NUR 425 Final Exam: Medical Surgical V2 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient who is 12 hours postoperative following a total hip arthroplasty. Which of
the following actions should the nurse take?
A. Keep the patient’s legs adducted.
B. Maintain abduction of the affected extremity.
C. Allow the patient to cross their legs.
D. Position the patient with the hip flexed more than 90 degrees.
Ans: B
Explanation: Maintaining abduction prevents the prosthesis from dislocating after surgery. An abduction
pillow or splint is typically used to keep the legs apart. Adduction or crossing the legs increases the risk of
the hip popping out of the socket. Flexing the hip beyond 90 degrees must also be avoided to ensure joint
stability. The nurse must educate the patient on these positioning precautions to prevent surgical failure.
2. Which laboratory value should the nurse prioritize when monitoring a patient with acute pancreatitis?
A. Serum amylase
B. Serum sodium
C. Platelet count
D. Hemoglobin level
Ans: A
Explanation: Serum amylase levels rise significantly within the first 24 hours of acute pancreatitis. This
enzyme is released as the pancreas undergoes autodigestion and inflammation. While lipase is more
,specific, amylase remains a primary diagnostic marker in the clinical setting. Monitoring these levels
helps assess the severity and progression of the disease. Other values like sodium or hemoglobin are less
directly indicative of pancreatic injury.
3. A patient is admitted with a diagnosis of Grave’s disease. Which of the following clinical manifestations
should the nurse expect?
A. Bradycardia
B. Exophthalmos
C. Weight gain
D. Cold intolerance
Ans: B
Explanation: Exophthalmos, or bulging of the eyes, is a classic sign of hyperthyroidism in Grave’s
disease. This occurs due to tissue edema and increased deposits in the retro-orbital area. Patients with
this condition also typically experience tachycardia and weight loss rather than bradycardia. Heat
intolerance is common because the metabolic rate is significantly elevated. The nurse should provide eye
care and monitor for thyroid storm.
4. A nurse is reviewing the arterial blood gas (ABG) results for a patient: pH 7.30, PaCO2 55, HCO3 26. How
should the nurse interpret these results?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis
Ans: A
, Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 indicates a respiratory cause.
The bicarbonate level is within the normal range, suggesting no compensation has occurred yet. This
pattern is commonly seen in patients with hypoventilation or obstructive lung diseases. The nurse should
focus on improving the patient’s ventilation to clear the excess carbon dioxide. Understanding ABGs is
essential for identifying the underlying physiological disturbance.
5. What is the priority assessment for a patient receiving an infusion of magnesium sulfate for
preeclampsia?
A. Daily weight
B. Serum glucose
C. Deep tendon reflexes
D. Bowel sounds
Ans: C
Explanation: Diminished or absent deep tendon reflexes are an early sign of magnesium toxicity.
Magnesium sulfate acts as a central nervous system depressant to prevent seizures. The nurse must also
monitor respiratory rate and urinary output closely during the infusion. Calcium gluconate should be
readily available as the antidote for magnesium toxicity. Consistent monitoring ensures the safety of both
the mother and the fetus.
6. A patient with a history of heart failure reports a weight gain of 3 pounds in 24 hours. What is the nurse’s
first action?
A. Notify the healthcare provider.
B. Restrict all fluid intake.
C. Assess the patient for peripheral edema.
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient who is 12 hours postoperative following a total hip arthroplasty. Which of
the following actions should the nurse take?
A. Keep the patient’s legs adducted.
B. Maintain abduction of the affected extremity.
C. Allow the patient to cross their legs.
D. Position the patient with the hip flexed more than 90 degrees.
Ans: B
Explanation: Maintaining abduction prevents the prosthesis from dislocating after surgery. An abduction
pillow or splint is typically used to keep the legs apart. Adduction or crossing the legs increases the risk of
the hip popping out of the socket. Flexing the hip beyond 90 degrees must also be avoided to ensure joint
stability. The nurse must educate the patient on these positioning precautions to prevent surgical failure.
2. Which laboratory value should the nurse prioritize when monitoring a patient with acute pancreatitis?
A. Serum amylase
B. Serum sodium
C. Platelet count
D. Hemoglobin level
Ans: A
Explanation: Serum amylase levels rise significantly within the first 24 hours of acute pancreatitis. This
enzyme is released as the pancreas undergoes autodigestion and inflammation. While lipase is more
,specific, amylase remains a primary diagnostic marker in the clinical setting. Monitoring these levels
helps assess the severity and progression of the disease. Other values like sodium or hemoglobin are less
directly indicative of pancreatic injury.
3. A patient is admitted with a diagnosis of Grave’s disease. Which of the following clinical manifestations
should the nurse expect?
A. Bradycardia
B. Exophthalmos
C. Weight gain
D. Cold intolerance
Ans: B
Explanation: Exophthalmos, or bulging of the eyes, is a classic sign of hyperthyroidism in Grave’s
disease. This occurs due to tissue edema and increased deposits in the retro-orbital area. Patients with
this condition also typically experience tachycardia and weight loss rather than bradycardia. Heat
intolerance is common because the metabolic rate is significantly elevated. The nurse should provide eye
care and monitor for thyroid storm.
4. A nurse is reviewing the arterial blood gas (ABG) results for a patient: pH 7.30, PaCO2 55, HCO3 26. How
should the nurse interpret these results?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis
Ans: A
, Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 indicates a respiratory cause.
The bicarbonate level is within the normal range, suggesting no compensation has occurred yet. This
pattern is commonly seen in patients with hypoventilation or obstructive lung diseases. The nurse should
focus on improving the patient’s ventilation to clear the excess carbon dioxide. Understanding ABGs is
essential for identifying the underlying physiological disturbance.
5. What is the priority assessment for a patient receiving an infusion of magnesium sulfate for
preeclampsia?
A. Daily weight
B. Serum glucose
C. Deep tendon reflexes
D. Bowel sounds
Ans: C
Explanation: Diminished or absent deep tendon reflexes are an early sign of magnesium toxicity.
Magnesium sulfate acts as a central nervous system depressant to prevent seizures. The nurse must also
monitor respiratory rate and urinary output closely during the infusion. Calcium gluconate should be
readily available as the antidote for magnesium toxicity. Consistent monitoring ensures the safety of both
the mother and the fetus.
6. A patient with a history of heart failure reports a weight gain of 3 pounds in 24 hours. What is the nurse’s
first action?
A. Notify the healthcare provider.
B. Restrict all fluid intake.
C. Assess the patient for peripheral edema.
