NUR 170 MEDICAL SURGICAL NURSING EXAMS 1-4 EXAM] –
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1. A patient is admitted with a diagnosis of acute pancreatitis. Which serum laboratory
value should the nurse anticipate being elevated?
A. Serum albumin
B. Serum lipase
C. Serum calcium
D. Serum potassium
Rationale: Lipase is a pancreatic enzyme that becomes significantly elevated during acute
pancreatic inflammation. Serum calcium typically decreases in acute pancreatitis due to fat
necrosis, while albumin and potassium are not primary diagnostic markers for this condition.
2. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The
patient exhibits a barrel chest and pursed-lip breathing. Which arterial blood gas (ABG)
result does the nurse expect to see?
A. pH 7.32, PaCO2 55 mmHg, HCO3 28 mEq/L
B. pH 7.48, PaCO2 30 mmHg, HCO3 22 mEq/L
C. pH 7.40, PaCO2 40 mmHg, HCO3 24 mEq/L
D. pH 7.35, PaCO2 45 mmHg, HCO3 26 mEq/L
Rationale: Patients with COPD often develop chronic respiratory acidosis characterized by
CO2 retention (hypercapnia) and compensatory metabolic alkalosis (increased bicarbonate).
Option A reflects this uncompensated or partially compensated respiratory acidosis.
3. When assessing a patient post-thyroidectomy, the nurse notes positive Trousseau’s and
Chvostek’s signs. Which electrolyte imbalance should the nurse suspect?
A. Hyperkalemia
B. Hypernatremia
C. Hypocalcemia
D. Hypomagnesemia
Rationale: Positive Trousseau’s and Chvostek’s signs are classic indicators of neuromuscular
irritability caused by hypocalcemia, which can occur post-thyroidectomy if the parathyroid
glands are inadvertently damaged or removed.
, 4. A patient with hypertension is prescribed lisinopril. Which patient teaching is most
important to include?
A. Take the medication with a high-potassium snack.
B. Avoid using salt substitutes containing potassium.
C. Monitor your blood glucose levels daily.
D. Stop the medication if you develop a dry cough.
Rationale: Lisinopril is an ACE inhibitor that promotes potassium retention. Salt substitutes
are often composed of potassium chloride, which increases the risk of hyperkalemia. A cough
is a common side effect but does not require immediate discontinuation without provider
consultation.
5. A patient is brought to the emergency department following a motor vehicle accident.
The nurse observes tracheal deviation to the left and absent breath sounds on the right.
What is the priority nursing action?
A. Prepare for a chest tube insertion on the right side.
B. Administer oxygen via non-rebreather mask.
C. Call for a portable chest X-ray.
D. Document the finding in the electronic health record.
Rationale: Tracheal deviation and absent breath sounds are hallmark signs of a tension
pneumothorax, a life-threatening emergency that requires immediate decompression, usually
via chest tube or needle thoracostomy.
6. A nurse is managing a patient receiving a blood transfusion. The patient develops chills,
back pain, and tachycardia. What is the first action the nurse should take?
A. Notify the healthcare provider.
B. Slow the infusion rate.
C. Stop the blood transfusion immediately.
D. Check the patient’s vital signs again in 15 minutes.
Rationale: The patient is exhibiting signs of an acute hemolytic transfusion reaction. The first
and most critical action is to stop the infusion to prevent further administration of
incompatible blood, then disconnect the tubing and maintain IV access with normal saline.
7. Which instruction is essential for a patient being discharged with a new permanent
colostomy?
A. Empty the pouch when it is 50% to 75% full.
B. Change the entire appliance every day.
C. Use an oil-based cream to protect the peristomal skin.
D. Irrigate the colostomy daily to maintain function.
QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS PLUS RATIONALES | GUARANTEED PASS | LATEST
EXAM UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE
TEST| DOWNLOAD INSTANT PDF
1. A patient is admitted with a diagnosis of acute pancreatitis. Which serum laboratory
value should the nurse anticipate being elevated?
A. Serum albumin
B. Serum lipase
C. Serum calcium
D. Serum potassium
Rationale: Lipase is a pancreatic enzyme that becomes significantly elevated during acute
pancreatic inflammation. Serum calcium typically decreases in acute pancreatitis due to fat
necrosis, while albumin and potassium are not primary diagnostic markers for this condition.
2. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The
patient exhibits a barrel chest and pursed-lip breathing. Which arterial blood gas (ABG)
result does the nurse expect to see?
A. pH 7.32, PaCO2 55 mmHg, HCO3 28 mEq/L
B. pH 7.48, PaCO2 30 mmHg, HCO3 22 mEq/L
C. pH 7.40, PaCO2 40 mmHg, HCO3 24 mEq/L
D. pH 7.35, PaCO2 45 mmHg, HCO3 26 mEq/L
Rationale: Patients with COPD often develop chronic respiratory acidosis characterized by
CO2 retention (hypercapnia) and compensatory metabolic alkalosis (increased bicarbonate).
Option A reflects this uncompensated or partially compensated respiratory acidosis.
3. When assessing a patient post-thyroidectomy, the nurse notes positive Trousseau’s and
Chvostek’s signs. Which electrolyte imbalance should the nurse suspect?
A. Hyperkalemia
B. Hypernatremia
C. Hypocalcemia
D. Hypomagnesemia
Rationale: Positive Trousseau’s and Chvostek’s signs are classic indicators of neuromuscular
irritability caused by hypocalcemia, which can occur post-thyroidectomy if the parathyroid
glands are inadvertently damaged or removed.
, 4. A patient with hypertension is prescribed lisinopril. Which patient teaching is most
important to include?
A. Take the medication with a high-potassium snack.
B. Avoid using salt substitutes containing potassium.
C. Monitor your blood glucose levels daily.
D. Stop the medication if you develop a dry cough.
Rationale: Lisinopril is an ACE inhibitor that promotes potassium retention. Salt substitutes
are often composed of potassium chloride, which increases the risk of hyperkalemia. A cough
is a common side effect but does not require immediate discontinuation without provider
consultation.
5. A patient is brought to the emergency department following a motor vehicle accident.
The nurse observes tracheal deviation to the left and absent breath sounds on the right.
What is the priority nursing action?
A. Prepare for a chest tube insertion on the right side.
B. Administer oxygen via non-rebreather mask.
C. Call for a portable chest X-ray.
D. Document the finding in the electronic health record.
Rationale: Tracheal deviation and absent breath sounds are hallmark signs of a tension
pneumothorax, a life-threatening emergency that requires immediate decompression, usually
via chest tube or needle thoracostomy.
6. A nurse is managing a patient receiving a blood transfusion. The patient develops chills,
back pain, and tachycardia. What is the first action the nurse should take?
A. Notify the healthcare provider.
B. Slow the infusion rate.
C. Stop the blood transfusion immediately.
D. Check the patient’s vital signs again in 15 minutes.
Rationale: The patient is exhibiting signs of an acute hemolytic transfusion reaction. The first
and most critical action is to stop the infusion to prevent further administration of
incompatible blood, then disconnect the tubing and maintain IV access with normal saline.
7. Which instruction is essential for a patient being discharged with a new permanent
colostomy?
A. Empty the pouch when it is 50% to 75% full.
B. Change the entire appliance every day.
C. Use an oil-based cream to protect the peristomal skin.
D. Irrigate the colostomy daily to maintain function.
