✅ NUR 201 FINAL EXAM — ORIGINAL
QUESTIONS (1_ 150)
Medical-Surgical Nursing I | Fortis Style | Correct Answers + Rationales
1. A client with pneumonia is receiving oxygen at 2 L/min
via nasal cannula. Which finding shows the treatment is
effective?
✔️
A. RR 32/min
B. SpO₂ 95%
C. Use of accessory muscles
D. Cyanosis
Rationale: SpO₂ ≥ 94% indicates improved oxygenation. Tachypnea, accessory muscle use,
and cyanosis indicate worsening.
2. A patient with heart failure reports sudden weight gain
of 4 lbs in 24 hours. What should the nurse do first?
✔️
A. Teach sodium restriction
B. Notify the provider
C. Encourage fluids
D. Document and recheck tomorrow
Rationale: A gain of >2 lbs in 24 hrs = acute fluid retention → requires provider notification.
3. Which lab value is most important before giving
furosemide?
,A. Hemoglobin
✔️
B. Sodium
C. Potassium
D. Calcium
Rationale: Furosemide can cause severe hypokalemia → check potassium first.
4. A client with COPD has a PaCO₂ of 58 mmHg. What is
the priority?
✔️
A. Increase oxygen to 6 L/min
B. Encourage pursed-lip breathing
C. Position in supine
D. Restrict fluids
Rationale: Pursed-lip breathing improves CO₂ elimination. High O₂ flow may worsen CO₂
retention.
5. The nurse hears crackles in the lower lobes. What is
the most likely cause?
A. Bronchospasm
✔️
B. Air in pleural space
C. Fluid in alveoli
D. Upper airway obstruction
Rationale: Crackles = fluid accumulation (HF, pneumonia).
6. Which diet is best for a patient with hypertension?
✔️
A. Canned soup and cold cuts
B. Fresh fruits, vegetables, grilled fish
C. Fast-food burger and fries
D. Processed snacks
Rationale: DASH diet lowers blood pressure.
, 7. Post-op client reports calf pain and swelling. What is
priority?
A. Ambulate the client
✔️
B. Apply heat
C. Assess for DVT and notify provider
D. Elevate foot of bed only
Rationale: Signs of DVT → urgent evaluation.
8. Which finding suggests dehydration?
A. Bounding pulse
✔️
B. Low urine specific gravity
C. Dry mucous membranes
D. Crackles
Rationale: Dry membranes indicate fluid deficit.
9. A diabetic client has blood glucose 52 mg/dL. What
should the nurse give first?
A. Orange juice ✔️
B. Insulin
C. Water only
D. Glucagon IM
Rationale: Conscious hypoglycemic patient → fast-acting oral glucose.
10. Before blood transfusion, the most important nursing
action is:
QUESTIONS (1_ 150)
Medical-Surgical Nursing I | Fortis Style | Correct Answers + Rationales
1. A client with pneumonia is receiving oxygen at 2 L/min
via nasal cannula. Which finding shows the treatment is
effective?
✔️
A. RR 32/min
B. SpO₂ 95%
C. Use of accessory muscles
D. Cyanosis
Rationale: SpO₂ ≥ 94% indicates improved oxygenation. Tachypnea, accessory muscle use,
and cyanosis indicate worsening.
2. A patient with heart failure reports sudden weight gain
of 4 lbs in 24 hours. What should the nurse do first?
✔️
A. Teach sodium restriction
B. Notify the provider
C. Encourage fluids
D. Document and recheck tomorrow
Rationale: A gain of >2 lbs in 24 hrs = acute fluid retention → requires provider notification.
3. Which lab value is most important before giving
furosemide?
,A. Hemoglobin
✔️
B. Sodium
C. Potassium
D. Calcium
Rationale: Furosemide can cause severe hypokalemia → check potassium first.
4. A client with COPD has a PaCO₂ of 58 mmHg. What is
the priority?
✔️
A. Increase oxygen to 6 L/min
B. Encourage pursed-lip breathing
C. Position in supine
D. Restrict fluids
Rationale: Pursed-lip breathing improves CO₂ elimination. High O₂ flow may worsen CO₂
retention.
5. The nurse hears crackles in the lower lobes. What is
the most likely cause?
A. Bronchospasm
✔️
B. Air in pleural space
C. Fluid in alveoli
D. Upper airway obstruction
Rationale: Crackles = fluid accumulation (HF, pneumonia).
6. Which diet is best for a patient with hypertension?
✔️
A. Canned soup and cold cuts
B. Fresh fruits, vegetables, grilled fish
C. Fast-food burger and fries
D. Processed snacks
Rationale: DASH diet lowers blood pressure.
, 7. Post-op client reports calf pain and swelling. What is
priority?
A. Ambulate the client
✔️
B. Apply heat
C. Assess for DVT and notify provider
D. Elevate foot of bed only
Rationale: Signs of DVT → urgent evaluation.
8. Which finding suggests dehydration?
A. Bounding pulse
✔️
B. Low urine specific gravity
C. Dry mucous membranes
D. Crackles
Rationale: Dry membranes indicate fluid deficit.
9. A diabetic client has blood glucose 52 mg/dL. What
should the nurse give first?
A. Orange juice ✔️
B. Insulin
C. Water only
D. Glucagon IM
Rationale: Conscious hypoglycemic patient → fast-acting oral glucose.
10. Before blood transfusion, the most important nursing
action is:
