NUR 170 Exam 4 V1 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 4) | Galen
1. Mr. Henderson, a 68-year-old patient with a history of heart failure, presents to the
emergency department with shortness of breath and an audible S3 heart sound. Upon
assessment, the nurse notes crackles in the lung bases and 3+ pitting edema in the lower
extremities. Which nursing intervention should be prioritized first?
A. Administering a prescribed dose of intravenous Furosemide.
B. Initiating a 1,500 mL fluid restriction protocol.
C. Obtaining a strictly accurate daily weight measurement.
D. Elevating the head of the bed to a high-Fowler’s position.
Answer: D
Rationale: Elevating the head of the bed to high-Fowler’s position is the priority
intervention to facilitate lung expansion and improve gas exchange. This immediate action
addresses the patient’s acute respiratory distress by decreasing venous return and work of
breathing. While diuretics and fluid restrictions are necessary for long-term management,
positioning is the immediate priority in the ABC (Airway, Breathing, Circulation)
framework.
2. A nurse is caring for Ms. Thompson, who has been diagnosed with deep vein thrombosis
(DVT) in her left calf. The patient is currently receiving a continuous Heparin infusion. Which
finding would require the nurse to stop the infusion immediately and notify the healthcare
provider?
A. An Activated Partial Thromboplastin Time (aPTT) of 70 seconds.
B. A platelet count decrease from 250,000/mm³ to 110,000/mm³.
C. Report of mild discomfort in the left calf during dorsiflexion.
D. Presence of localized bruising at the abdominal injection site.
Answer: B
Rationale: A significant drop in platelet count (greater than 50% from baseline) suggests
Heparin-Induced Thrombocytopenia (HIT), a life-threatening complication. The nurse must
immediately stop the heparin and notify the provider to prevent further paradoxical
clotting. An aPTT of 70 seconds is typically within the therapeutic range for DVT treatment,
and mild calf discomfort is expected with the diagnosis.
,3. Mr. Rodriguez is a 55-year-old male recovering from an abdominal cholecystectomy. Four
hours post-operatively, he reports severe abdominal pain and is noted to have a heart rate of
115 bpm and a blood pressure of 90/58 mmHg. What is the nurse’s first action?
A. Administer the prescribed PRN opioid analgesic.
B. Increase the rate of the intravenous maintenance fluids.
C. Perform a head-to-toe assessment and check the surgical site.
D. Place the patient in a Trendelenburg position.
Answer: C
Rationale: The patient is exhibiting signs of potential postoperative hemorrhage or shock,
including tachycardia and hypotension. The nurse must first assess the surgical site and
look for signs of internal bleeding to gather clinical data before intervening or notifying the
provider. Administering pain medication without assessing the source of pain and
hemodynamic instability could mask symptoms of a surgical complication.
4. A 42-year-old female patient, Ms. Miller, is admitted for an exacerbation of Graves’ disease
(hyperthyroidism). While performing an assessment, the nurse notes a temperature of
102.4°F (39.1°C), heart rate of 142 bpm, and increased agitation. Which condition should the
nurse suspect?
A. Myxedema Coma
B. Pheochromocytoma
C. Hypoparathyroidism
D. Thyroid Storm
Answer: D
Rationale: Thyroid storm is a medical emergency characterized by extreme
hypermetabolism, including high fever, severe tachycardia, and central nervous system
changes. This condition is triggered by stress or infection in patients with underlying
hyperthyroidism. Myxedema coma is the opposite extreme, representing severe, untreated
hypothyroidism.
5. A nurse is providing discharge education for a patient newly diagnosed with Type 1
Diabetes Mellitus. The patient asks why they cannot take their insulin in pill form. What is the
most accurate response by the nurse?
A. Insulin pills would be absorbed too quickly into the bloodstream.
B. Pill forms of insulin cause severe gastric ulcers and bleeding.
C. The liver would filter out all the insulin before it could reach the cells.
D. Insulin is a protein and would be destroyed by stomach acids and enzymes.
, Answer: D
Rationale: Insulin is a peptide hormone, meaning it is a protein that is broken down by
digestive enzymes in the stomach and small intestine if taken orally. Because of this, it must
be administered parenterally (usually subcutaneously) to bypass the GI tract. Oral
hypoglycemic agents work by different mechanisms and are not insulin themselves.
6. Mr. Lee is being treated for a small bowel obstruction. He has a nasogastric (NG) tube set
to low intermittent suction. Which laboratory result should the nurse monitor most closely
for this patient?
A. Serum Creatinine
B. Serum Calcium
C. Serum Potassium
D. Serum Albumin
Answer: C
Rationale: NG tube suctioning removes gastric secretions which are rich in electrolytes,
particularly potassium and chloride. Prolonged suctioning puts the patient at high risk for
hypokalemia and metabolic alkalosis. Monitoring serum potassium levels is essential to
prevent cardiac dysrhythmias and muscle weakness associated with electrolyte
imbalances.
7. A patient with Chronic Obstructive Pulmonary Disease (COPD) is admitted with an acute
exacerbation. The nurse notes the patient is leaning forward with arms on the over-bed table
and using pursed-lip breathing. What is the nurse’s best interpretation of these findings?
A. The patient is using compensatory techniques to improve ventilation.
B. The patient is experiencing severe anxiety and requires sedation.
C. The patient is confused and trying to get out of the bed.
D. The patient is exhibiting signs of an impending stroke.
Answer: A
Rationale: Leaning forward (tripod position) and pursed-lip breathing are classic
compensatory mechanisms used by COPD patients to decrease the work of breathing and
improve expiratory airflow. Pursed-lip breathing creates positive expiratory pressure,
which helps keep the airways open longer. These actions indicate the patient is working
hard to breathe and requires assessment of oxygenation and ventilation.
8. Which clinical manifestation would a nurse expect to find in a patient experiencing
autonomic dysreflexia following a spinal cord injury at the T4 level?
A. Hypotension and tachycardia.
B. Flaccid paralysis and loss of all reflex activity below the injury.
with Rationale (NUR 170 Exam 4) | Galen
1. Mr. Henderson, a 68-year-old patient with a history of heart failure, presents to the
emergency department with shortness of breath and an audible S3 heart sound. Upon
assessment, the nurse notes crackles in the lung bases and 3+ pitting edema in the lower
extremities. Which nursing intervention should be prioritized first?
A. Administering a prescribed dose of intravenous Furosemide.
B. Initiating a 1,500 mL fluid restriction protocol.
C. Obtaining a strictly accurate daily weight measurement.
D. Elevating the head of the bed to a high-Fowler’s position.
Answer: D
Rationale: Elevating the head of the bed to high-Fowler’s position is the priority
intervention to facilitate lung expansion and improve gas exchange. This immediate action
addresses the patient’s acute respiratory distress by decreasing venous return and work of
breathing. While diuretics and fluid restrictions are necessary for long-term management,
positioning is the immediate priority in the ABC (Airway, Breathing, Circulation)
framework.
2. A nurse is caring for Ms. Thompson, who has been diagnosed with deep vein thrombosis
(DVT) in her left calf. The patient is currently receiving a continuous Heparin infusion. Which
finding would require the nurse to stop the infusion immediately and notify the healthcare
provider?
A. An Activated Partial Thromboplastin Time (aPTT) of 70 seconds.
B. A platelet count decrease from 250,000/mm³ to 110,000/mm³.
C. Report of mild discomfort in the left calf during dorsiflexion.
D. Presence of localized bruising at the abdominal injection site.
Answer: B
Rationale: A significant drop in platelet count (greater than 50% from baseline) suggests
Heparin-Induced Thrombocytopenia (HIT), a life-threatening complication. The nurse must
immediately stop the heparin and notify the provider to prevent further paradoxical
clotting. An aPTT of 70 seconds is typically within the therapeutic range for DVT treatment,
and mild calf discomfort is expected with the diagnosis.
