NUR 170 Exam 3 V1 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 3) | Galen
1. A 68-year-old male patient with a history of Chronic Obstructive Pulmonary Disease (COPD)
is admitted to the unit with increased dyspnea and a productive cough. His pulse oximetry is
currently 88% on room air. Which action should the nurse prioritize first?
A. Initiate oxygen therapy at 6L/min via simple face mask.
B. Request a stat arterial blood gas (ABG) draw.
C. Place the patient in a High-Fowler’s position.
D. Administer the prescribed PRN albuterol nebulizer.
Answer: C
Rationale: Placing the patient in High-Fowler’s position is the priority because it allows for
maximum lung expansion and improves gas exchange through gravity. This is a non-
invasive nursing intervention that addresses the ‘Breathing’ aspect of the ABCs
immediately. While oxygen and medications are important, mechanical positioning should
occur first to stabilize the patient’s respiratory effort.
2. A nurse is caring for a patient who is 24 hours post-operative following a total hip
arthroplasty. The patient suddenly reports sharp chest pain and shortness of breath. The
nurse notes the patient is tachycardic and tachypneic. Which complication should the nurse
suspect?
A. Pulmonary Embolism
B. Pneumonia
C. Myocardial Infarction
D. Hypovolemic Shock
Answer: A
Rationale: Pulmonary Embolism (PE) is a common and life-threatening complication
following major orthopedic surgery due to immobility and venous stasis. The sudden onset
of pleuritic chest pain and respiratory distress are classic clinical manifestations of PE. The
nurse must immediately notify the healthcare provider and prepare for diagnostic imaging
and anticoagulation therapy.
3. An 82-year-old female patient is admitted with a diagnosis of Decompensated Heart
Failure. During the morning assessment, the nurse notes 3+ pitting edema in the lower
extremities and crackles in the bases of the lungs. The patient’s potassium level is reported at
3.2 mEq/L. Which medication order should the nurse question?
A. Furosemide 40 mg IV push
,B. Lisinopril 5 mg PO daily
C. Spironolactone 25 mg PO daily
D. Digoxin 0.125 mg PO daily
Answer: D
Rationale: The nurse should question the Digoxin order because hypokalemia (potassium
< 3.5 mEq/L) significantly increases the risk of Digoxin toxicity. Although Digoxin is used
for heart failure, the low potassium level (3.2 mEq/L) makes its administration dangerous
at this time. The nurse must monitor the patient for signs of toxicity such as visual changes
or arrhythmias and consult the provider regarding potassium replacement.
4. A patient with Type 1 Diabetes Mellitus is found confused, diaphoretic, and pale. The
bedside glucose monitor shows a reading of 48 mg/dL. The patient is awake but unable to
follow complex commands. What is the nurse’s priority action?
A. Administer 15 grams of simple carbohydrates, such as 4 oz of orange juice.
B. Administer 1 mg of Glucagon intramuscularly.
C. Administer 50% Dextrose (D50) via IV push.
D. Recheck the blood glucose in 15 minutes to confirm the reading.
Answer: A
Rationale: Because the patient is conscious and able to swallow, the ‘Rule of 15’ should be
followed by providing 15 grams of simple carbohydrates orally. D50 or Glucagon are
reserved for patients who are unconscious or unable to swallow safely. Monitoring the
patient and retesting after 15 minutes is the standard protocol for resolving hypoglycemia.
5. A patient is receiving a continuous intravenous infusion of Heparin for a deep vein
thrombosis. The nurse reviews the morning labs and finds an Activated Partial
Thromboplastin Time (aPTT) of 110 seconds (Control: 25-35 seconds). What is the appropriate
nursing intervention?
A. Increase the infusion rate by 10% to reach a therapeutic level.
B. Turn off the infusion for 1 hour and then restart at a lower rate per protocol.
C. Continue the infusion at the current rate and document the finding.
D. Stop the infusion and prepare to administer Protamine Sulfate.
Answer: B
Rationale: An aPTT of 110 seconds is significantly above the therapeutic range, which is
typically 1.5 to 2.5 times the control (approx. 45-87 seconds). According to standard
Heparin protocols, the infusion should be held to allow the levels to drop to avoid
, hemorrhage. Protamine sulfate is the antidote but is usually only administered if there is
active, uncontrollable bleeding.
