NURS 201 Quiz 4 V1 | NURS 201 Medical
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 4) | West Coast
University
1. A patient with chronic obstructive pulmonary disease (COPD) is being discharged home
with oxygen therapy. Which statement by the patient indicates a need for further teaching?
A. I will use petroleum jelly on my lips to prevent dryness from the nasal cannula.
B. I will keep the oxygen tank at least 10 feet away from the fireplace.
C. I will check the oxygen flow rate every morning to ensure it is at the prescribed level.
D. I will wear cotton clothing instead of synthetic materials to reduce static electricity.
Answer: A
Rationale: Petroleum-based products are flammable and should never be used around
oxygen therapy as they pose a significant fire risk. Patients should use water-based
lubricants instead to alleviate dryness caused by the cannula. Safety education is a priority
in home oxygen therapy to prevent accidental combustion.
2. The nurse is interpreting the Arterial Blood Gas (ABG) results for a patient with severe
vomiting: pH 7.50, PaCO2 48 mmHg, and HCO3 34 mEq/L. Which condition does the nurse
suspect?
A. Respiratory Acidosis
,B. Respiratory Alkalosis
C. Metabolic Alkalosis partially compensated
D. Metabolic Acidosis uncompensated
Answer: C
Rationale: The pH is elevated (alkalosis) and the bicarbonate (HCO3) is also elevated,
pointing toward a metabolic cause. The PaCO2 is slightly elevated as the body attempts to
compensate by retaining CO2 through hypoventilation. This combination indicates partially
compensated metabolic alkalosis, common in patients losing gastric acid.
3. A patient with Type 1 Diabetes Mellitus is found unconscious and clammy. What is the
priority nursing action?
A. Obtain a bedside blood glucose reading.
B. Administer 15 grams of oral glucose paste.
C. Inject 10 units of Regular insulin subcutaneously.
D. Administer Glucagon 1 mg intramuscularly.
Answer: D
Rationale: When a diabetic patient is unconscious, they cannot safely swallow oral
carbohydrates, making intramuscular glucagon or IV dextrose the priority intervention.
Hypoglycemia is a life-threatening emergency that requires immediate reversal to prevent
, neurological damage. Assessing the blood glucose is important, but if the patient is
symptomatic and unresponsive, treatment should not be delayed.
4. A nurse is caring for a patient with liver cirrhosis who exhibits tremors and confusion.
Which laboratory value is most critical for the nurse to monitor?
A. Serum Potassium
B. Serum Ammonia
C. Alanine Aminotransferase (ALT)
D. Serum Albumin
Answer: B
Rationale: Elevated serum ammonia levels are a hallmark of hepatic encephalopathy,
which manifests as confusion, lethargy, and asterixis (tremors). In cirrhosis, the liver is
unable to convert ammonia into urea for excretion, leading to toxic accumulation in the
brain. Monitoring this value helps guide the administration of treatments like lactulose.
5. A patient post-op gastrectomy is experiencing dizziness, sweating, and palpitations after
eating. Which intervention should the nurse recommend?
A. Lie down for 30 minutes after consuming meals.
B. Eat three large meals a day to ensure adequate nutrition.
C. Drink a large glass of water with every meal.
D. Increase intake of simple carbohydrates for quick energy.
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 4) | West Coast
University
1. A patient with chronic obstructive pulmonary disease (COPD) is being discharged home
with oxygen therapy. Which statement by the patient indicates a need for further teaching?
A. I will use petroleum jelly on my lips to prevent dryness from the nasal cannula.
B. I will keep the oxygen tank at least 10 feet away from the fireplace.
C. I will check the oxygen flow rate every morning to ensure it is at the prescribed level.
D. I will wear cotton clothing instead of synthetic materials to reduce static electricity.
Answer: A
Rationale: Petroleum-based products are flammable and should never be used around
oxygen therapy as they pose a significant fire risk. Patients should use water-based
lubricants instead to alleviate dryness caused by the cannula. Safety education is a priority
in home oxygen therapy to prevent accidental combustion.
2. The nurse is interpreting the Arterial Blood Gas (ABG) results for a patient with severe
vomiting: pH 7.50, PaCO2 48 mmHg, and HCO3 34 mEq/L. Which condition does the nurse
suspect?
A. Respiratory Acidosis
,B. Respiratory Alkalosis
C. Metabolic Alkalosis partially compensated
D. Metabolic Acidosis uncompensated
Answer: C
Rationale: The pH is elevated (alkalosis) and the bicarbonate (HCO3) is also elevated,
pointing toward a metabolic cause. The PaCO2 is slightly elevated as the body attempts to
compensate by retaining CO2 through hypoventilation. This combination indicates partially
compensated metabolic alkalosis, common in patients losing gastric acid.
3. A patient with Type 1 Diabetes Mellitus is found unconscious and clammy. What is the
priority nursing action?
A. Obtain a bedside blood glucose reading.
B. Administer 15 grams of oral glucose paste.
C. Inject 10 units of Regular insulin subcutaneously.
D. Administer Glucagon 1 mg intramuscularly.
Answer: D
Rationale: When a diabetic patient is unconscious, they cannot safely swallow oral
carbohydrates, making intramuscular glucagon or IV dextrose the priority intervention.
Hypoglycemia is a life-threatening emergency that requires immediate reversal to prevent
, neurological damage. Assessing the blood glucose is important, but if the patient is
symptomatic and unresponsive, treatment should not be delayed.
4. A nurse is caring for a patient with liver cirrhosis who exhibits tremors and confusion.
Which laboratory value is most critical for the nurse to monitor?
A. Serum Potassium
B. Serum Ammonia
C. Alanine Aminotransferase (ALT)
D. Serum Albumin
Answer: B
Rationale: Elevated serum ammonia levels are a hallmark of hepatic encephalopathy,
which manifests as confusion, lethargy, and asterixis (tremors). In cirrhosis, the liver is
unable to convert ammonia into urea for excretion, leading to toxic accumulation in the
brain. Monitoring this value helps guide the administration of treatments like lactulose.
5. A patient post-op gastrectomy is experiencing dizziness, sweating, and palpitations after
eating. Which intervention should the nurse recommend?
A. Lie down for 30 minutes after consuming meals.
B. Eat three large meals a day to ensure adequate nutrition.
C. Drink a large glass of water with every meal.
D. Increase intake of simple carbohydrates for quick energy.
