NUR 170 Final Exam V1 | NUR 170 Medical-Surgical Nursing | Actual
Q&A with Rationale (NUR 170 Final Exam) | Galen
1. A 68-year-old patient, Mr. Davis, is admitted with an exacerbation of heart failure. He
presents with peripheral edema, jugular venous distention, and bilateral crackles in the lung
bases. Which of the following provider orders should the nurse prioritize first?
A. Obtain a 12-lead electrocardiogram (ECG).
B. Administer Furosemide 40 mg IV push.
C. Insert a Foley catheter for accurate intake and output.
D. Request a chest X-ray to evaluate pulmonary congestion.
Answer: B
Rationale: In the context of acute heart failure exacerbation with pulmonary crackles, the
priority is to reduce fluid volume to improve oxygenation and cardiac output. Furosemide
is a loop diuretic that acts quickly when given intravenously to promote diuresis and
decrease preload. While the other tasks are important for the overall plan of care, they do
not address the immediate life-threatening issue of fluid overload and potential respiratory
distress.
2. Ms. Thompson is a 45-year-old patient who underwent a total abdominal hysterectomy 24
hours ago. During the morning assessment, she complains of sudden shortness of breath and
sharp chest pain that worsens with deep inspiration. What is the nurse’s immediate priority
action?
A. Apply oxygen via nasal cannula and raise the head of the bed.
B. Administer the prescribed PRN morphine for chest pain.
C. Encourage the patient to use her incentive spirometer.
D. Assess the surgical incision for signs of dehiscence.
Answer: A
Rationale: The patient’s symptoms are highly suggestive of a pulmonary embolism, a
common post-operative complication. The nurse’s first priority is to stabilize the patient’s
respiratory status by providing supplemental oxygen and positioning her to facilitate
breathing. Following these immediate interventions, the nurse should notify the Rapid
Response Team or the healthcare provider for further diagnostic evaluation.
3. A nurse is caring for a patient, Mr. Miller, who has a history of Type 2 Diabetes Mellitus. At
10:00 AM, the patient becomes diaphoretic, shaky, and complains of a headache. His capillary
blood glucose is 58 mg/dL. Which action should the nurse take first?
A. Call the healthcare provider to report the hypoglycemic event.
,B. Administer 15 grams of a fast-acting carbohydrate, such as 4 oz of orange juice.
C. Administer the scheduled dose of 10 units of NPH insulin.
D. Recheck the blood glucose in 30 minutes to confirm the trend.
Answer: B
Rationale: The patient is experiencing symptomatic hypoglycemia, defined as a blood
glucose level below 70 mg/dL. The standard of care is the ‘Rule of 15,’ which involves
giving 15 grams of simple carbohydrates to quickly raise the blood sugar. Rechecking the
glucose in 30 minutes is too long to wait, and administering insulin would dangerously
further lower the blood sugar.
4. A 72-year-old female patient is being treated for a severe urinary tract infection (UTI). The
nurse notes that the patient’s latest arterial blood gas (ABG) results are: pH 7.31, PaCO2 36
mmHg, and HCO3 18 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is below the normal range of 7.35-7.45, indicating acidosis. The HCO3
(bicarbonate) is below the normal range of 22-26 mEq/L, which signifies a metabolic cause.
Since the PaCO2 is within the normal range (35-45 mmHg), this represents uncompensated
metabolic acidosis, likely due to sepsis or renal compensation issues related to the
infection.
5. Mr. Garcia is scheduled for an elective cholecystectomy. While the nurse is performing the
preoperative checklist, the patient states, ‘I’m still not really sure why I need this surgery.’
Which action by the nurse is most appropriate?
A. Notify the surgeon that the patient requires further clarification before signing the
consent.
B. Tell the patient that the surgeon is very experienced and there is nothing to worry about.
C. Explain the risks and benefits of the cholecystectomy to the patient.
D. Proceed with the preoperative sedation as scheduled to reduce the patient’s anxiety.
Answer: A
Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
patient is competent. If the patient expresses a lack of understanding regarding the
procedure, the nurse must notify the surgeon, as it is the surgeon’s legal responsibility to
, provide the explanation. The nurse should not explain the risks and benefits themselves, as
this falls outside the nursing scope of practice for surgical consent.
