NURS 201 Final Quiz V3 | NURS 201
Medical Surgical Nursing | Actual Q&A
with Rationale (NURS201 Final Quiz) |
West Coast University
1. A nurse is caring for a patient who is 24 hours postoperative following an abdominal
surgery. Which finding should the nurse report to the provider immediately?
A. Serosanguineous drainage on the dressing
B. Urine output of 150 mL over the last 4 hours
C. Patient reporting pain at a 6 on a scale of 0 to 10
D. Absent bowel sounds with abdominal distension and vomiting
Answer: D
Rationale: Absent bowel sounds combined with distension and vomiting may indicate a
paralytic ileus or bowel obstruction, which are serious postoperative complications. While
pain and serosanguineous drainage are common, they do not take priority over a potential
obstruction. The nurse must assess for return of peristalsis before advancing the patient’s
diet.
2. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 2 L/min via nasal cannula. The nurse notes the patient’s respiratory rate is 22/min
and SpO2 is 90%. Which action should the nurse take?
A. Continue to monitor the patient as these findings are expected
,B. Place the patient in a supine position
C. Increase the oxygen flow to 6 L/min
D. Prepare for immediate endotracheal intubation
Answer: A
Rationale: For patients with COPD, an SpO2 level between 88% and 92% is often the
target range to avoid suppressing the hypoxic drive. Increasing oxygen to high levels can
lead to carbon dioxide retention and respiratory acidosis. The nurse should recognize these
values as stable for a patient with chronic lung disease.
3. The nurse is preparing to administer levothyroxine to a patient with hypothyroidism.
Which assessment finding should lead the nurse to withhold the medication?
A. Blood pressure of 110/70 mmHg
B. Heart rate of 110 beats per minute
C. Weight gain of 2 lbs in the past week
D. Patient reports feeling cold all the time
Answer: B
Rationale: Levothyroxine is a thyroid hormone replacement that can cause symptoms of
hyperthyroidism if the dose is too high. Tachycardia (HR > 100 bpm) is a sign of toxicity or
excessive dosage and should be reported before administration. Feeling cold and weight
gain are symptoms of hypothyroidism, which the medication is intended to treat.
, 4. A nurse is assessing a patient with suspected hypocalcemia. Which clinical sign should the
nurse look for?
A. Negative Babinski reflex
B. Positive Chvostek’s sign
C. Hypoactive deep tendon reflexes
D. Flaccid paralysis
Answer: B
Rationale: Chvostek’s sign is a clinical indicator of hypocalcemia characterized by facial
twitching when the facial nerve is tapped. This occurs due to increased neuromuscular
excitability caused by low serum calcium levels. The nurse should also check for
Trousseau’s sign to further confirm the imbalance.
5. A patient is admitted with a diagnosis of Deep Vein Thrombosis (DVT) in the right leg.
Which intervention should the nurse include in the plan of care?
A. Elevate the affected extremity above the level of the heart
B. Apply a cold compress to the affected calf
C. Massage the affected leg twice daily
D. Maintain strict bed rest for the duration of therapy
Answer: A
Medical Surgical Nursing | Actual Q&A
with Rationale (NURS201 Final Quiz) |
West Coast University
1. A nurse is caring for a patient who is 24 hours postoperative following an abdominal
surgery. Which finding should the nurse report to the provider immediately?
A. Serosanguineous drainage on the dressing
B. Urine output of 150 mL over the last 4 hours
C. Patient reporting pain at a 6 on a scale of 0 to 10
D. Absent bowel sounds with abdominal distension and vomiting
Answer: D
Rationale: Absent bowel sounds combined with distension and vomiting may indicate a
paralytic ileus or bowel obstruction, which are serious postoperative complications. While
pain and serosanguineous drainage are common, they do not take priority over a potential
obstruction. The nurse must assess for return of peristalsis before advancing the patient’s
diet.
2. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 2 L/min via nasal cannula. The nurse notes the patient’s respiratory rate is 22/min
and SpO2 is 90%. Which action should the nurse take?
A. Continue to monitor the patient as these findings are expected
,B. Place the patient in a supine position
C. Increase the oxygen flow to 6 L/min
D. Prepare for immediate endotracheal intubation
Answer: A
Rationale: For patients with COPD, an SpO2 level between 88% and 92% is often the
target range to avoid suppressing the hypoxic drive. Increasing oxygen to high levels can
lead to carbon dioxide retention and respiratory acidosis. The nurse should recognize these
values as stable for a patient with chronic lung disease.
3. The nurse is preparing to administer levothyroxine to a patient with hypothyroidism.
Which assessment finding should lead the nurse to withhold the medication?
A. Blood pressure of 110/70 mmHg
B. Heart rate of 110 beats per minute
C. Weight gain of 2 lbs in the past week
D. Patient reports feeling cold all the time
Answer: B
Rationale: Levothyroxine is a thyroid hormone replacement that can cause symptoms of
hyperthyroidism if the dose is too high. Tachycardia (HR > 100 bpm) is a sign of toxicity or
excessive dosage and should be reported before administration. Feeling cold and weight
gain are symptoms of hypothyroidism, which the medication is intended to treat.
, 4. A nurse is assessing a patient with suspected hypocalcemia. Which clinical sign should the
nurse look for?
A. Negative Babinski reflex
B. Positive Chvostek’s sign
C. Hypoactive deep tendon reflexes
D. Flaccid paralysis
Answer: B
Rationale: Chvostek’s sign is a clinical indicator of hypocalcemia characterized by facial
twitching when the facial nerve is tapped. This occurs due to increased neuromuscular
excitability caused by low serum calcium levels. The nurse should also check for
Trousseau’s sign to further confirm the imbalance.
5. A patient is admitted with a diagnosis of Deep Vein Thrombosis (DVT) in the right leg.
Which intervention should the nurse include in the plan of care?
A. Elevate the affected extremity above the level of the heart
B. Apply a cold compress to the affected calf
C. Massage the affected leg twice daily
D. Maintain strict bed rest for the duration of therapy
Answer: A
