NUR 170 Final Exam V3 | NUR 170 Medical-Surgical Nursing | Actual
Q&A with Rationale (NUR 170 Final Exam) | Galen
1. A 65-year-old male patient, Mr. Miller, is admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). His arterial blood gas (ABG) results show: pH 7.30,
PaCO2 56 mmHg, PaO2 78 mmHg, and HCO3 26 mEq/L. Which acid-base imbalance is the
patient experiencing?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The patient’s pH is below the normal range of 7.35, indicating acidosis, and the
PaCO2 is above the normal range of 45 mmHg, indicating a respiratory cause. The HCO3 is
within the normal range, suggesting that compensation has not yet occurred significantly.
This clinical picture is typical for an acute exacerbation of COPD where gas exchange is
impaired.
2. Mrs. Davis is a 54-year-old patient who underwent an abdominal hysterectomy 24 hours
ago. During your morning assessment, she complains of sudden sharp chest pain and
shortness of breath. Her heart rate is 112 beats/minute and her oxygen saturation is 89% on
room air. What is the nurse’s priority action?
A. Administer the prescribed PRN morphine for chest pain.
B. Assist the patient to use the incentive spirometer.
C. Apply oxygen via nasal cannula and notify the Rapid Response Team.
D. Obtain a 12-lead electrocardiogram (ECG) immediately.
Answer: C
Rationale: The patient is exhibiting classic signs of a pulmonary embolism (PE), which is a
common and life-threatening post-operative complication. Initial nursing management
must prioritize oxygenation and immediate medical escalation through a Rapid Response
Team call. While an ECG and pain management are important, they do not address the
immediate life-threatening hypoxia.
3. Mr. Thompson, a 72-year-old patient with Heart Failure, is prescribed Digoxin 0.125 mg
daily. During his assessment, he reports experiencing nausea and seeing yellow halos around
lights. Which laboratory result should the nurse evaluate first?
A. Serum Potassium level
,B. Serum Sodium level
C. Serum Creatinine level
D. Serum Calcium level
Answer: A
Rationale: Hypokalemia increases the risk of digoxin toxicity because potassium and
digoxin compete for binding sites on the sodium-potassium ATPase pump. The patient is
exhibiting classic signs of digoxin toxicity, such as gastrointestinal distress and visual
disturbances. Checking the potassium level is critical because low levels can exacerbate the
toxic effects of the medication.
4. A 48-year-old patient, James, is admitted for a total thyroidectomy. While assessing him in
the PACU, the nurse notes that James has developed a high-pitched, harsh respiratory sound
on inspiration. What does the nurse recognize this as, and what is the immediate
intervention?
A. Wheezing; administer a bronchodilator.
B. Crackles; encourage deep breathing and coughing.
C. Stridor; prepare for emergency intubation or tracheostomy.
D. Rhonchi; perform nasotracheal suctioning.
Answer: C
Rationale: Stridor is a medical emergency following thyroid surgery and indicates an
obstructed airway, often due to laryngeal edema or nerve damage. The nurse must
recognize this sound immediately as it signals impending respiratory failure. Immediate
preparation for airway management is necessary to save the patient’s life.
5. Mrs. Rodriguez is a 60-year-old patient with Chronic Kidney Disease (CKD) who is receiving
hemodialysis. She presents with a serum potassium level of 6.8 mEq/L. Which medication
should the nurse anticipate administering to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin and Dextrose 50%
D. Calcium Gluconate
Answer: D
Rationale: In cases of severe hyperkalemia, Calcium Gluconate is administered to protect
the heart by stabilizing the myocardial cell membrane. While insulin and Kayexalate help
lower the actual potassium level, they do not provide the immediate cardiac protection
, required. Furosemide is ineffective if the kidneys are not functioning adequately as seen in
end-stage CKD.
6. Mr. Henderson, a 42-year-old patient, is diagnosed with Peptic Ulcer Disease (PUD). He
tests positive for H. pylori. Which combination of medications is most commonly prescribed
for this condition?
A. An antacid and a histamine-2 (H2) receptor antagonist.
B. A proton pump inhibitor (PPI) and two antibiotics.
C. A PPI and a nonsteroidal anti-inflammatory drug (NSAID).
D. Sucralfate and a stimulant laxative.
Answer: B
Rationale: The standard treatment for H. pylori infection involves ‘triple therapy’ to
eradicate the bacteria and reduce acid production. This usually includes a PPI like
omeprazole and two antibiotics such as clarithromycin and amoxicillin. This combination
ensures the underlying infection is cleared while allowing the ulcer to heal in a less acidic
environment.
7. A 66-year-old patient, Linda, is 2 days post-op from a total hip arthroplasty. The nurse
notices Linda is confused, has a petechial rash on her chest, and is complaining of shortness
of breath. Which condition should the nurse suspect?
A. Deep Vein Thrombosis (DVT)
B. Hypovolemic Shock
C. Sepsis
D. Fat Embolism Syndrome
Answer: D
Rationale: Fat Embolism Syndrome (FES) is a risk after long bone or joint surgeries and is
characterized by a triad of symptoms: respiratory distress, neurologic dysfunction
(confusion), and a petechial rash. The rash is a distinguishing feature from a pulmonary
embolism. Immediate notification of the provider and supportive care, especially
oxygenation, are required.
8. Mr. Carter is being treated for a deep vein thrombosis (DVT) in his right leg and is receiving
a continuous intravenous heparin infusion. His latest aPTT is 105 seconds (control 35
seconds). What is the nurse’s priority action?
