NSG223/NSG 223 Final Exam V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is caring for a patient who is 24 hours post-thyroidectomy. The patient reports
tingling in the fingers and around the mouth. Which action should the nurse take first?
A. Check the patient’s temperature.
B. Administer a dose of levothyroxine.
C. Assess for Chvostek’s sign.
D. Encourage the patient to use an incentive spirometer.
Correct Answer: C
Rationale: Tingling around the mouth and in the extremities is a classic sign of
hypocalcemia, which can occur after thyroid surgery if the parathyroid glands are
accidentally damaged or removed. Assessing for Chvostek’s sign helps confirm
neuromuscular irritability associated with low calcium levels. The nurse must prioritize
this assessment to determine the need for immediate calcium gluconate administration.
2. A patient with a history of cirrhosis is admitted with suspected hepatic encephalopathy.
Which laboratory result would most likely confirm this diagnosis?
A. Elevated serum creatinine level.
B. Decreased serum potassium level.
,C. Elevated serum ammonia level.
D. Decreased blood urea nitrogen (BUN).
Correct Answer: C
Rationale: Hepatic encephalopathy is primarily caused by the liver’s inability to convert
ammonia into urea, leading to high levels of ammonia in the blood that cross the blood-
brain barrier. High ammonia levels result in neurological symptoms such as confusion,
lethargy, and asterixis. Monitoring this lab value is crucial for assessing the severity of the
condition and the effectiveness of lactulose therapy.
3. A nurse is assessing a patient with a suspected diagnosis of Syndrome of Inappropriate
Antidiuretic Hormone (SIADH). Which finding is consistent with this condition?
A. Generalized weight loss.
B. Urine specific gravity of 1.002.
C. Increased urinary output.
D. Serum sodium of 122 mEq/L.
Correct Answer: D
Rationale: SIADH involves the excessive release of antidiuretic hormone, leading to water
retention and dilutional hyponatremia. A serum sodium level of 122 mEq/L indicates
significant hyponatremia, which can cause neurological changes. In this condition, the
nurse would also expect high urine specific gravity and weight gain without edema.
, 4. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). Which ventilator
setting is specifically utilized to prevent alveolar collapse at the end of expiration?
A. Positive End-Expiratory Pressure (PEEP).
B. Tidal Volume (VT).
C. Fraction of Inspired Oxygen (FiO2).
D. Inspiratory Pressure Limit.
Correct Answer: A
Rationale: PEEP is the application of positive pressure during the expiratory phase of
mechanical ventilation. It keeps the alveoli open, improving gas exchange and reducing the
risk of atelectasis in patients with ARDS. High levels of PEEP can, however, increase
intrathoracic pressure and decrease cardiac output.
5. Which clinical manifestation should a nurse expect to find in a patient experiencing
Autonomic Dysreflexia?
A. Tachycardia and hypotension.
B. Pounding headache and severe hypertension.
C. Pale, cool skin above the level of injury.
D. Extreme lethargy and low blood sugar.
Correct Answer: B
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is caring for a patient who is 24 hours post-thyroidectomy. The patient reports
tingling in the fingers and around the mouth. Which action should the nurse take first?
A. Check the patient’s temperature.
B. Administer a dose of levothyroxine.
C. Assess for Chvostek’s sign.
D. Encourage the patient to use an incentive spirometer.
Correct Answer: C
Rationale: Tingling around the mouth and in the extremities is a classic sign of
hypocalcemia, which can occur after thyroid surgery if the parathyroid glands are
accidentally damaged or removed. Assessing for Chvostek’s sign helps confirm
neuromuscular irritability associated with low calcium levels. The nurse must prioritize
this assessment to determine the need for immediate calcium gluconate administration.
2. A patient with a history of cirrhosis is admitted with suspected hepatic encephalopathy.
Which laboratory result would most likely confirm this diagnosis?
A. Elevated serum creatinine level.
B. Decreased serum potassium level.
,C. Elevated serum ammonia level.
D. Decreased blood urea nitrogen (BUN).
Correct Answer: C
Rationale: Hepatic encephalopathy is primarily caused by the liver’s inability to convert
ammonia into urea, leading to high levels of ammonia in the blood that cross the blood-
brain barrier. High ammonia levels result in neurological symptoms such as confusion,
lethargy, and asterixis. Monitoring this lab value is crucial for assessing the severity of the
condition and the effectiveness of lactulose therapy.
3. A nurse is assessing a patient with a suspected diagnosis of Syndrome of Inappropriate
Antidiuretic Hormone (SIADH). Which finding is consistent with this condition?
A. Generalized weight loss.
B. Urine specific gravity of 1.002.
C. Increased urinary output.
D. Serum sodium of 122 mEq/L.
Correct Answer: D
Rationale: SIADH involves the excessive release of antidiuretic hormone, leading to water
retention and dilutional hyponatremia. A serum sodium level of 122 mEq/L indicates
significant hyponatremia, which can cause neurological changes. In this condition, the
nurse would also expect high urine specific gravity and weight gain without edema.
, 4. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). Which ventilator
setting is specifically utilized to prevent alveolar collapse at the end of expiration?
A. Positive End-Expiratory Pressure (PEEP).
B. Tidal Volume (VT).
C. Fraction of Inspired Oxygen (FiO2).
D. Inspiratory Pressure Limit.
Correct Answer: A
Rationale: PEEP is the application of positive pressure during the expiratory phase of
mechanical ventilation. It keeps the alveoli open, improving gas exchange and reducing the
risk of atelectasis in patients with ARDS. High levels of PEEP can, however, increase
intrathoracic pressure and decrease cardiac output.
5. Which clinical manifestation should a nurse expect to find in a patient experiencing
Autonomic Dysreflexia?
A. Tachycardia and hypotension.
B. Pounding headache and severe hypertension.
C. Pale, cool skin above the level of injury.
D. Extreme lethargy and low blood sugar.
Correct Answer: B
