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 62-year-old patient with dark skin is admitted with suspected hepatitis. The nurse knows
that assessing for jaundice in this patient requires examining which site for yellow discoloration?
A. Palms and soles
B. Sclera and hard palate
C. Nail beds and lips
D. Earlobes and nasal bridge
Correct Answer: B
Rationale: Correct because the sclera and hard palate contain minimal melanin and provide
reliable visualization of bilirubin-induced yellow discoloration regardless of skin pigmentation.
Palms, soles, nail beds, lips, earlobes, and nasal bridge have variable melanin content that can
mask or mimic jaundice, leading to inaccurate assessment. According to nursing assessment
standards for patients with dark skin, mucous membranes and sclera are the definitive sites for
detecting early jaundice before it becomes visible on external skin surfaces.
Q2: A patient receiving a unit of packed red blood cells develops fever, chills, and lower back
pain 20 minutes into the transfusion. Which type of transfusion reaction is most likely, and what
is the priority nursing action?
A. Allergic reaction; slow the transfusion and administer antihistamines
B. Febrile non-hemolytic reaction; administer acetaminophen and continue monitoring
C. Acute hemolytic reaction; stop the transfusion immediately and maintain IV access with
normal saline
D. Circulatory overload; administer oxygen and furosemide
Correct Answer: C
,Rationale: Correct because fever, chills, and lower back pain constitute the classic triad of acute
hemolytic transfusion reaction caused by ABO incompatibility, which is the most dangerous
transfusion reaction and requires immediate cessation of the blood product to prevent massive
hemolysis, renal failure, and disseminated intravascular coagulation. The nurse must stop the
transfusion, maintain IV patency with normal saline using new tubing, assess vital signs, and
notify the provider and blood bank immediately. Allergic reactions present with urticaria and
pruritus; febrile reactions cause fever without back pain; and circulatory overload presents with
dyspnea and hypertension.
Q3: A patient with chronic alcoholism presents with anorexia, nausea, and muscle twitching.
Laboratory studies reveal magnesium of 1.4 mEq/L. Which additional assessment finding is most
consistent with this electrolyte imbalance?
A. Positive Chvostek's and Trousseau's signs
B. Bradycardia and hypotension
C. Decreased deep tendon reflexes
D. Flaccid paralysis and respiratory depression
Correct Answer: A
Rationale: Correct because hypomagnesemia causes neuromuscular hyperexcitability
manifesting as positive Chvostek's sign (facial twitching when tapping the facial nerve) and
positive Trousseau's sign (carpal spasm with BP cuff inflation), along with tremors,
fasciculations, and tetany due to decreased acetylcholine release at the neuromuscular junction.
Bradycardia and hypotension indicate hypermagnesemia; decreased reflexes and flaccid
paralysis occur with severe hypermagnesemia; and respiratory depression is a late sign of
magnesium toxicity. According to electrolyte management guidelines, alcoholism is a leading
cause of hypomagnesemia due to poor intake, malabsorption, and increased renal excretion.
Q4: A patient with sickle cell disease is admitted with severe abdominal pain, vomiting, and
fever. The nurse notes a new cough and declining oxygen saturation. Which complication is most
likely, and what are the priority interventions? (Select all that apply.)
A. Acute chest syndrome; administer oxygen, IV fluids, and pain management
B. Splenic sequestration; prepare for emergent splenectomy
C. Aplastic crisis; administer folic acid and red blood cell transfusion
D. Vaso-occlusive crisis; apply warm compresses and implement aggressive hydration
Correct Answer: A, D
, Rationale: Correct because the combination of sickle cell disease with fever, cough, hypoxia,
and chest symptoms indicates acute chest syndrome, a life-threatening pulmonary vaso-occlusion
requiring oxygen to maintain SpO2 above 95%, aggressive IV hydration to reduce blood
viscosity, and IV opioid analgesia for severe pain. Warm compresses promote vasodilation and
are appropriate for vaso-occlusive pain. Splenic sequestration presents with left upper quadrant
pain and rapidly enlarging spleen; aplastic crisis causes severe anemia with reticulocytopenia.
