PNR 408 Medical-Surgical Nursing Final Exam Lewis Chapters
54 56 59 61 63 2026/2027 - Questions and Answers 100%
Verified Detailed Rationales - Pass Guaranteed - A+ Graded
This final examination assesses mastery of high-acuity medical-surgical nursing across five Lewis chapters:
neurological (ICP, stroke, seizures), musculoskeletal (fractures, compartment syndrome, joint replacement),
renal/urinary (AKI, CKD, dialysis, electrolyte-acid base), reproductive (prostate, hysterectomy, breast, STIs), and
endocrine (DKA, thyroid storm, SIADH, adrenal crisis) disorders. Items emphasize clinical judgment,
prioritization, and evidence-based management per the NCSBN Clinical Judgment Measurement Model and Lewis
12th edition. It contains 94 multiple-choice questions, each with four distractors and a fully worked rationale that
explains why the keyed answer is correct. Questions are organized into clearly labelled sections that mirror the
major content areas of the course. Targeted learning outcomes include: Apply the NCSBN Clinical Judgment
Measurement Model to prioritize nursing care for patients with complex medical-surgical disorders.; Analyze
laboratory and diagnostic data to differentiate acute versus chronic disease processes and select appropriate
interventions.; Evaluate the effectiveness of prescribed therapies and identify complications requiring immediate
provider notification.; Synthesize pathophysiologic concepts to predict risk and implement prevention strategies
across neurological, musculoskeletal, renal, reproductive, and endocrine systems.. Every item has been reviewed
for clinical accuracy, current guidelines, and clarity so that students can study with confidence and self-correct as
they work through the bank. Use it as a high-yield review immediately before the exam, or as a structured practice
Section 1: General (Questions 1-94)
1 Which early sign best differentiates increasing intracranial pressure from
opioid-induced sedation?
A) Pinpoint pupils with bradypnea
B) Restlessness and confusion with unchanged pupils
C) Decreased deep tendon reflexes
D) Systolic hypertension with widened pulse pressure
Answer: B
Rationale: Restlessness and confusion are early signs of rising ICP; opioid sedation
causes pinpoint pupils and bradypnea without ICP changes. Widened pulse pressure
is a late Cushing response. Decreased reflexes are nonspecific.
2 Which finding most urgently suggests compartment syndrome after a tibial
fracture?
A) Pain relieved by elevation and analgesia
B) Pallor and pulselessness distally
C) Pain with passive stretch of toes
D) Mild swelling and warmth at site
Answer: C
Rationale: Pain with passive stretch is the earliest and most sensitive indicator of
,compartment syndrome. Pulselessness and pallor are late signs. Elevation may
worsen ischemia; mild swelling is expected.
3 Which parameter best detects early acute kidney injury in a critically ill patient?
A) Serum creatinine rise of 0.3 mg/dL in 48 hours
B) Urine output of 0.6 mL/kg/hr for 6 hours
C) BUN-to-creatinine ratio of 12:1
D) Serum potassium of 4.8 mEq/L
Answer: A
Rationale: KDIGO criteria define AKI as a creatinine increase "e0.3 mg/dL within 48
hours or 1.5 times baseline within 7 days. Oliguria (<0.5 mL/kg/hr for 6 hours) is
also diagnostic, but 0.6 mL/kg/hr does not meet threshold. BUN:creatinine of 12:1 is
normal; potassium 4.8 is within normal limits.
4 Which assessment finding is most concerning after transurethral resection of the
prostate?
A) Serum sodium 128 mEq/L with confusion
B) Pink-tinged urine with clots
C) Bladder spasms relieved by antispasmodics
D) Urine output 50 mL/hr via catheter
Answer: A
Rationale: Hyponatremia with confusion indicates TUR syndrome from absorption
of irrigation fluid, a life-threatening complication. Pink urine and clots are expected;
spasms are common and treatable; urine output of 50 mL/hr is adequate.
