassess in 24 hours
C. Notify the surgeon immediately
D. Increase oral fluid intake and reassess
Answer: C
Rationale: A dark purple, dry stoma indicates ischemia/necrosis and requires immediate surgical
evaluation; a healthy stoma is pink to red and moist. Moist dressings and increased fluids do not
address compromised perfusion. Documenting as normal delays necessary intervention.
8. Which laboratory value is most important for the nurse to monitor in a patient receiving
continuous bladder irrigation after transurethral resection of the prostate (TURP)?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Answer: A
Rationale: TURP syndrome results from absorption of hypotonic irrigation fluid, causing
dilutional hyponatremia; serum sodium is the priority monitoring parameter. Potassium,
calcium, and magnesium are not the primary electrolytes affected by TURP syndrome.
9. A patient receiving chemotherapy has an absolute neutrophil count (ANC) of 400/mm³.
Which instruction is most important for the nurse to include in discharge teaching?
A. Avoid crowded places and report a temperature of 100.4°F (38°C) or higher immediately
B. Increase intake of fresh fruits and vegetables
C. Use a soft toothbrush and avoid flossing
D. Take acetaminophen for any fever
Answer: A
Rationale: Severe neutropenia (ANC < 500) increases risk for life-threatening infection; avoiding
crowds and reporting fever promptly is critical. Fresh fruits/vegetables may harbor pathogens
and are often restricted. Soft toothbrush use prevents bleeding but addresses thrombocytopenia,
and acetaminophen can mask fever.
10. A patient with acute decompensated heart failure is started on IV furosemide. Which
assessment finding best indicates the medication is producing the intended therapeutic
effect?
A. Serum potassium rises from 3.2 to 4.0 mEq/L
B. Urine output increases to 100 mL/hr with a 1.5 kg weight loss
C. Heart rate decreases from 110 to 88 beats/min
Page 3
, D. Bilateral crackles clear after a single dose
Answer: B
Rationale: Loop diuretics work by promoting diuresis, so increased urine output with
corresponding weight loss reflects effective decongestion. Potassium typically falls, not rises,
with furosemide. Heart rate and crackle changes are secondary and not the primary indicator of
diuretic efficacy.
11. A patient with chronic kidney disease has a serum potassium of 6.4 mEq/L and peaked
T waves on ECG. Which prescription should the nurse anticipate administering first?
A. Oral sodium polystyrene sulfonate
B. IV calcium gluconate
C. IV regular insulin with dextrose
D. IV furosemide
Answer: B
Rationale: IV calcium gluconate is given first to stabilize the myocardium and prevent lethal
dysrhythmias from hyperkalemia, acting within minutes without lowering potassium.
Insulin/dextrose and furosemide shift or eliminate potassium but take longer. Sodium polystyrene
sulfonate works slowly in the gut.
12. Which finding in a patient receiving a blood transfusion should prompt the nurse to
stop the transfusion immediately?
A. Temperature rise of 0.5°C (0.9°F) at 30 minutes
B. Mild urticaria at the IV site
C. Flank pain and dark urine
D. Complaint of feeling cold
Answer: C
Rationale: Flank pain and hemoglobinuria suggest acute hemolytic transfusion reaction,
requiring immediate cessation and emergency management. A low-grade fever may be a febrile
nonhemolytic reaction managed per protocol. Mild urticaria indicates a mild allergic reaction.
Feeling cold alone is nonspecific.
13. A patient is prescribed enoxaparin for DVT prophylaxis. Which laboratory value is
most important to monitor before administration?
A. International normalized ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Bleeding time
Answer: C
Rationale: Heparin-induced thrombocytopenia is a serious risk with low-molecular-weight
heparin, so platelet counts must be monitored. INR and aPTT are not used to monitor
enoxaparin. Bleeding time is not a standard monitoring test for LMWH therapy.
Page 4