6. A nurse is caring for a patient who underwent a thyroidectomy 12 hours ago. The patient
reports a ‘tingling’ sensation in the fingers and around the mouth. Which assessment should
the nurse perform next?
A. Obtain a blood pressure reading to check for hypotension.
B. Check the surgical dressing for signs of hemorrhage.
C. Assess the patient for a positive Chvostek’s sign.
D. Ask the patient to speak to evaluate for laryngeal nerve damage.
Answer: C
Rationale: Tingling in the extremities (paresthesia) and circumoral numbness are early
signs of hypocalcemia, which can occur if the parathyroid glands are accidentally damaged
or removed during a thyroidectomy. A positive Chvostek’s sign (facial twitching when the
facial nerve is tapped) confirms neuromuscular irritability related to low calcium. The
nurse should notify the provider and anticipate an order for Calcium Gluconate.
7. The nurse is reviewing the laboratory results for a patient with Chronic Kidney Disease
(CKD). The potassium level is 6.4 mEq/L. Which cardiac monitor finding is most consistent
with this lab value?
A. ST-segment depression
B. Prolonged QT interval
C. Prominent U waves
D. Tall, peaked T waves
Answer: D
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) causes specific EKG changes, most
notably tall, peaked T waves and a widened QRS complex. This is a medical emergency
because it can lead to ventricular fibrillation or cardiac arrest. The nurse must prioritize
monitoring the patient and preparing for treatments such as Kayexalate or IV insulin with
dextrose.
8. A patient with a history of Cirrhosis and esophageal varices is admitted with hematemesis.
The patient’s blood pressure is 88/50 mmHg and heart rate is 124 bpm. Which IV fluid should
the nurse anticipate administering first?
A. 0.45% Normal Saline
B. 0.9% Normal Saline
C. 5% Dextrose in Water (D5W)
with Rationale (NUR 170 Exam 3) | Galen
1. A 68-year-old male patient with a history of Chronic Obstructive Pulmonary Disease (COPD)
is admitted to the unit with increased dyspnea and a productive cough. His pulse oximetry is
currently 88% on room air. Which action should the nurse prioritize first?
A. Initiate oxygen therapy at 6L/min via simple face mask.
B. Request a stat arterial blood gas (ABG) draw.
C. Place the patient in a High-Fowler’s position.
D. Administer the prescribed PRN albuterol nebulizer.
Answer: C
Rationale: Placing the patient in High-Fowler’s position is the priority because it allows for
maximum lung expansion and improves gas exchange through gravity. This is a non-
invasive nursing intervention that addresses the ‘Breathing’ aspect of the ABCs
immediately. While oxygen and medications are important, mechanical positioning should
occur first to stabilize the patient’s respiratory effort.
2. A nurse is caring for a patient who is 24 hours post-operative following a total hip
arthroplasty. The patient suddenly reports sharp chest pain and shortness of breath. The
nurse notes the patient is tachycardic and tachypneic. Which complication should the nurse
suspect?
A. Pulmonary Embolism
B. Pneumonia
C. Myocardial Infarction
D. Hypovolemic Shock
Answer: A
Rationale: Pulmonary Embolism (PE) is a common and life-threatening complication
following major orthopedic surgery due to immobility and venous stasis. The sudden onset
of pleuritic chest pain and respiratory distress are classic clinical manifestations of PE. The
nurse must immediately notify the healthcare provider and prepare for diagnostic imaging
and anticoagulation therapy.
3. An 82-year-old female patient is admitted with a diagnosis of Decompensated Heart
Failure. During the morning assessment, the nurse notes 3+ pitting edema in the lower
extremities and crackles in the bases of the lungs. The patient’s potassium level is reported at
3.2 mEq/L. Which medication order should the nurse question?