,3. Mr. Rodriguez is a 55-year-old male recovering from an abdominal cholecystectomy. Four
hours post-operatively, he reports severe abdominal pain and is noted to have a heart rate of
115 bpm and a blood pressure of 90/58 mmHg. What is the nurse’s first action?
A. Administer the prescribed PRN opioid analgesic.
B. Increase the rate of the intravenous maintenance fluids.
C. Perform a head-to-toe assessment and check the surgical site.
D. Place the patient in a Trendelenburg position.
Answer: C
Rationale: The patient is exhibiting signs of potential postoperative hemorrhage or shock,
including tachycardia and hypotension. The nurse must first assess the surgical site and
look for signs of internal bleeding to gather clinical data before intervening or notifying the
provider. Administering pain medication without assessing the source of pain and
hemodynamic instability could mask symptoms of a surgical complication.
4. A 42-year-old female patient, Ms. Miller, is admitted for an exacerbation of Graves’ disease
(hyperthyroidism). While performing an assessment, the nurse notes a temperature of
102.4°F (39.1°C), heart rate of 142 bpm, and increased agitation. Which condition should the
nurse suspect?
A. Myxedema Coma
B. Pheochromocytoma
C. Hypoparathyroidism
D. Thyroid Storm
Answer: D
Rationale: Thyroid storm is a medical emergency characterized by extreme
hypermetabolism, including high fever, severe tachycardia, and central nervous system
changes. This condition is triggered by stress or infection in patients with underlying
hyperthyroidism. Myxedema coma is the opposite extreme, representing severe, untreated
hypothyroidism.
5. A nurse is providing discharge education for a patient newly diagnosed with Type 1
Diabetes Mellitus. The patient asks why they cannot take their insulin in pill form. What is the
most accurate response by the nurse?
A. Insulin pills would be absorbed too quickly into the bloodstream.
B. Pill forms of insulin cause severe gastric ulcers and bleeding.
C. The liver would filter out all the insulin before it could reach the cells.
D. Insulin is a protein and would be destroyed by stomach acids and enzymes.
, Answer: D
Rationale: Insulin is a peptide hormone, meaning it is a protein that is broken down by
digestive enzymes in the stomach and small intestine if taken orally. Because of this, it must
be administered parenterally (usually subcutaneously) to bypass the GI tract. Oral
hypoglycemic agents work by different mechanisms and are not insulin themselves.
6. Mr. Lee is being treated for a small bowel obstruction. He has a nasogastric (NG) tube set
to low intermittent suction. Which laboratory result should the nurse monitor most closely
for this patient?
A. Serum Creatinine
B. Serum Calcium
C. Serum Potassium
D. Serum Albumin
Answer: C
Rationale: NG tube suctioning removes gastric secretions which are rich in electrolytes,
particularly potassium and chloride. Prolonged suctioning puts the patient at high risk for
hypokalemia and metabolic alkalosis. Monitoring serum potassium levels is essential to
prevent cardiac dysrhythmias and muscle weakness associated with electrolyte
imbalances.
7. A patient with Chronic Obstructive Pulmonary Disease (COPD) is admitted with an acute
exacerbation. The nurse notes the patient is leaning forward with arms on the over-bed table
and using pursed-lip breathing. What is the nurse’s best interpretation of these findings?
A. The patient is using compensatory techniques to improve ventilation.
B. The patient is experiencing severe anxiety and requires sedation.
C. The patient is confused and trying to get out of the bed.
D. The patient is exhibiting signs of an impending stroke.
Answer: A
Rationale: Leaning forward (tripod position) and pursed-lip breathing are classic
compensatory mechanisms used by COPD patients to decrease the work of breathing and
improve expiratory airflow. Pursed-lip breathing creates positive expiratory pressure,
which helps keep the airways open longer. These actions indicate the patient is working
hard to breathe and requires assessment of oxygenation and ventilation.
8. Which clinical manifestation would a nurse expect to find in a patient experiencing
autonomic dysreflexia following a spinal cord injury at the T4 level?
A. Hypotension and tachycardia.
B. Flaccid paralysis and loss of all reflex activity below the injury.