5 Which laboratory pattern is most consistent with diabetic ketoacidosis?
A) pH 7.30, HCO3 15, glucose 450, positive ketones
B) pH 7.50, HCO3 30, glucose 600, negative ketones
C) pH 7.35, HCO3 24, glucose 200, trace ketones
D) pH 7.25, HCO3 20, glucose 300, negative ketones
Answer: A
Rationale: DKA presents with metabolic acidosis (pH <7.35, HCO3 <18),
hyperglycemia >250 mg/dL, and ketonemia/ketonuria. Option B describes
hyperglycemic hyperosmolar state. Option C is normal. Option D lacks ketones.
6 Which intervention is priority for a patient with acute ischemic stroke and
aphasia?
A) Maintain NPO until swallow screen completed
,B) Encourage frequent oral fluids
C) Provide a picture board for communication
D) Perform passive range-of-motion exercises
Answer: A
Rationale: Aphasia often accompanies dysphagia; NPO until a swallow screen
prevents aspiration, the priority safety concern. Communication boards and ROM
are important but not immediate life-preserving priorities. Oral fluids could cause
aspiration.
7 Which finding most suggests thyroid storm in a patient with Graves' disease?
A) Temperature 102.2°F, tachycardia, agitation
B) Weight gain, bradycardia, constipation
C) Cold intolerance, dry skin, hoarseness
D) Hypotension, hypoglycemia, hyperpigmentation
Answer: A
Rationale: Thyroid storm is a life-threatening exacerbation of hyperthyroidism
characterized by hyperpyrexia, tachycardia, and agitation. Options B and C describe
hypothyroidism. Option D suggests adrenal insufficiency.
8 Which assessment finding is most indicative of syndrome of inappropriate
antidiuretic hormone?
A) Serum osmolality 250 mOsm/kg, urine osmolality 600 mOsm/kg
B) Serum osmolality 310 mOsm/kg, urine osmolality 200 mOsm/kg
C) Serum sodium 150 mEq/L, urine sodium 10 mEq/L
D) Serum potassium 3.0 mEq/L, urine potassium 40 mEq/L
Answer: A
Rationale: SIADH causes dilutional hyponatremia with low serum osmolality and
inappropriately concentrated urine (high urine osmolality). Option B indicates
diabetes insipidus. Options C and D do not reflect SIADH.
9 Which statement by a patient with a new ileal conduit indicates need for further
teaching?
A) I will clean the stoma with soap and water daily.
B) I will restrict fluids to 1 liter per day.
C) I will empty the pouch when it is one-third full.
D) I will avoid heavy lifting for 6 weeks.
Answer: B
, Rationale: Patients with an ileal conduit need adequate hydration (2-3 L/day) to
prevent mucus plugging and UTI. Soap and water cleaning, frequent pouch
emptying, and avoiding heavy lifting are correct.
10 Which finding most indicates adrenal crisis in a patient with Addison's disease?
A) Hyperpigmentation and weight loss
B) Hypotension unresponsive to fluids, hyponatremia, hyperkalemia
C) Hypertension, hypokalemia, hypernatremia
D) Moon face, buffalo hump, purple striae
Answer: B
Rationale: Adrenal crisis presents with refractory hypotension, hyponatremia, and
hyperkalemia due to lack of cortisol and aldosterone. Option A describes chronic
Addison's. Option C suggests hyperaldosteronism. Option D describes Cushing's
syndrome.
11 Which finding most specifically indicates increased intracranial pressure rather
than metabolic encephalopathy?
A) Bilateral Babinski signs with hyperreflexia
B) Unilateral pupil dilation with sluggish light reflex
C) Asterixis with fluctuating alertness
D) Symmetric weakness with preserved oculocephalic reflex
Answer: B
Rationale: Unilateral pupillary dilation with sluggish reactivity reflects ipsilateral
uncal herniation from focal ICP mass effect, highly specific to structural intracranial
hypertension. Asterixis and fluctuating alertness typify metabolic encephalopathy;
symmetric findings and intact oculocephalic responses argue against focal
herniation.
12 Which early serum marker best detects rhabdomyolysis-induced acute kidney
injury before creatinine rises?
