NUR 170 Exam 3 V3 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 3) | Galen
1. A 68-year-old client, Mr. Evelyn, with a history of COPD is admitted with increased
shortness of breath and a productive cough. The nurse notes the client’s oxygen saturation is
88% on room air. Which oxygen delivery method and rate should the nurse expect to be
ordered initially?
A. Nasal cannula at 2 L/min
B. Simple face mask at 10 L/min
C. Non-rebreather mask at 15 L/min
D. Venturi mask at 50% FiO2
Answer: A
Rationale: Clients with COPD often rely on a hypoxic drive to breathe due to chronic CO2
retention. Administering high concentrations of oxygen can suppress this drive, leading to
respiratory depression. A low-flow nasal cannula at 2 L/min is usually the safest starting
point to maintain saturations between 88-92%.
2. Mr. Rodriguez is 2 days post-operative following an abdominal surgery. While the nurse is
assisting him to ambulate, he suddenly states, ‘I felt something pop,’ and the nurse observes
a loop of bowel protruding through the incision. What is the priority nursing action?
A. Apply a sterile dressing moistened with warm sterile normal saline.
B. Attempt to gently push the bowel back into the abdominal cavity.
C. Place the client in a high-Fowler’s position to assist breathing.
D. Call the surgeon immediately before performing any other interventions.
Answer: A
Rationale: Wound evisceration is a medical emergency requiring immediate action to
protect the protruding organs. The nurse should cover the area with sterile dressings
soaked in sterile saline to prevent tissue drying and necrosis. The client should be kept in a
low-Fowler’s position with knees flexed to reduce abdominal pressure while waiting for
the surgical team.
3. Sarah, a 19-year-old with Type 1 Diabetes, is admitted to the emergency department with
a blood glucose of 580 mg/dL and Kussmaul respirations. The nurse identifies these findings
as consistent with Diabetic Ketoacidosis (DKA). What is the priority nursing intervention?
A. Administer 10 units of subcutaneous Glargine insulin.
B. Offer the client a glass of orange juice to prevent a crash.
,C. Start an intravenous infusion of 0.9% Normal Saline.
D. Administer sodium bicarbonate to correct the acidosis.
Answer: C
Rationale: The initial priority in treating DKA is fluid resuscitation to correct dehydration
and restore perfusion. Dehydration in DKA is severe due to osmotic diuresis caused by
hyperglycemia. Once fluid replacement is initiated, IV regular insulin is typically started to
lower blood glucose and stop ketone production.
4. Mr. Lee is being treated for heart failure and is taking Digoxin 0.125 mg daily. During the
morning assessment, he complains of nausea and seeing ‘yellow halos’ around the lights.
What should the nurse do first?
A. Assess the apical pulse and hold the next dose.
B. Encourage the client to drink more fluids.
C. Administer an antiemetic as ordered.
D. Document the findings as a normal side effect.
Answer: A
Rationale: Nausea, vomiting, and visual disturbances like yellow-green halos are classic
signs of Digoxin toxicity. The nurse must immediately assess the client’s heart rate and
rhythm, as bradycardia is common. The medication should be held, and the healthcare
provider must be notified to obtain a serum digoxin level.
5. Brittany, a 22-year-old with a history of asthma, presents to the clinic with acute wheezing
and a peak flow reading in the ‘Red Zone.’ Which medication should the nurse administer
first?
A. Albuterol (Proventil) nebulizer
B. Salmeterol (Serevent) inhaler
C. Fluticasone (Flovent) MDI
D. Oral Prednisone
Answer: A
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) that acts as a rescue
medication by providing rapid bronchodilation. During an acute asthma exacerbation,
immediate relief of airway obstruction is the priority. Other medications like Salmeterol or
Fluticasone are for long-term control and are not effective in emergencies.
6. Ms. Davis is being discharged following a diagnosis of Gastroesophageal Reflux Disease
(GERD). Which statement by the client indicates a need for further teaching?