6. A patient, Mrs. Lee, is 2 days postoperative following a colon resection. During an
assessment, the nurse notes that the patient’s abdominal wound has partially opened, and a
loop of bowel is protruding. What is the nurse’s first action?
A. Gently push the bowel back into the abdominal cavity.
B. Apply a tight abdominal binder to prevent further protrusion.
C. Place the patient in a high-Fowler’s position to reduce abdominal pressure.
D. Cover the protruding organ with sterile gauze moistened with sterile normal saline.
Answer: D
Rationale: This scenario describes wound evisceration, a surgical emergency. The nurse
must keep the exposed viscera moist to prevent tissue necrosis and infection by using
sterile, saline-soaked dressings. The nurse should also notify the surgeon immediately and
prepare the patient for emergency surgery; pushing the bowel back or applying a binder
can cause further damage.
7. A nurse is reviewing the laboratory results for a patient receiving Lasix (furosemide) for
hypertension. The potassium level is 3.1 mEq/L. Which clinical manifestation should the
nurse monitor for most closely?
A. Peaked T-waves on the EKG.
B. Muscle weakness and cardiac arrhythmias.
C. Hyperactive bowel sounds and diarrhea.
D. Numbness and tingling in the extremities.
Answer: B
Rationale: A potassium level of 3.1 mEq/L indicates hypokalemia (normal range: 3.5-5.0
mEq/L). Hypokalemia commonly causes muscle weakness, leg cramps, and potentially fatal
cardiac arrhythmias such as PVCs or U-waves. Peaked T-waves and hyperactive bowel
sounds are associated with hyperkalemia, not hypokalemia.
8. A 60-year-old male with end-stage renal disease (ESRD) has a potassium level of 6.5 mEq/L.
Which medication should the nurse anticipate the provider ordering to quickly shift
potassium into the cells?
A. Sodium polystyrene sulfonate (Kayexalate).
B. Regular insulin with 50% dextrose (D50).
C. Spironolactone (Aldactone).
D. Epoetin alfa (Epogen).
Q&A with Rationale (NUR 170 Final Exam) | Galen
1. A 68-year-old patient, Mr. Davis, is admitted with an exacerbation of heart failure. He
presents with peripheral edema, jugular venous distention, and bilateral crackles in the lung
bases. Which of the following provider orders should the nurse prioritize first?
A. Obtain a 12-lead electrocardiogram (ECG).
B. Administer Furosemide 40 mg IV push.
C. Insert a Foley catheter for accurate intake and output.
D. Request a chest X-ray to evaluate pulmonary congestion.
Answer: B
Rationale: In the context of acute heart failure exacerbation with pulmonary crackles, the
priority is to reduce fluid volume to improve oxygenation and cardiac output. Furosemide
is a loop diuretic that acts quickly when given intravenously to promote diuresis and
decrease preload. While the other tasks are important for the overall plan of care, they do
not address the immediate life-threatening issue of fluid overload and potential respiratory
distress.
2. Ms. Thompson is a 45-year-old patient who underwent a total abdominal hysterectomy 24
hours ago. During the morning assessment, she complains of sudden shortness of breath and
sharp chest pain that worsens with deep inspiration. What is the nurse’s immediate priority
action?
A. Apply oxygen via nasal cannula and raise the head of the bed.
B. Administer the prescribed PRN morphine for chest pain.
C. Encourage the patient to use her incentive spirometer.
D. Assess the surgical incision for signs of dehiscence.
Answer: A
Rationale: The patient’s symptoms are highly suggestive of a pulmonary embolism, a
common post-operative complication. The nurse’s first priority is to stabilize the patient’s
respiratory status by providing supplemental oxygen and positioning her to facilitate
breathing. Following these immediate interventions, the nurse should notify the Rapid
Response Team or the healthcare provider for further diagnostic evaluation.
3. A nurse is caring for a patient, Mr. Miller, who has a history of Type 2 Diabetes Mellitus. At
10:00 AM, the patient becomes diaphoretic, shaky, and complains of a headache. His capillary
blood glucose is 58 mg/dL. Which action should the nurse take first?