A) Blood urea nitrogen-to-creatinine ratio
B) Urine sodium concentration
C) Creatine kinase level
D) Serum myoglobin with urine dipstick
Answer: C
Rationale: Creatine kinase rises within hours of muscle injury and predicts
rhabdomyolytic AKI before creatinine, which lags 24-48 hours. Urine dipstick for
blood with absent RBCs supports myoglobinuria but is less quantitative;
54 56 59 61 63 2026/2027 - Questions and Answers 100%
Verified Detailed Rationales - Pass Guaranteed - A+ Graded
This final examination assesses mastery of high-acuity medical-surgical nursing across five Lewis chapters:
neurological (ICP, stroke, seizures), musculoskeletal (fractures, compartment syndrome, joint replacement),
renal/urinary (AKI, CKD, dialysis, electrolyte-acid base), reproductive (prostate, hysterectomy, breast, STIs), and
endocrine (DKA, thyroid storm, SIADH, adrenal crisis) disorders. Items emphasize clinical judgment,
prioritization, and evidence-based management per the NCSBN Clinical Judgment Measurement Model and Lewis
12th edition. It contains 94 multiple-choice questions, each with four distractors and a fully worked rationale that
explains why the keyed answer is correct. Questions are organized into clearly labelled sections that mirror the
major content areas of the course. Targeted learning outcomes include: Apply the NCSBN Clinical Judgment
Measurement Model to prioritize nursing care for patients with complex medical-surgical disorders.; Analyze
laboratory and diagnostic data to differentiate acute versus chronic disease processes and select appropriate
interventions.; Evaluate the effectiveness of prescribed therapies and identify complications requiring immediate
provider notification.; Synthesize pathophysiologic concepts to predict risk and implement prevention strategies
across neurological, musculoskeletal, renal, reproductive, and endocrine systems.. Every item has been reviewed
for clinical accuracy, current guidelines, and clarity so that students can study with confidence and self-correct as
they work through the bank. Use it as a high-yield review immediately before the exam, or as a structured practice
Section 1: General (Questions 1-94)
1 Which early sign best differentiates increasing intracranial pressure from
opioid-induced sedation?
A) Pinpoint pupils with bradypnea
B) Restlessness and confusion with unchanged pupils
C) Decreased deep tendon reflexes
D) Systolic hypertension with widened pulse pressure
Answer: B
Rationale: Restlessness and confusion are early signs of rising ICP; opioid sedation
causes pinpoint pupils and bradypnea without ICP changes. Widened pulse pressure
is a late Cushing response. Decreased reflexes are nonspecific.
2 Which finding most urgently suggests compartment syndrome after a tibial
fracture?
A) Pain relieved by elevation and analgesia
B) Pallor and pulselessness distally
C) Pain with passive stretch of toes
D) Mild swelling and warmth at site
Answer: C
Rationale: Pain with passive stretch is the earliest and most sensitive indicator of
,compartment syndrome. Pulselessness and pallor are late signs. Elevation may
worsen ischemia; mild swelling is expected.
3 Which parameter best detects early acute kidney injury in a critically ill patient?
A) Serum creatinine rise of 0.3 mg/dL in 48 hours
B) Urine output of 0.6 mL/kg/hr for 6 hours
C) BUN-to-creatinine ratio of 12:1
D) Serum potassium of 4.8 mEq/L
Answer: A
Rationale: KDIGO criteria define AKI as a creatinine increase "e0.3 mg/dL within 48
hours or 1.5 times baseline within 7 days. Oliguria (<0.5 mL/kg/hr for 6 hours) is
also diagnostic, but 0.6 mL/kg/hr does not meet threshold. BUN:creatinine of 12:1 is
normal; potassium 4.8 is within normal limits.
4 Which assessment finding is most concerning after transurethral resection of the
prostate?
A) Serum sodium 128 mEq/L with confusion
B) Pink-tinged urine with clots
C) Bladder spasms relieved by antispasmodics
D) Urine output 50 mL/hr via catheter
Answer: A
Rationale: Hyponatremia with confusion indicates TUR syndrome from absorption
of irrigation fluid, a life-threatening complication. Pink urine and clots are expected;
spasms are common and treatable; urine output of 50 mL/hr is adequate.
5 Which laboratory pattern is most consistent with diabetic ketoacidosis?
A) pH 7.30, HCO3 15, glucose 450, positive ketones
B) pH 7.50, HCO3 30, glucose 600, negative ketones
C) pH 7.35, HCO3 24, glucose 200, trace ketones
D) pH 7.25, HCO3 20, glucose 300, negative ketones
Answer: A
Rationale: DKA presents with metabolic acidosis (pH <7.35, HCO3 <18),
hyperglycemia >250 mg/dL, and ketonemia/ketonuria. Option B describes
hyperglycemic hyperosmolar state. Option C is normal. Option D lacks ketones.