A. I will avoid eating for at least 3 hours before going to bed.
, B. I will sleep with the head of my bed elevated.
C. I will limit my intake of caffeine and chocolate.
D. I will drink a glass of milk before bed to soothe my stomach.
Answer: D
Rationale: Milk can actually stimulate gastric acid secretion and should be avoided before
bedtime in clients with GERD. Eating right before bed increases the risk of reflux while
lying flat. Elevation of the head of the bed and avoiding triggers like caffeine are correct
management strategies.
7. James, a 34-year-old male, had a plaster cast applied to his right lower leg 4 hours ago for a
tibia fracture. He now reports intense pain that is not relieved by his prescribed morphine.
His toes are pale and cool to the touch. What is the nurse’s priority action?
A. Elevate the leg above the level of the heart.
B. Apply a cold pack to the casted area.
C. Notify the healthcare provider immediately.
D. Administer an extra dose of pain medication.
Answer: C
Rationale: These symptoms are hallmark signs of Compartment Syndrome, which is a
surgical emergency. Pain unrelieved by opioids and neurovascular changes (pale, cool toes)
indicate compromised blood flow to the extremity. The nurse must notify the provider
immediately as a fasciotomy may be required to prevent permanent tissue damage.
8. Mrs. White is 24 hours post-operative after a total hip replacement. She suddenly develops
sharp chest pain and tachypnea. Her heart rate is 115 bpm and O2 saturation is 86%. What
complication does the nurse suspect?
A. Pulmonary Embolism
B. Myocardial Infarction
C. Pneumonia
D. Hypovolemic Shock
Answer: A
Rationale: Sudden onset of chest pain, shortness of breath, and tachycardia in a post-
operative orthopedic patient are classic signs of a pulmonary embolism (PE). Orthopedic
surgeries carry a high risk for Deep Vein Thrombosis (DVT), which can lead to PE.
Immediate intervention with oxygen and notification of the rapid response team is
necessary.
with Rationale (NUR 170 Exam 3) | Galen
1. A 68-year-old client, Mr. Evelyn, with a history of COPD is admitted with increased
shortness of breath and a productive cough. The nurse notes the client’s oxygen saturation is
88% on room air. Which oxygen delivery method and rate should the nurse expect to be
ordered initially?
A. Nasal cannula at 2 L/min
B. Simple face mask at 10 L/min
C. Non-rebreather mask at 15 L/min
D. Venturi mask at 50% FiO2
Answer: A
Rationale: Clients with COPD often rely on a hypoxic drive to breathe due to chronic CO2
retention. Administering high concentrations of oxygen can suppress this drive, leading to
respiratory depression. A low-flow nasal cannula at 2 L/min is usually the safest starting
point to maintain saturations between 88-92%.
2. Mr. Rodriguez is 2 days post-operative following an abdominal surgery. While the nurse is
assisting him to ambulate, he suddenly states, ‘I felt something pop,’ and the nurse observes
a loop of bowel protruding through the incision. What is the priority nursing action?
A. Apply a sterile dressing moistened with warm sterile normal saline.
B. Attempt to gently push the bowel back into the abdominal cavity.
C. Place the client in a high-Fowler’s position to assist breathing.
D. Call the surgeon immediately before performing any other interventions.
Answer: A
Rationale: Wound evisceration is a medical emergency requiring immediate action to
protect the protruding organs. The nurse should cover the area with sterile dressings
soaked in sterile saline to prevent tissue drying and necrosis. The client should be kept in a
low-Fowler’s position with knees flexed to reduce abdominal pressure while waiting for
the surgical team.
3. Sarah, a 19-year-old with Type 1 Diabetes, is admitted to the emergency department with
a blood glucose of 580 mg/dL and Kussmaul respirations. The nurse identifies these findings
as consistent with Diabetic Ketoacidosis (DKA). What is the priority nursing intervention?