A. Furosemide 40 mg IV push
,B. Lisinopril 5 mg PO daily
C. Spironolactone 25 mg PO daily
D. Digoxin 0.125 mg PO daily
Answer: D
Rationale: The nurse should question the Digoxin order because hypokalemia (potassium
< 3.5 mEq/L) significantly increases the risk of Digoxin toxicity. Although Digoxin is used
for heart failure, the low potassium level (3.2 mEq/L) makes its administration dangerous
at this time. The nurse must monitor the patient for signs of toxicity such as visual changes
or arrhythmias and consult the provider regarding potassium replacement.
4. A patient with Type 1 Diabetes Mellitus is found confused, diaphoretic, and pale. The
bedside glucose monitor shows a reading of 48 mg/dL. The patient is awake but unable to
follow complex commands. What is the nurse’s priority action?
A. Administer 15 grams of simple carbohydrates, such as 4 oz of orange juice.
B. Administer 1 mg of Glucagon intramuscularly.
C. Administer 50% Dextrose (D50) via IV push.
D. Recheck the blood glucose in 15 minutes to confirm the reading.
Answer: A
Rationale: Because the patient is conscious and able to swallow, the ‘Rule of 15’ should be
followed by providing 15 grams of simple carbohydrates orally. D50 or Glucagon are
reserved for patients who are unconscious or unable to swallow safely. Monitoring the
patient and retesting after 15 minutes is the standard protocol for resolving hypoglycemia.
5. A patient is receiving a continuous intravenous infusion of Heparin for a deep vein
thrombosis. The nurse reviews the morning labs and finds an Activated Partial
Thromboplastin Time (aPTT) of 110 seconds (Control: 25-35 seconds). What is the appropriate
nursing intervention?
A. Increase the infusion rate by 10% to reach a therapeutic level.
B. Turn off the infusion for 1 hour and then restart at a lower rate per protocol.
C. Continue the infusion at the current rate and document the finding.
D. Stop the infusion and prepare to administer Protamine Sulfate.
Answer: B
Rationale: An aPTT of 110 seconds is significantly above the therapeutic range, which is
typically 1.5 to 2.5 times the control (approx. 45-87 seconds). According to standard
Heparin protocols, the infusion should be held to allow the levels to drop to avoid
, hemorrhage. Protamine sulfate is the antidote but is usually only administered if there is
active, uncontrollable bleeding.
6. A nurse is caring for a patient who underwent a thyroidectomy 12 hours ago. The patient
reports a ‘tingling’ sensation in the fingers and around the mouth. Which assessment should
the nurse perform next?
A. Obtain a blood pressure reading to check for hypotension.
B. Check the surgical dressing for signs of hemorrhage.
C. Assess the patient for a positive Chvostek’s sign.
D. Ask the patient to speak to evaluate for laryngeal nerve damage.
Answer: C
Rationale: Tingling in the extremities (paresthesia) and circumoral numbness are early
signs of hypocalcemia, which can occur if the parathyroid glands are accidentally damaged
or removed during a thyroidectomy. A positive Chvostek’s sign (facial twitching when the
facial nerve is tapped) confirms neuromuscular irritability related to low calcium. The
nurse should notify the provider and anticipate an order for Calcium Gluconate.
7. The nurse is reviewing the laboratory results for a patient with Chronic Kidney Disease
(CKD). The potassium level is 6.4 mEq/L. Which cardiac monitor finding is most consistent
with this lab value?
A. ST-segment depression
B. Prolonged QT interval
C. Prominent U waves
D. Tall, peaked T waves
Answer: D
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) causes specific EKG changes, most
notably tall, peaked T waves and a widened QRS complex. This is a medical emergency
because it can lead to ventricular fibrillation or cardiac arrest. The nurse must prioritize
monitoring the patient and preparing for treatments such as Kayexalate or IV insulin with
dextrose.
8. A patient with a history of Cirrhosis and esophageal varices is admitted with hematemesis.
The patient’s blood pressure is 88/50 mmHg and heart rate is 124 bpm. Which IV fluid should
the nurse anticipate administering first?
A. 0.45% Normal Saline
B. 0.9% Normal Saline
C. 5% Dextrose in Water (D5W)