6 Which intervention is priority for a patient with acute ischemic stroke and
aphasia?
A) Maintain NPO until swallow screen completed
,B) Encourage frequent oral fluids
C) Provide a picture board for communication
D) Perform passive range-of-motion exercises
Answer: A
Rationale: Aphasia often accompanies dysphagia; NPO until a swallow screen
prevents aspiration, the priority safety concern. Communication boards and ROM
are important but not immediate life-preserving priorities. Oral fluids could cause
aspiration.
7 Which finding most suggests thyroid storm in a patient with Graves' disease?
A) Temperature 102.2°F, tachycardia, agitation
B) Weight gain, bradycardia, constipation
C) Cold intolerance, dry skin, hoarseness
D) Hypotension, hypoglycemia, hyperpigmentation
Answer: A
Rationale: Thyroid storm is a life-threatening exacerbation of hyperthyroidism
characterized by hyperpyrexia, tachycardia, and agitation. Options B and C describe
hypothyroidism. Option D suggests adrenal insufficiency.
8 Which assessment finding is most indicative of syndrome of inappropriate
antidiuretic hormone?
A) Serum osmolality 250 mOsm/kg, urine osmolality 600 mOsm/kg
B) Serum osmolality 310 mOsm/kg, urine osmolality 200 mOsm/kg
C) Serum sodium 150 mEq/L, urine sodium 10 mEq/L
D) Serum potassium 3.0 mEq/L, urine potassium 40 mEq/L
Answer: A
Rationale: SIADH causes dilutional hyponatremia with low serum osmolality and
inappropriately concentrated urine (high urine osmolality). Option B indicates
diabetes insipidus. Options C and D do not reflect SIADH.
9 Which statement by a patient with a new ileal conduit indicates need for further
teaching?
A) I will clean the stoma with soap and water daily.
B) I will restrict fluids to 1 liter per day.
C) I will empty the pouch when it is one-third full.
D) I will avoid heavy lifting for 6 weeks.
Answer: B
, Rationale: Patients with an ileal conduit need adequate hydration (2-3 L/day) to
prevent mucus plugging and UTI. Soap and water cleaning, frequent pouch
emptying, and avoiding heavy lifting are correct.
10 Which finding most indicates adrenal crisis in a patient with Addison's disease?
A) Hyperpigmentation and weight loss
B) Hypotension unresponsive to fluids, hyponatremia, hyperkalemia
C) Hypertension, hypokalemia, hypernatremia
D) Moon face, buffalo hump, purple striae
Answer: B
Rationale: Adrenal crisis presents with refractory hypotension, hyponatremia, and
hyperkalemia due to lack of cortisol and aldosterone. Option A describes chronic
Addison's. Option C suggests hyperaldosteronism. Option D describes Cushing's
syndrome.
11 Which finding most specifically indicates increased intracranial pressure rather
than metabolic encephalopathy?
A) Bilateral Babinski signs with hyperreflexia
B) Unilateral pupil dilation with sluggish light reflex
C) Asterixis with fluctuating alertness
D) Symmetric weakness with preserved oculocephalic reflex
Answer: B
Rationale: Unilateral pupillary dilation with sluggish reactivity reflects ipsilateral
uncal herniation from focal ICP mass effect, highly specific to structural intracranial
hypertension. Asterixis and fluctuating alertness typify metabolic encephalopathy;
symmetric findings and intact oculocephalic responses argue against focal
herniation.
12 Which early serum marker best detects rhabdomyolysis-induced acute kidney
injury before creatinine rises?
A) Blood urea nitrogen-to-creatinine ratio
B) Urine sodium concentration
C) Creatine kinase level
D) Serum myoglobin with urine dipstick
Answer: C
Rationale: Creatine kinase rises within hours of muscle injury and predicts
rhabdomyolytic AKI before creatinine, which lags 24-48 hours. Urine dipstick for
blood with absent RBCs supports myoglobinuria but is less quantitative;
