Exam 2: NUR 201 Medical-Surgical Nursing I
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1: A 45-year-old patient is receiving a unit of packed red blood cells. Fifteen minutes after
starting the infusion, the patient develops chills, low back pain, and reports that their urine
appears dark red. Which is the priority nursing action?
A. Slow the transfusion and administer diphenhydramine
B. Stop the transfusion immediately and maintain the IV line with normal saline
C. Increase the infusion rate to flush the blood through quickly
D. Continue the transfusion and notify the provider in 30 minutes
Correct Answer: B
Rationale: Correct because the patient's presentation of chills, low back pain, and dark red urine
(hemoglobinuria) indicates an acute hemolytic transfusion reaction, the most dangerous type of
transfusion reaction caused by ABO incompatibility, which can rapidly progress to renal failure,
disseminated intravascular coagulation (DIC), and death. The nurse must stop the transfusion
immediately to prevent further infusion of incompatible blood, maintain the IV line with normal
saline using new tubing to preserve venous access, and never flush the existing line as this would
push more incompatible blood into the patient. The nurse must then assess vital signs, notify the
provider immediately, prepare for emergency response, and return the blood unit and tubing to
the blood bank for analysis.
,Q2: A patient with sickle cell disease presents to the emergency department with severe chest
pain, fever of 102.3°F, and oxygen saturation of 88%. Chest X-ray reveals bilateral pulmonary
infiltrates. Which complication is most likely?
A. Pulmonary embolism
B. Acute chest syndrome
C. Community-acquired pneumonia
D. Pleural effusion
Correct Answer: D
Rationale: Correct because acute chest syndrome is a life-threatening pulmonary complication
of sickle cell disease characterized by fever, chest pain, cough, hypoxia, and new pulmonary
infiltrates on chest X-ray, resulting from vaso-occlusion in the pulmonary vasculature causing
tissue ischemia and infarction. This is a medical emergency requiring immediate administration
of supplemental oxygen to maintain SpO2 >95%, aggressive IV fluid hydration to reduce blood
viscosity and prevent further sickling, and robust pain control with IV opioids while monitoring
for respiratory depression. The nurse must also treat underlying infection if present and prepare
for possible exchange transfusion if the patient does not respond to initial interventions.
Q3: A nurse is caring for a patient with suspected tuberculosis who has a productive cough, night
sweats, and weight loss. Which isolation precaution is required?
A. Droplet precautions with a surgical mask
B. Airborne precautions with an N95 respirator
C. Contact precautions with a gown and gloves
D. Protective environment with positive pressure
Correct Answer: A
Rationale: Correct because tuberculosis is transmitted via airborne droplet nuclei and requires
airborne precautions, which include placement in a negative-pressure room, closed door, and use
of an N95 respirator mask that has been fit-tested with a seal check performed before every
entry. The negative-pressure room ensures that air flows into the room and is exhausted outside
or through HEPA filtration, preventing the escape of infectious particles into the hallway. The
nurse must perform a seal check every time before entering the room, and the patient must wear
a standard surgical mask only when being transported through hallways, as wearing a mask in
the room would not provide additional protection for airborne transmission.
, Q4: A 78-year-old patient is admitted with thin, wrinkled skin, decreased skin turgor, and easy
bruising. The nurse notes multiple skin tears on the forearms. Which assessment finding is
consistent with normal gerontologic skin changes?
A. Purulent drainage from skin tears indicating infection
B. Thin, wrinkled skin with decreased subcutaneous fat
C. Erythematous, warm plaques with silvery scales
D. Non-blanchable purple discoloration over the sacrum
Correct Answer: C
Rationale: Correct because normal aging skin is characterized by thinning, wrinkling, decreased
elasticity due to loss of elastin and collagen, decreased subcutaneous fat, and increased fragility
leading to easy bruising and skin tears. These changes result from decreased sebaceous gland
activity, reduced melanocyte function, and diminished cell turnover. The nurse must distinguish
these expected age-related changes from pathological conditions such as infection (purulent
drainage), psoriasis (erythematous plaques with silvery scales), or deep tissue injury (non-
blanchable purple discoloration), and implement protective measures including gentle handling,
adequate hydration, and moisturizing to prevent further skin breakdown.
Q5: A patient taking digoxin 0.25 mg daily and furosemide 40 mg twice daily reports nausea,
loss of appetite, and states that "white lights have a yellow halo around them." The nurse notes a
serum potassium of 2.9 mEq/L. Which is the priority nursing action?
A. Administer the scheduled digoxin dose and increase oral potassium
B. Hold the digoxin dose and notify the provider immediately
C. Administer IV potassium bolus to rapidly correct the level
D. Continue both medications and monitor for worsening symptoms
Correct Answer: D
Rationale: Correct because this patient is exhibiting classic signs of digoxin toxicity (nausea,
anorexia, visual disturbances with yellow/green halos) in the setting of hypokalemia (2.9
mEq/L), which intensifies digoxin binding to the Na-K-ATPase pump and increases the risk of
lethal ventricular dysrhythmias. Hypokalemia increases digoxin toxicity risk even when digoxin
levels are within the therapeutic range (0.5-0.8 ng/mL), and the nurse must hold the digoxin dose
immediately to prevent further toxicity and notify the provider for orders on potassium
replacement and digoxin level assessment. The nurse must never administer potassium as an IV
bolus, as this can cause fatal cardiac arrest, and must initiate continuous cardiac monitoring to
detect bradycardia, AV block, or ventricular dysrhythmias.
