NUR 170 Exam 2 V3 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 2) | Galen
1. Mr. Thompson, a 67-year-old patient with a history of COPD, is admitted with an acute
exacerbation. His ABG results show pH 7.30, PaCO2 58 mmHg, and HCO3 26 mEq/L. Which
acid-base imbalance is the patient experiencing?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The patient’s pH is below 7.35, indicating acidosis, and the PaCO2 is elevated
above 45 mmHg, which points to a respiratory cause. The bicarbonate level is within the
normal range, suggesting that compensation has not yet occurred. This clinical picture is
classic for a patient with COPD who is retaining carbon dioxide due to alveolar
hypoventilation.
2. Mrs. Rodriguez is a 45-year-old patient scheduled for an elective cholecystectomy. While
performing the preoperative assessment, the nurse notices the patient is wearing a copper
bracelet for arthritis. What is the most appropriate nursing action?
A. Allow the patient to keep the bracelet on during surgery.
B. Tape the bracelet securely to the patient’s wrist.
C. Ask the patient to remove the bracelet and place it in a secure location.
D. Consult the surgeon to see if the bracelet interferes with the procedure.
Answer: C
Rationale: All jewelry and metallic objects must be removed prior to surgery to prevent
burns when electrosurgery or cautery is used. Taping the bracelet is not sufficient because
it still poses a safety risk for thermal injury or skin breakdown. The nurse should explain
the safety rationale to the patient and ensure the item is documented and stored according
to facility policy.
3. Mr. Harrison is being treated for a severe case of pneumonia. During the assessment, the
nurse notes that the patient’s tactile fremitus is increased over the right lower lobe. How
should the nurse interpret this finding?
A. The patient has lung consolidation from the infection.
B. The patient has air-filled lungs.
,C. The patient has a pneumothorax.
D. The patient is experiencing pleural effusion.
Answer: A
Rationale: Increased tactile fremitus occurs when there is consolidation of lung tissue,
such as in pneumonia, because sound travels better through solid or fluid-filled mediums
than through air. If the patient had a pneumothorax or pleural effusion, the fremitus would
be decreased or absent. This assessment finding helps confirm the presence of an infectious
process in the specific lobe.
4. A 58-year-old male, Mr. Bennett, is 24 hours post-abdominal surgery. He reports sudden
onset of shortness of breath and sharp chest pain that worsens with deep inspiration. His
heart rate is 112 bpm and SpO2 is 88% on room air. What is the nurse’s priority action?
A. Obtain an EKG to rule out myocardial infarction.
B. Administer a PRN dose of morphine for pain.
C. Encourage the patient to use his incentive spirometer.
D. Apply oxygen and notify the Rapid Response Team.
Answer: D
Rationale: The patient’s symptoms are highly suggestive of a pulmonary embolism, which
is a medical emergency requiring immediate intervention. Applying oxygen addresses the
hypoxia, while calling the Rapid Response Team ensures that advanced life support and
diagnostic imaging are initiated quickly. Delaying care to perform an EKG or administer
pain medication could lead to further clinical deterioration.
5. Ms. Clara, a 32-year-old patient, is admitted with severe vomiting and diarrhea for the past
three days. Her laboratory results show a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse monitor for most closely?
A. Hyperactive bowel sounds and abdominal cramping.
B. Positive Trousseau’s and Chvostek’s signs.
C. U waves and ST-segment depression on the EKG.
D. Tall, peaked T-waves and a widened QRS complex.
Answer: C
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, which can lead to
significant cardiac dysrhythmias and characteristic EKG changes like U waves. Tall peaked
T-waves are associated with hyperkalemia, not hypokalemia. The nurse must monitor the
patient’s cardiac rhythm closely and prepare for potassium replacement to avoid life-
threatening complications.
, 6. Mrs. Jenkins is being prepared for a total hip replacement. The nurse is verifying the
surgical consent form. The patient states, ‘I’m still not really sure why they have to cut into
my hip instead of just doing physical therapy.’ What is the best action by the nurse?
A. Explain the surgical procedure and its benefits to the patient.
B. Reassure the patient that the surgeon knows what is best for her.
C. Witness the signature and document the patient’s concerns.
D. Notify the surgeon that the patient has questions about the procedure.
Answer: D
Rationale: It is the surgeon’s legal responsibility to provide informed consent, which
includes explaining the risks, benefits, and alternatives to the patient. The nurse’s role is to
witness the signature and verify that the patient understands the process; if the patient
expresses doubt or lack of understanding, the surgeon must be called back to provide
further explanation. The nurse should not explain the procedure herself as this exceeds the
nursing scope of practice regarding informed consent.
7. Mr. Miller, a 72-year-old patient with chronic heart failure, is prescribed Furosemide (Lasix)
40mg IV daily. Which electrolyte imbalance is this patient at highest risk for developing?
A. Hypermagnesemia
B. Hypokalemia
C. Hyponatremia
D. Hypercalcemia
Answer: B
Rationale: Furosemide is a loop diuretic that promotes the excretion of sodium, water, and
potassium. Hypokalemia is a very common side effect of loop diuretics and can lead to
dangerous cardiac arrhythmias. The nurse must monitor serum potassium levels and
encourage the intake of potassium-rich foods or administer supplements as ordered.
8. A patient, Ms. Davis, is admitted with a diagnosis of Syndrome of Inappropriate
Antidiuretic Hormone (SIADH). Her serum sodium level is 122 mEq/L. Which nursing
intervention is a priority for this patient?