A. Administer 10 units of subcutaneous Glargine insulin.
B. Offer the client a glass of orange juice to prevent a crash.
,C. Start an intravenous infusion of 0.9% Normal Saline.
D. Administer sodium bicarbonate to correct the acidosis.
Answer: C
Rationale: The initial priority in treating DKA is fluid resuscitation to correct dehydration
and restore perfusion. Dehydration in DKA is severe due to osmotic diuresis caused by
hyperglycemia. Once fluid replacement is initiated, IV regular insulin is typically started to
lower blood glucose and stop ketone production.
4. Mr. Lee is being treated for heart failure and is taking Digoxin 0.125 mg daily. During the
morning assessment, he complains of nausea and seeing ‘yellow halos’ around the lights.
What should the nurse do first?
A. Assess the apical pulse and hold the next dose.
B. Encourage the client to drink more fluids.
C. Administer an antiemetic as ordered.
D. Document the findings as a normal side effect.
Answer: A
Rationale: Nausea, vomiting, and visual disturbances like yellow-green halos are classic
signs of Digoxin toxicity. The nurse must immediately assess the client’s heart rate and
rhythm, as bradycardia is common. The medication should be held, and the healthcare
provider must be notified to obtain a serum digoxin level.
5. Brittany, a 22-year-old with a history of asthma, presents to the clinic with acute wheezing
and a peak flow reading in the ‘Red Zone.’ Which medication should the nurse administer
first?
A. Albuterol (Proventil) nebulizer
B. Salmeterol (Serevent) inhaler
C. Fluticasone (Flovent) MDI
D. Oral Prednisone
Answer: A
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) that acts as a rescue
medication by providing rapid bronchodilation. During an acute asthma exacerbation,
immediate relief of airway obstruction is the priority. Other medications like Salmeterol or
Fluticasone are for long-term control and are not effective in emergencies.
6. Ms. Davis is being discharged following a diagnosis of Gastroesophageal Reflux Disease
(GERD). Which statement by the client indicates a need for further teaching?
A. I will avoid eating for at least 3 hours before going to bed.
, B. I will sleep with the head of my bed elevated.
C. I will limit my intake of caffeine and chocolate.
D. I will drink a glass of milk before bed to soothe my stomach.
Answer: D
Rationale: Milk can actually stimulate gastric acid secretion and should be avoided before
bedtime in clients with GERD. Eating right before bed increases the risk of reflux while
lying flat. Elevation of the head of the bed and avoiding triggers like caffeine are correct
management strategies.
7. James, a 34-year-old male, had a plaster cast applied to his right lower leg 4 hours ago for a
tibia fracture. He now reports intense pain that is not relieved by his prescribed morphine.
His toes are pale and cool to the touch. What is the nurse’s priority action?
A. Elevate the leg above the level of the heart.
B. Apply a cold pack to the casted area.
C. Notify the healthcare provider immediately.
D. Administer an extra dose of pain medication.
Answer: C
Rationale: These symptoms are hallmark signs of Compartment Syndrome, which is a
surgical emergency. Pain unrelieved by opioids and neurovascular changes (pale, cool toes)
indicate compromised blood flow to the extremity. The nurse must notify the provider
immediately as a fasciotomy may be required to prevent permanent tissue damage.
8. Mrs. White is 24 hours post-operative after a total hip replacement. She suddenly develops
sharp chest pain and tachypnea. Her heart rate is 115 bpm and O2 saturation is 86%. What
complication does the nurse suspect?
A. Pulmonary Embolism
B. Myocardial Infarction
C. Pneumonia
D. Hypovolemic Shock
Answer: A
Rationale: Sudden onset of chest pain, shortness of breath, and tachycardia in a post-
operative orthopedic patient are classic signs of a pulmonary embolism (PE). Orthopedic
surgeries carry a high risk for Deep Vein Thrombosis (DVT), which can lead to PE.
Immediate intervention with oxygen and notification of the rapid response team is
necessary.