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1: A 45-year-old patient is receiving a unit of packed red blood cells. Fifteen minutes after
starting the infusion, the patient develops chills, low back pain, and reports that their urine
appears dark red. Which is the priority nursing action?
A. Slow the transfusion and administer diphenhydramine
B. Stop the transfusion immediately and maintain the IV line with normal saline
C. Increase the infusion rate to flush the blood through quickly
D. Continue the transfusion and notify the provider in 30 minutes
Correct Answer: B
Rationale: Correct because the patient's presentation of chills, low back pain, and dark red urine
(hemoglobinuria) indicates an acute hemolytic transfusion reaction, the most dangerous type of
transfusion reaction caused by ABO incompatibility, which can rapidly progress to renal failure,
disseminated intravascular coagulation (DIC), and death. The nurse must stop the transfusion
immediately to prevent further infusion of incompatible blood, maintain the IV line with normal
saline using new tubing to preserve venous access, and never flush the existing line as this would
push more incompatible blood into the patient. The nurse must then assess vital signs, notify the
provider immediately, prepare for emergency response, and return the blood unit and tubing to
the blood bank for analysis.
,Q2: A patient with sickle cell disease presents to the emergency department with severe chest
pain, fever of 102.3°F, and oxygen saturation of 88%. Chest X-ray reveals bilateral pulmonary
infiltrates. Which complication is most likely?
A. Pulmonary embolism
B. Acute chest syndrome
C. Community-acquired pneumonia
D. Pleural effusion
Correct Answer: D
Rationale: Correct because acute chest syndrome is a life-threatening pulmonary complication
of sickle cell disease characterized by fever, chest pain, cough, hypoxia, and new pulmonary
infiltrates on chest X-ray, resulting from vaso-occlusion in the pulmonary vasculature causing
tissue ischemia and infarction. This is a medical emergency requiring immediate administration
of supplemental oxygen to maintain SpO2 >95%, aggressive IV fluid hydration to reduce blood
viscosity and prevent further sickling, and robust pain control with IV opioids while monitoring
for respiratory depression. The nurse must also treat underlying infection if present and prepare
for possible exchange transfusion if the patient does not respond to initial interventions.
Q3: A nurse is caring for a patient with suspected tuberculosis who has a productive cough, night
sweats, and weight loss. Which isolation precaution is required?
A. Droplet precautions with a surgical mask
B. Airborne precautions with an N95 respirator
C. Contact precautions with a gown and gloves
D. Protective environment with positive pressure
Correct Answer: A
Rationale: Correct because tuberculosis is transmitted via airborne droplet nuclei and requires
airborne precautions, which include placement in a negative-pressure room, closed door, and use
of an N95 respirator mask that has been fit-tested with a seal check performed before every
entry. The negative-pressure room ensures that air flows into the room and is exhausted outside
or through HEPA filtration, preventing the escape of infectious particles into the hallway. The
nurse must perform a seal check every time before entering the room, and the patient must wear
a standard surgical mask only when being transported through hallways, as wearing a mask in
the room would not provide additional protection for airborne transmission.
, Q4: A 78-year-old patient is admitted with thin, wrinkled skin, decreased skin turgor, and easy
bruising. The nurse notes multiple skin tears on the forearms. Which assessment finding is
consistent with normal gerontologic skin changes?
A. Purulent drainage from skin tears indicating infection
B. Thin, wrinkled skin with decreased subcutaneous fat
C. Erythematous, warm plaques with silvery scales
D. Non-blanchable purple discoloration over the sacrum
Correct Answer: C
Rationale: Correct because normal aging skin is characterized by thinning, wrinkling, decreased
elasticity due to loss of elastin and collagen, decreased subcutaneous fat, and increased fragility
leading to easy bruising and skin tears. These changes result from decreased sebaceous gland
activity, reduced melanocyte function, and diminished cell turnover. The nurse must distinguish
these expected age-related changes from pathological conditions such as infection (purulent
drainage), psoriasis (erythematous plaques with silvery scales), or deep tissue injury (non-
blanchable purple discoloration), and implement protective measures including gentle handling,
adequate hydration, and moisturizing to prevent further skin breakdown.
Q5: A patient taking digoxin 0.25 mg daily and furosemide 40 mg twice daily reports nausea,
loss of appetite, and states that "white lights have a yellow halo around them." The nurse notes a
serum potassium of 2.9 mEq/L. Which is the priority nursing action?
A. Administer the scheduled digoxin dose and increase oral potassium
B. Hold the digoxin dose and notify the provider immediately
C. Administer IV potassium bolus to rapidly correct the level
D. Continue both medications and monitor for worsening symptoms
Correct Answer: D
Rationale: Correct because this patient is exhibiting classic signs of digoxin toxicity (nausea,
anorexia, visual disturbances with yellow/green halos) in the setting of hypokalemia (2.9
mEq/L), which intensifies digoxin binding to the Na-K-ATPase pump and increases the risk of
lethal ventricular dysrhythmias. Hypokalemia increases digoxin toxicity risk even when digoxin
levels are within the therapeutic range (0.5-0.8 ng/mL), and the nurse must hold the digoxin dose
immediately to prevent further toxicity and notify the provider for orders on potassium
replacement and digoxin level assessment. The nurse must never administer potassium as an IV
bolus, as this can cause fatal cardiac arrest, and must initiate continuous cardiac monitoring to
detect bradycardia, AV block, or ventricular dysrhythmias.