A. Implementing seizure precautions and strict fluid restriction.
B. Administering a bolus of 0.45% Normal Saline.
C. Encouraging the intake of at least 2,000 mL of water daily.
D. Monitoring for signs of hypercalcemia and bone pain.
Answer: A
with Rationale (NUR 170 Exam 2) | Galen
1. Mr. Thompson, a 67-year-old patient with a history of COPD, is admitted with an acute
exacerbation. His ABG results show pH 7.30, PaCO2 58 mmHg, and HCO3 26 mEq/L. Which
acid-base imbalance is the patient experiencing?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The patient’s pH is below 7.35, indicating acidosis, and the PaCO2 is elevated
above 45 mmHg, which points to a respiratory cause. The bicarbonate level is within the
normal range, suggesting that compensation has not yet occurred. This clinical picture is
classic for a patient with COPD who is retaining carbon dioxide due to alveolar
hypoventilation.
2. Mrs. Rodriguez is a 45-year-old patient scheduled for an elective cholecystectomy. While
performing the preoperative assessment, the nurse notices the patient is wearing a copper
bracelet for arthritis. What is the most appropriate nursing action?
A. Allow the patient to keep the bracelet on during surgery.
B. Tape the bracelet securely to the patient’s wrist.
C. Ask the patient to remove the bracelet and place it in a secure location.
D. Consult the surgeon to see if the bracelet interferes with the procedure.
Answer: C
Rationale: All jewelry and metallic objects must be removed prior to surgery to prevent
burns when electrosurgery or cautery is used. Taping the bracelet is not sufficient because
it still poses a safety risk for thermal injury or skin breakdown. The nurse should explain
the safety rationale to the patient and ensure the item is documented and stored according
to facility policy.
3. Mr. Harrison is being treated for a severe case of pneumonia. During the assessment, the
nurse notes that the patient’s tactile fremitus is increased over the right lower lobe. How
should the nurse interpret this finding?
A. The patient has lung consolidation from the infection.
B. The patient has air-filled lungs.
,C. The patient has a pneumothorax.
D. The patient is experiencing pleural effusion.
Answer: A
Rationale: Increased tactile fremitus occurs when there is consolidation of lung tissue,
such as in pneumonia, because sound travels better through solid or fluid-filled mediums
than through air. If the patient had a pneumothorax or pleural effusion, the fremitus would
be decreased or absent. This assessment finding helps confirm the presence of an infectious
process in the specific lobe.
4. A 58-year-old male, Mr. Bennett, is 24 hours post-abdominal surgery. He reports sudden
onset of shortness of breath and sharp chest pain that worsens with deep inspiration. His
heart rate is 112 bpm and SpO2 is 88% on room air. What is the nurse’s priority action?
A. Obtain an EKG to rule out myocardial infarction.
B. Administer a PRN dose of morphine for pain.
C. Encourage the patient to use his incentive spirometer.
D. Apply oxygen and notify the Rapid Response Team.
Answer: D
Rationale: The patient’s symptoms are highly suggestive of a pulmonary embolism, which
is a medical emergency requiring immediate intervention. Applying oxygen addresses the
hypoxia, while calling the Rapid Response Team ensures that advanced life support and
diagnostic imaging are initiated quickly. Delaying care to perform an EKG or administer
pain medication could lead to further clinical deterioration.
5. Ms. Clara, a 32-year-old patient, is admitted with severe vomiting and diarrhea for the past
three days. Her laboratory results show a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse monitor for most closely?
A. Hyperactive bowel sounds and abdominal cramping.
B. Positive Trousseau’s and Chvostek’s signs.
C. U waves and ST-segment depression on the EKG.
D. Tall, peaked T-waves and a widened QRS complex.
Answer: C
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, which can lead to
significant cardiac dysrhythmias and characteristic EKG changes like U waves. Tall peaked
T-waves are associated with hyperkalemia, not hypokalemia. The nurse must monitor the
patient’s cardiac rhythm closely and prepare for potassium replacement to avoid life-
threatening complications.
, 6. Mrs. Jenkins is being prepared for a total hip replacement. The nurse is verifying the
surgical consent form. The patient states, ‘I’m still not really sure why they have to cut into
my hip instead of just doing physical therapy.’ What is the best action by the nurse?
A. Explain the surgical procedure and its benefits to the patient.
B. Reassure the patient that the surgeon knows what is best for her.
C. Witness the signature and document the patient’s concerns.
D. Notify the surgeon that the patient has questions about the procedure.
Answer: D
Rationale: It is the surgeon’s legal responsibility to provide informed consent, which
includes explaining the risks, benefits, and alternatives to the patient. The nurse’s role is to
witness the signature and verify that the patient understands the process; if the patient
expresses doubt or lack of understanding, the surgeon must be called back to provide
further explanation. The nurse should not explain the procedure herself as this exceeds the
nursing scope of practice regarding informed consent.
7. Mr. Miller, a 72-year-old patient with chronic heart failure, is prescribed Furosemide (Lasix)
40mg IV daily. Which electrolyte imbalance is this patient at highest risk for developing?
A. Hypermagnesemia
B. Hypokalemia
C. Hyponatremia
D. Hypercalcemia
Answer: B
Rationale: Furosemide is a loop diuretic that promotes the excretion of sodium, water, and
potassium. Hypokalemia is a very common side effect of loop diuretics and can lead to
dangerous cardiac arrhythmias. The nurse must monitor serum potassium levels and
encourage the intake of potassium-rich foods or administer supplements as ordered.
8. A patient, Ms. Davis, is admitted with a diagnosis of Syndrome of Inappropriate
Antidiuretic Hormone (SIADH). Her serum sodium level is 122 mEq/L. Which nursing
intervention is a priority for this patient?
A. Implementing seizure precautions and strict fluid restriction.
B. Administering a bolus of 0.45% Normal Saline.
C. Encouraging the intake of at least 2,000 mL of water daily.
D. Monitoring for signs of hypercalcemia and bone pain.
Answer: A