According to sickle cell protocols, acute chest syndrome is the leading cause of death in adults
with sickle cell disease and requires immediate multidisciplinary intervention.
Q5: A patient with suspected active tuberculosis is placed in a private room. Which essential
feature must this room have to prevent transmission to healthcare workers?
A. Positive-pressure ventilation with HEPA filtration
B. Negative-pressure ventilation with air exhausted outside or HEPA-filtered
C. Standard room airflow with door open for observation
D. Ultraviolet light irradiation with continuous room air recirculation
Correct Answer: B
Rationale: Correct because Mycobacterium tuberculosis is transmitted via airborne droplet
nuclei smaller than 5 microns that remain suspended in air for prolonged periods, requiring
negative-pressure rooms where air flows into the room and is exhausted directly outside or
through high-efficiency particulate air filtration to prevent contaminated air from entering
adjacent spaces. Positive-pressure rooms protect immunocompromised patients from external
pathogens; open doors allow contaminated air escape; and UV irradiation is adjunctive but does
not replace engineered ventilation controls. According to CDC airborne infection isolation
standards, negative pressure with 6–12 air exchanges per hour is mandatory for TB isolation.
Q6: A patient with heart failure is prescribed furosemide 80 mg IV daily and digoxin 0.25 mg
orally daily. The morning laboratory results show potassium of 3.1 mEq/L. Which nursing action
is the priority?
A. Administer both medications as scheduled and recheck potassium in 24 hours
B. Hold the digoxin, notify the provider, and anticipate potassium replacement
C. Increase the furosemide dose to enhance diuresis
D. Administer potassium-sparing spironolactone instead of furosemide
Correct Answer: B
Rationale: Correct because hypokalemia potentiates digoxin toxicity by increasing myocardial
binding of digoxin to Na-K-ATPase pumps, and even therapeutic digoxin levels become
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1: A 62-year-old patient with dark skin is admitted with suspected hepatitis. The nurse knows
that assessing for jaundice in this patient requires examining which site for yellow discoloration?
A. Palms and soles
B. Sclera and hard palate
C. Nail beds and lips
D. Earlobes and nasal bridge
Correct Answer: B
Rationale: Correct because the sclera and hard palate contain minimal melanin and provide
reliable visualization of bilirubin-induced yellow discoloration regardless of skin pigmentation.
Palms, soles, nail beds, lips, earlobes, and nasal bridge have variable melanin content that can
mask or mimic jaundice, leading to inaccurate assessment. According to nursing assessment
standards for patients with dark skin, mucous membranes and sclera are the definitive sites for
detecting early jaundice before it becomes visible on external skin surfaces.
Q2: A patient receiving a unit of packed red blood cells develops fever, chills, and lower back
pain 20 minutes into the transfusion. Which type of transfusion reaction is most likely, and what
is the priority nursing action?
A. Allergic reaction; slow the transfusion and administer antihistamines
B. Febrile non-hemolytic reaction; administer acetaminophen and continue monitoring
C. Acute hemolytic reaction; stop the transfusion immediately and maintain IV access with
normal saline
D. Circulatory overload; administer oxygen and furosemide
Correct Answer: C
,Rationale: Correct because fever, chills, and lower back pain constitute the classic triad of acute
hemolytic transfusion reaction caused by ABO incompatibility, which is the most dangerous
transfusion reaction and requires immediate cessation of the blood product to prevent massive
hemolysis, renal failure, and disseminated intravascular coagulation. The nurse must stop the
transfusion, maintain IV patency with normal saline using new tubing, assess vital signs, and
notify the provider and blood bank immediately. Allergic reactions present with urticaria and
pruritus; febrile reactions cause fever without back pain; and circulatory overload presents with
dyspnea and hypertension.
Q3: A patient with chronic alcoholism presents with anorexia, nausea, and muscle twitching.