A. Increase the infusion rate according to the hospital protocol.
B. Maintain the current infusion rate and document the findings.
C. Stop the heparin infusion and notify the healthcare provider.
Q&A with Rationale (NUR 170 Final Exam) | Galen
1. A 65-year-old male patient, Mr. Miller, is admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). His arterial blood gas (ABG) results show: pH 7.30,
PaCO2 56 mmHg, PaO2 78 mmHg, and HCO3 26 mEq/L. Which acid-base imbalance is the
patient experiencing?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The patient’s pH is below the normal range of 7.35, indicating acidosis, and the
PaCO2 is above the normal range of 45 mmHg, indicating a respiratory cause. The HCO3 is
within the normal range, suggesting that compensation has not yet occurred significantly.
This clinical picture is typical for an acute exacerbation of COPD where gas exchange is
impaired.
2. Mrs. Davis is a 54-year-old patient who underwent an abdominal hysterectomy 24 hours
ago. During your morning assessment, she complains of sudden sharp chest pain and
shortness of breath. Her heart rate is 112 beats/minute and her oxygen saturation is 89% on
room air. What is the nurse’s priority action?
A. Administer the prescribed PRN morphine for chest pain.
B. Assist the patient to use the incentive spirometer.
C. Apply oxygen via nasal cannula and notify the Rapid Response Team.
D. Obtain a 12-lead electrocardiogram (ECG) immediately.
Answer: C
Rationale: The patient is exhibiting classic signs of a pulmonary embolism (PE), which is a
common and life-threatening post-operative complication. Initial nursing management
must prioritize oxygenation and immediate medical escalation through a Rapid Response
Team call. While an ECG and pain management are important, they do not address the
immediate life-threatening hypoxia.
3. Mr. Thompson, a 72-year-old patient with Heart Failure, is prescribed Digoxin 0.125 mg
daily. During his assessment, he reports experiencing nausea and seeing yellow halos around
lights. Which laboratory result should the nurse evaluate first?
A. Serum Potassium level
,B. Serum Sodium level
C. Serum Creatinine level
D. Serum Calcium level
Answer: A
Rationale: Hypokalemia increases the risk of digoxin toxicity because potassium and
digoxin compete for binding sites on the sodium-potassium ATPase pump. The patient is
exhibiting classic signs of digoxin toxicity, such as gastrointestinal distress and visual
disturbances. Checking the potassium level is critical because low levels can exacerbate the
toxic effects of the medication.
4. A 48-year-old patient, James, is admitted for a total thyroidectomy. While assessing him in
the PACU, the nurse notes that James has developed a high-pitched, harsh respiratory sound
on inspiration. What does the nurse recognize this as, and what is the immediate
intervention?
A. Wheezing; administer a bronchodilator.
B. Crackles; encourage deep breathing and coughing.
C. Stridor; prepare for emergency intubation or tracheostomy.
D. Rhonchi; perform nasotracheal suctioning.
Answer: C
Rationale: Stridor is a medical emergency following thyroid surgery and indicates an
obstructed airway, often due to laryngeal edema or nerve damage. The nurse must
recognize this sound immediately as it signals impending respiratory failure. Immediate
preparation for airway management is necessary to save the patient’s life.
5. Mrs. Rodriguez is a 60-year-old patient with Chronic Kidney Disease (CKD) who is receiving
hemodialysis. She presents with a serum potassium level of 6.8 mEq/L. Which medication
should the nurse anticipate administering to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin and Dextrose 50%
D. Calcium Gluconate
Answer: D
Rationale: In cases of severe hyperkalemia, Calcium Gluconate is administered to protect
the heart by stabilizing the myocardial cell membrane. While insulin and Kayexalate help
lower the actual potassium level, they do not provide the immediate cardiac protection
, required. Furosemide is ineffective if the kidneys are not functioning adequately as seen in
end-stage CKD.
6. Mr. Henderson, a 42-year-old patient, is diagnosed with Peptic Ulcer Disease (PUD). He
tests positive for H. pylori. Which combination of medications is most commonly prescribed
for this condition?
A. An antacid and a histamine-2 (H2) receptor antagonist.
B. A proton pump inhibitor (PPI) and two antibiotics.
C. A PPI and a nonsteroidal anti-inflammatory drug (NSAID).
D. Sucralfate and a stimulant laxative.
Answer: B
Rationale: The standard treatment for H. pylori infection involves ‘triple therapy’ to
eradicate the bacteria and reduce acid production. This usually includes a PPI like
omeprazole and two antibiotics such as clarithromycin and amoxicillin. This combination
ensures the underlying infection is cleared while allowing the ulcer to heal in a less acidic
environment.
7. A 66-year-old patient, Linda, is 2 days post-op from a total hip arthroplasty. The nurse
notices Linda is confused, has a petechial rash on her chest, and is complaining of shortness
of breath. Which condition should the nurse suspect?
A. Deep Vein Thrombosis (DVT)
B. Hypovolemic Shock
C. Sepsis
D. Fat Embolism Syndrome
Answer: D
Rationale: Fat Embolism Syndrome (FES) is a risk after long bone or joint surgeries and is
characterized by a triad of symptoms: respiratory distress, neurologic dysfunction
(confusion), and a petechial rash. The rash is a distinguishing feature from a pulmonary
embolism. Immediate notification of the provider and supportive care, especially
oxygenation, are required.
8. Mr. Carter is being treated for a deep vein thrombosis (DVT) in his right leg and is receiving
a continuous intravenous heparin infusion. His latest aPTT is 105 seconds (control 35
seconds). What is the nurse’s priority action?
A. Increase the infusion rate according to the hospital protocol.
B. Maintain the current infusion rate and document the findings.
C. Stop the heparin infusion and notify the healthcare provider.
