NSG223/NSG 223 Exam 4 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient is admitted to the emergency department with a suspected diagnosis of Diabetic
Ketoacidosis (DKA). Which of the following initial nursing interventions is the highest
priority?
A. Initiating rapid fluid resuscitation with normal saline
B. Administering intravenous regular insulin infusion
C. Administering intravenous potassium supplements
D. Checking the patient’s arterial blood gas (ABG) levels
Correct Answer: A
Rationale: The priority in treating DKA is to address dehydration and restore circulatory
volume through fluid resuscitation. Dehydration in DKA is often severe and can lead to
hypovolemic shock if not managed immediately. Once volume is being restored, insulin
therapy can be initiated to lower blood glucose and stop ketone production.
2. A client with a T4 spinal cord injury reports a sudden, severe headache and has a blood
pressure of 190/110 mmHg. What is the nurse’s first action?
A. Elevate the head of the bed to a high-Fowler’s position
B. Administer prescribed antihypertensive medication
,C. Perform a bladder scan to check for retention
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: Autonomic dysreflexia is a medical emergency that occurs in patients with
spinal cord injuries above T6. Elevating the head of the bed is the first action to take
because it uses gravity to help lower blood pressure via orthostatic changes. After
positioning, the nurse should assess for the triggering cause, such as a distended bladder or
fecal impaction.
3. When assessing a patient using the Glasgow Coma Scale (GCS), the patient opens their eyes
to sound, uses inappropriate words, and withdraws from painful stimuli. What is the
calculated GCS score?
A. GCS 12
B. GCS 9
C. GCS 10
D. GCS 11
Correct Answer: C
Rationale: The score is calculated as follows: Eyes opening to sound is 3 points,
inappropriate words is 3 points, and withdrawal from pain is 4 points. Summing these
values results in a total GCS score of 10. This score indicates a moderate brain injury and
requires close neurological monitoring.
, 4. A patient with Diabetes Insipidus (DI) is receiving treatment. Which finding indicates that
the medication, desmopressin (DDAVP), is effective?
A. Urine specific gravity of 1.015
B. Serum sodium of 150 mEq/L
C. Urine output of 400 mL/hr
D. Increased thirst and polydipsia
Correct Answer: A
Rationale: Desmopressin is a synthetic form of ADH that helps the kidneys conserve water.
A urine specific gravity of 1.015 is within the normal range (1.005-1.030), indicating that
the urine is becoming more concentrated. Improved concentration of urine and decreased
urine output are the primary goals of therapy for DI.
5. A patient with a head injury exhibits Cushing’s triad. Which of the following sets of vital
signs is consistent with this finding?
A. BP 90/50, Pulse 120, rapid shallow respirations
B. BP 160/60, Pulse 50, irregular respirations
C. BP 120/80, Pulse 80, regular respirations
D. BP 180/100, Pulse 110, labored respirations
Correct Answer: B
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient is admitted to the emergency department with a suspected diagnosis of Diabetic
Ketoacidosis (DKA). Which of the following initial nursing interventions is the highest
priority?
A. Initiating rapid fluid resuscitation with normal saline
B. Administering intravenous regular insulin infusion
C. Administering intravenous potassium supplements
D. Checking the patient’s arterial blood gas (ABG) levels
Correct Answer: A
Rationale: The priority in treating DKA is to address dehydration and restore circulatory
volume through fluid resuscitation. Dehydration in DKA is often severe and can lead to
hypovolemic shock if not managed immediately. Once volume is being restored, insulin
therapy can be initiated to lower blood glucose and stop ketone production.
2. A client with a T4 spinal cord injury reports a sudden, severe headache and has a blood
pressure of 190/110 mmHg. What is the nurse’s first action?
A. Elevate the head of the bed to a high-Fowler’s position
B. Administer prescribed antihypertensive medication
,C. Perform a bladder scan to check for retention
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: Autonomic dysreflexia is a medical emergency that occurs in patients with
spinal cord injuries above T6. Elevating the head of the bed is the first action to take
because it uses gravity to help lower blood pressure via orthostatic changes. After
positioning, the nurse should assess for the triggering cause, such as a distended bladder or
fecal impaction.
3. When assessing a patient using the Glasgow Coma Scale (GCS), the patient opens their eyes
to sound, uses inappropriate words, and withdraws from painful stimuli. What is the
calculated GCS score?
A. GCS 12
B. GCS 9
C. GCS 10
D. GCS 11
Correct Answer: C
Rationale: The score is calculated as follows: Eyes opening to sound is 3 points,
inappropriate words is 3 points, and withdrawal from pain is 4 points. Summing these
values results in a total GCS score of 10. This score indicates a moderate brain injury and
requires close neurological monitoring.
, 4. A patient with Diabetes Insipidus (DI) is receiving treatment. Which finding indicates that
the medication, desmopressin (DDAVP), is effective?
A. Urine specific gravity of 1.015
B. Serum sodium of 150 mEq/L
C. Urine output of 400 mL/hr
D. Increased thirst and polydipsia
Correct Answer: A
Rationale: Desmopressin is a synthetic form of ADH that helps the kidneys conserve water.
A urine specific gravity of 1.015 is within the normal range (1.005-1.030), indicating that
the urine is becoming more concentrated. Improved concentration of urine and decreased
urine output are the primary goals of therapy for DI.
5. A patient with a head injury exhibits Cushing’s triad. Which of the following sets of vital
signs is consistent with this finding?
A. BP 90/50, Pulse 120, rapid shallow respirations
B. BP 160/60, Pulse 50, irregular respirations
C. BP 120/80, Pulse 80, regular respirations
D. BP 180/100, Pulse 110, labored respirations
Correct Answer: B
