NURS 201 Final Quiz V1 | NURS 201
Medical Surgical Nursing | Actual Q&A
with Rationale (NURS201 Final Quiz) |
West Coast University
1. A nurse is caring for a client who has a serum potassium level of 6.2 mEq/L. Which of the
following interventions should the nurse prioritize?
A. Obtain a 12-lead electrocardiogram (ECG) immediately
B. Encourage the intake of potassium-rich foods like bananas
C. Administer an oral dose of spironolactone as ordered
D. Monitor the client’s hourly urine output for polyuria
Answer: A
Rationale: Hyperkalemia is a critical electrolyte imbalance that can lead to fatal cardiac
dysrhythmias and cardiac arrest. Obtaining an ECG is the priority action to assess for
changes such as peaked T waves or a widened QRS complex. The nurse must monitor the
heart’s electrical activity while preparing for interventions to lower potassium levels.
2. A postoperative client is experiencing wound evisceration. Which of the following actions
should the nurse take first?
A. Place the client in a high-Fowler’s position to reduce pressure
B. Attempt to reinsert the organs back into the abdominal cavity gently
,C. Cover the protruding organs with sterile towels soaked in sterile normal saline
D. Instruct the client to cough and deep breathe to clear the airway
Answer: C
Rationale: Wound evisceration is a surgical emergency where internal organs protrude
through an incision. The nurse must protect the exposed tissue from drying and infection
by applying sterile, saline-soaked dressings. This intervention maintains tissue integrity
while the surgical team is notified for emergency repair.
3. An arterial blood gas (ABG) result shows pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L.
The nurse interprets this as:
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH level of 7.30 indicates acidosis, as it is below the normal range of 7.35 to
7.45. The PaCO2 is elevated above the normal 35-45 mmHg range, which suggests a
respiratory cause for the acidity. Because the bicarbonate level is within the normal range,
this is considered uncompensated respiratory acidosis.
, 4. A nurse is monitoring a client with a suspected pulmonary embolism. Which of the
following clinical manifestations should the nurse expect?
A. Bradycardia and hypertension with a widened pulse pressure
B. Productive cough with thick, green-tinged sputum
C. Gradual increase in peripheral edema in the lower extremities
D. Sudden onset of dyspnea and stabbing chest pain
Answer: D
Rationale: A pulmonary embolism typically presents with a sudden onset of shortness of
breath and pleuritic chest pain. The blockage of pulmonary blood flow leads to ventilation-
perfusion mismatch and acute respiratory distress. The nurse should immediately assess
oxygen saturation and notify the rapid response team.
5. Which of the following instructions is most important for a nurse to include in the
discharge teaching for a client with Chronic Obstructive Pulmonary Disease (COPD)?
A. Perform pursed-lip breathing exercises during periods of dyspnea
B. Use oxygen at 6 L/min via nasal cannula at all times
C. Increase intake of high-carbohydrate foods for energy
D. Limit fluid intake to 1 liter per day to prevent edema
Answer: A
Medical Surgical Nursing | Actual Q&A
with Rationale (NURS201 Final Quiz) |
West Coast University
1. A nurse is caring for a client who has a serum potassium level of 6.2 mEq/L. Which of the
following interventions should the nurse prioritize?
A. Obtain a 12-lead electrocardiogram (ECG) immediately
B. Encourage the intake of potassium-rich foods like bananas
C. Administer an oral dose of spironolactone as ordered
D. Monitor the client’s hourly urine output for polyuria
Answer: A
Rationale: Hyperkalemia is a critical electrolyte imbalance that can lead to fatal cardiac
dysrhythmias and cardiac arrest. Obtaining an ECG is the priority action to assess for
changes such as peaked T waves or a widened QRS complex. The nurse must monitor the
heart’s electrical activity while preparing for interventions to lower potassium levels.
2. A postoperative client is experiencing wound evisceration. Which of the following actions
should the nurse take first?
A. Place the client in a high-Fowler’s position to reduce pressure
B. Attempt to reinsert the organs back into the abdominal cavity gently
,C. Cover the protruding organs with sterile towels soaked in sterile normal saline
D. Instruct the client to cough and deep breathe to clear the airway
Answer: C
Rationale: Wound evisceration is a surgical emergency where internal organs protrude
through an incision. The nurse must protect the exposed tissue from drying and infection
by applying sterile, saline-soaked dressings. This intervention maintains tissue integrity
while the surgical team is notified for emergency repair.
3. An arterial blood gas (ABG) result shows pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L.
The nurse interprets this as:
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH level of 7.30 indicates acidosis, as it is below the normal range of 7.35 to
7.45. The PaCO2 is elevated above the normal 35-45 mmHg range, which suggests a
respiratory cause for the acidity. Because the bicarbonate level is within the normal range,
this is considered uncompensated respiratory acidosis.
, 4. A nurse is monitoring a client with a suspected pulmonary embolism. Which of the
following clinical manifestations should the nurse expect?
A. Bradycardia and hypertension with a widened pulse pressure
B. Productive cough with thick, green-tinged sputum
C. Gradual increase in peripheral edema in the lower extremities
D. Sudden onset of dyspnea and stabbing chest pain
Answer: D
Rationale: A pulmonary embolism typically presents with a sudden onset of shortness of
breath and pleuritic chest pain. The blockage of pulmonary blood flow leads to ventilation-
perfusion mismatch and acute respiratory distress. The nurse should immediately assess
oxygen saturation and notify the rapid response team.
5. Which of the following instructions is most important for a nurse to include in the
discharge teaching for a client with Chronic Obstructive Pulmonary Disease (COPD)?
A. Perform pursed-lip breathing exercises during periods of dyspnea
B. Use oxygen at 6 L/min via nasal cannula at all times
C. Increase intake of high-carbohydrate foods for energy
D. Limit fluid intake to 1 liter per day to prevent edema
Answer: A