A. Call the healthcare provider to report the hypoglycemic event.
,B. Administer 15 grams of a fast-acting carbohydrate, such as 4 oz of orange juice.
C. Administer the scheduled dose of 10 units of NPH insulin.
D. Recheck the blood glucose in 30 minutes to confirm the trend.
Answer: B
Rationale: The patient is experiencing symptomatic hypoglycemia, defined as a blood
glucose level below 70 mg/dL. The standard of care is the ‘Rule of 15,’ which involves
giving 15 grams of simple carbohydrates to quickly raise the blood sugar. Rechecking the
glucose in 30 minutes is too long to wait, and administering insulin would dangerously
further lower the blood sugar.
4. A 72-year-old female patient is being treated for a severe urinary tract infection (UTI). The
nurse notes that the patient’s latest arterial blood gas (ABG) results are: pH 7.31, PaCO2 36
mmHg, and HCO3 18 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is below the normal range of 7.35-7.45, indicating acidosis. The HCO3
(bicarbonate) is below the normal range of 22-26 mEq/L, which signifies a metabolic cause.
Since the PaCO2 is within the normal range (35-45 mmHg), this represents uncompensated
metabolic acidosis, likely due to sepsis or renal compensation issues related to the
infection.
5. Mr. Garcia is scheduled for an elective cholecystectomy. While the nurse is performing the
preoperative checklist, the patient states, ‘I’m still not really sure why I need this surgery.’
Which action by the nurse is most appropriate?
A. Notify the surgeon that the patient requires further clarification before signing the
consent.
B. Tell the patient that the surgeon is very experienced and there is nothing to worry about.
C. Explain the risks and benefits of the cholecystectomy to the patient.
D. Proceed with the preoperative sedation as scheduled to reduce the patient’s anxiety.
Answer: A
Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
patient is competent. If the patient expresses a lack of understanding regarding the
procedure, the nurse must notify the surgeon, as it is the surgeon’s legal responsibility to
, provide the explanation. The nurse should not explain the risks and benefits themselves, as
this falls outside the nursing scope of practice for surgical consent.
6. A patient, Mrs. Lee, is 2 days postoperative following a colon resection. During an
assessment, the nurse notes that the patient’s abdominal wound has partially opened, and a
loop of bowel is protruding. What is the nurse’s first action?
A. Gently push the bowel back into the abdominal cavity.
B. Apply a tight abdominal binder to prevent further protrusion.
C. Place the patient in a high-Fowler’s position to reduce abdominal pressure.
D. Cover the protruding organ with sterile gauze moistened with sterile normal saline.
Answer: D
Rationale: This scenario describes wound evisceration, a surgical emergency. The nurse
must keep the exposed viscera moist to prevent tissue necrosis and infection by using
sterile, saline-soaked dressings. The nurse should also notify the surgeon immediately and
prepare the patient for emergency surgery; pushing the bowel back or applying a binder
can cause further damage.
7. A nurse is reviewing the laboratory results for a patient receiving Lasix (furosemide) for
hypertension. The potassium level is 3.1 mEq/L. Which clinical manifestation should the
nurse monitor for most closely?
A. Peaked T-waves on the EKG.
B. Muscle weakness and cardiac arrhythmias.
C. Hyperactive bowel sounds and diarrhea.
D. Numbness and tingling in the extremities.
Answer: B
Rationale: A potassium level of 3.1 mEq/L indicates hypokalemia (normal range: 3.5-5.0
mEq/L). Hypokalemia commonly causes muscle weakness, leg cramps, and potentially fatal
cardiac arrhythmias such as PVCs or U-waves. Peaked T-waves and hyperactive bowel
sounds are associated with hyperkalemia, not hypokalemia.
8. A 60-year-old male with end-stage renal disease (ESRD) has a potassium level of 6.5 mEq/L.
Which medication should the nurse anticipate the provider ordering to quickly shift
potassium into the cells?
A. Sodium polystyrene sulfonate (Kayexalate).
B. Regular insulin with 50% dextrose (D50).
C. Spironolactone (Aldactone).
D. Epoetin alfa (Epogen).
