NUR 3300 Exam 4 V1 | NUR 3300 Nursing
Practice II | Q&A with Rationale (NUR3300
Exam 4) | William Paterson University
1. A client is scheduled for an elective surgery in four hours. Which action should the nurse
prioritize during the preoperative phase to ensure legal and ethical standards are met?
A. Performing a comprehensive skin assessment.
B. Administering the prescribed preoperative antibiotic.
C. Confirming the patient has signed the informed consent form.
D. Teaching the client how to use an incentive spirometer.
Answer: C
Rationale: Informed consent is a legal requirement that must be completed before any
preoperative medication is administered. The nurse’s role is to witness the signature and
ensure the client understands the procedure as explained by the surgeon. Failure to secure
a signed consent can lead to legal implications and delay the surgical procedure.
2. Which intraoperative complication is characterized by a rapid rise in body temperature,
muscle rigidity, and tachycardia?
A. Malignant hyperthermia
B. Anaphylactic reaction
C. Hypovolemic shock
,D. Respiratory acidosis
Answer: A
Rationale: Malignant hyperthermia is a rare but life-threatening pharmacogenetic
disorder triggered by certain anesthetic agents. Immediate intervention with Dantrolene is
required to reverse the muscle metabolism dysfunction. The nurse must monitor for early
signs such as increased end-tidal CO2 and tachycardia before the temperature rises.
3. A postoperative patient is being monitored in the PACU. Which assessment finding
requires immediate notification of the healthcare provider?
A. Hypoactive bowel sounds in all quadrants.
B. Serosanguinous drainage on the dressing.
C. Oxygen saturation of 88% on room air.
D. Patient reporting a pain level of 4 out of 10.
Answer: C
Rationale: An oxygen saturation of 88% indicates significant hypoxia and requires
immediate intervention to maintain airway patency and gas exchange. While hypoactive
bowel sounds and mild pain are common postoperatively, they are not immediately life-
threatening. The nurse must apply oxygen and notify the provider to prevent further
respiratory compromise.
, 4. The nurse is teaching a client with Type 2 Diabetes about the ‘Rule of 15’ for managing
hypoglycemia. What should the client be instructed to do after consuming 15 grams of fast-
acting carbohydrates?
A. Administer an extra dose of rapid-acting insulin.
B. Wait 15 minutes and recheck the blood glucose level.
C. Lie down and rest for at least one hour.
D. Call 911 immediately regardless of the blood sugar level.
Answer: B
Rationale: The Rule of 15 involves consuming 15g of simple carbs and waiting 15 minutes
to retest blood glucose. If the level is still below 70 mg/dL, the process should be repeated
until the glucose stabilizes. This method provides a controlled way to raise blood sugar
without causing extreme hyperglycemia.
5. A client with Hyperthyroidism (Graves’ Disease) is admitted. Which vital sign change would
most likely indicate the onset of a Thyroid Storm?
A. Bradycardia and hypotension.
B. Normal temperature with decreased pulse pressure.
C. Bradypnea and hypothermia.
D. Hyperthermia and significant tachycardia.
Answer: D
Practice II | Q&A with Rationale (NUR3300
Exam 4) | William Paterson University
1. A client is scheduled for an elective surgery in four hours. Which action should the nurse
prioritize during the preoperative phase to ensure legal and ethical standards are met?
A. Performing a comprehensive skin assessment.
B. Administering the prescribed preoperative antibiotic.
C. Confirming the patient has signed the informed consent form.
D. Teaching the client how to use an incentive spirometer.
Answer: C
Rationale: Informed consent is a legal requirement that must be completed before any
preoperative medication is administered. The nurse’s role is to witness the signature and
ensure the client understands the procedure as explained by the surgeon. Failure to secure
a signed consent can lead to legal implications and delay the surgical procedure.
2. Which intraoperative complication is characterized by a rapid rise in body temperature,
muscle rigidity, and tachycardia?
A. Malignant hyperthermia
B. Anaphylactic reaction
C. Hypovolemic shock
,D. Respiratory acidosis
Answer: A
Rationale: Malignant hyperthermia is a rare but life-threatening pharmacogenetic
disorder triggered by certain anesthetic agents. Immediate intervention with Dantrolene is
required to reverse the muscle metabolism dysfunction. The nurse must monitor for early
signs such as increased end-tidal CO2 and tachycardia before the temperature rises.
3. A postoperative patient is being monitored in the PACU. Which assessment finding
requires immediate notification of the healthcare provider?
A. Hypoactive bowel sounds in all quadrants.
B. Serosanguinous drainage on the dressing.
C. Oxygen saturation of 88% on room air.
D. Patient reporting a pain level of 4 out of 10.
Answer: C
Rationale: An oxygen saturation of 88% indicates significant hypoxia and requires
immediate intervention to maintain airway patency and gas exchange. While hypoactive
bowel sounds and mild pain are common postoperatively, they are not immediately life-
threatening. The nurse must apply oxygen and notify the provider to prevent further
respiratory compromise.
, 4. The nurse is teaching a client with Type 2 Diabetes about the ‘Rule of 15’ for managing
hypoglycemia. What should the client be instructed to do after consuming 15 grams of fast-
acting carbohydrates?
A. Administer an extra dose of rapid-acting insulin.
B. Wait 15 minutes and recheck the blood glucose level.
C. Lie down and rest for at least one hour.
D. Call 911 immediately regardless of the blood sugar level.
Answer: B
Rationale: The Rule of 15 involves consuming 15g of simple carbs and waiting 15 minutes
to retest blood glucose. If the level is still below 70 mg/dL, the process should be repeated
until the glucose stabilizes. This method provides a controlled way to raise blood sugar
without causing extreme hyperglycemia.
5. A client with Hyperthyroidism (Graves’ Disease) is admitted. Which vital sign change would
most likely indicate the onset of a Thyroid Storm?
A. Bradycardia and hypotension.
B. Normal temperature with decreased pulse pressure.
C. Bradypnea and hypothermia.
D. Hyperthermia and significant tachycardia.
Answer: D