Laboratory studies reveal magnesium of 1.4 mEq/L. Which additional assessment finding is most
consistent with this electrolyte imbalance?
A. Positive Chvostek's and Trousseau's signs
B. Bradycardia and hypotension
C. Decreased deep tendon reflexes
D. Flaccid paralysis and respiratory depression
Correct Answer: A
Rationale: Correct because hypomagnesemia causes neuromuscular hyperexcitability
manifesting as positive Chvostek's sign (facial twitching when tapping the facial nerve) and
positive Trousseau's sign (carpal spasm with BP cuff inflation), along with tremors,
fasciculations, and tetany due to decreased acetylcholine release at the neuromuscular junction.
Bradycardia and hypotension indicate hypermagnesemia; decreased reflexes and flaccid
paralysis occur with severe hypermagnesemia; and respiratory depression is a late sign of
magnesium toxicity. According to electrolyte management guidelines, alcoholism is a leading
cause of hypomagnesemia due to poor intake, malabsorption, and increased renal excretion.
Q4: A patient with sickle cell disease is admitted with severe abdominal pain, vomiting, and
fever. The nurse notes a new cough and declining oxygen saturation. Which complication is most
likely, and what are the priority interventions? (Select all that apply.)
A. Acute chest syndrome; administer oxygen, IV fluids, and pain management
B. Splenic sequestration; prepare for emergent splenectomy
C. Aplastic crisis; administer folic acid and red blood cell transfusion
D. Vaso-occlusive crisis; apply warm compresses and implement aggressive hydration
Correct Answer: A, D
, Rationale: Correct because the combination of sickle cell disease with fever, cough, hypoxia,
and chest symptoms indicates acute chest syndrome, a life-threatening pulmonary vaso-occlusion
requiring oxygen to maintain SpO2 above 95%, aggressive IV hydration to reduce blood
viscosity, and IV opioid analgesia for severe pain. Warm compresses promote vasodilation and
are appropriate for vaso-occlusive pain. Splenic sequestration presents with left upper quadrant
pain and rapidly enlarging spleen; aplastic crisis causes severe anemia with reticulocytopenia.
According to sickle cell protocols, acute chest syndrome is the leading cause of death in adults
with sickle cell disease and requires immediate multidisciplinary intervention.
Q5: A patient with suspected active tuberculosis is placed in a private room. Which essential
feature must this room have to prevent transmission to healthcare workers?
A. Positive-pressure ventilation with HEPA filtration
B. Negative-pressure ventilation with air exhausted outside or HEPA-filtered
C. Standard room airflow with door open for observation
D. Ultraviolet light irradiation with continuous room air recirculation
Correct Answer: B
Rationale: Correct because Mycobacterium tuberculosis is transmitted via airborne droplet
nuclei smaller than 5 microns that remain suspended in air for prolonged periods, requiring
negative-pressure rooms where air flows into the room and is exhausted directly outside or
through high-efficiency particulate air filtration to prevent contaminated air from entering
adjacent spaces. Positive-pressure rooms protect immunocompromised patients from external
pathogens; open doors allow contaminated air escape; and UV irradiation is adjunctive but does
not replace engineered ventilation controls. According to CDC airborne infection isolation
standards, negative pressure with 6–12 air exchanges per hour is mandatory for TB isolation.
Q6: A patient with heart failure is prescribed furosemide 80 mg IV daily and digoxin 0.25 mg
orally daily. The morning laboratory results show potassium of 3.1 mEq/L. Which nursing action
is the priority?
A. Administer both medications as scheduled and recheck potassium in 24 hours
B. Hold the digoxin, notify the provider, and anticipate potassium replacement
C. Increase the furosemide dose to enhance diuresis
D. Administer potassium-sparing spironolactone instead of furosemide
Correct Answer: B
Rationale: Correct because hypokalemia potentiates digoxin toxicity by increasing myocardial
binding of digoxin to Na-K-ATPase pumps, and even therapeutic digoxin levels become
