PNR 206/PNR206 Exam 3 V3 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client with type 1 diabetes mellitus who is reporting feeling shaky
and lightheaded. The nurse performs a capillary blood glucose check, and the result is 58
mg/dL. Which of the following actions should the nurse take first?
A. Call the healthcare provider immediately.
B. Administer 1 mg of glucagon subcutaneously.
C. Give the client a high-protein snack.
D. Administer 15 g of a fast-acting carbohydrate.
Correct Answer: D
Explanation: The client is experiencing hypoglycemia, defined as blood glucose less than
70 mg/dL. The priority action is to follow the ‘15-15 rule’ by providing 15 grams of simple
carbohydrates to raise the blood glucose level quickly. This is the most appropriate first-
line intervention for a conscious patient who can swallow.
2. A nurse is assessing a client who has hyperthyroidism. Which of the following clinical
manifestations should the nurse expect to observe?
A. Bradycardia and cold intolerance
B. Exophthalmos and tremors
C. Weight gain and constipation
,D. Dry skin and brittle hair
Correct Answer: B
Explanation: Hyperthyroidism results in a hypermetabolic state, which commonly causes
symptoms like tachycardia, heat intolerance, and tremors. Exophthalmos, or bulging eyes,
is a classic sign specifically associated with Graves’ disease. The other options are
characteristic of hypothyroidism, where the metabolic rate is slowed.
3. A client is diagnosed with Cushing’s syndrome. Which of the following assessment findings
is most consistent with this diagnosis?
A. Moon face and truncal obesity
B. Bronze-colored skin pigmentation
C. Hypotension and weight loss
D. Hyperkalemia and hypoglycemia
Correct Answer: A
Explanation: Cushing’s syndrome is characterized by an excess of cortisol, leading to a
redistribution of body fat resulting in a ‘moon face’ and truncal obesity. Clients also often
exhibit a ‘buffalo hump’ and thin extremities. Conversely, hypotension and bronze skin are
typical signs of Addison’s disease, which is an adrenal insufficiency.
4. A nurse is preparing to administer insulin glargine to a client. Which of the following
actions is correct regarding the administration of this medication?
A. Do not mix it with any other insulin.
, B. Administer it 15 minutes before breakfast.
C. Mix it with regular insulin in the same syringe.
D. Monitor for a peak effect in 2 to 4 hours.
Correct Answer: A
Explanation: Insulin glargine is a long-acting insulin that is clear and must not be mixed
with other insulins in the same syringe because it can alter its onset and duration. It does
not have a distinct peak and provides a steady level of insulin over 24 hours. The nurse
must always use a separate syringe if the client also requires short-acting insulin.
5. Which of the following interventions should the nurse include in the plan of care for a
client who had a total thyroidectomy 4 hours ago?
A. Place the client in a supine position.
B. Keep a tracheostomy tray at the bedside.
C. Encourage the client to cough and deep breathe every hour.
D. Assess for Homan’s sign every shift.
Correct Answer: B
Explanation: Post-thyroidectomy, the nurse must monitor for airway obstruction caused
by edema or laryngeal nerve damage. Having a tracheostomy tray at the bedside is a critical
safety precaution for emergency use. The client should be kept in a semi-Fowler’s position
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client with type 1 diabetes mellitus who is reporting feeling shaky
and lightheaded. The nurse performs a capillary blood glucose check, and the result is 58
mg/dL. Which of the following actions should the nurse take first?
A. Call the healthcare provider immediately.
B. Administer 1 mg of glucagon subcutaneously.
C. Give the client a high-protein snack.
D. Administer 15 g of a fast-acting carbohydrate.
Correct Answer: D
Explanation: The client is experiencing hypoglycemia, defined as blood glucose less than
70 mg/dL. The priority action is to follow the ‘15-15 rule’ by providing 15 grams of simple
carbohydrates to raise the blood glucose level quickly. This is the most appropriate first-
line intervention for a conscious patient who can swallow.
2. A nurse is assessing a client who has hyperthyroidism. Which of the following clinical
manifestations should the nurse expect to observe?
A. Bradycardia and cold intolerance
B. Exophthalmos and tremors
C. Weight gain and constipation
,D. Dry skin and brittle hair
Correct Answer: B
Explanation: Hyperthyroidism results in a hypermetabolic state, which commonly causes
symptoms like tachycardia, heat intolerance, and tremors. Exophthalmos, or bulging eyes,
is a classic sign specifically associated with Graves’ disease. The other options are
characteristic of hypothyroidism, where the metabolic rate is slowed.
3. A client is diagnosed with Cushing’s syndrome. Which of the following assessment findings
is most consistent with this diagnosis?
A. Moon face and truncal obesity
B. Bronze-colored skin pigmentation
C. Hypotension and weight loss
D. Hyperkalemia and hypoglycemia
Correct Answer: A
Explanation: Cushing’s syndrome is characterized by an excess of cortisol, leading to a
redistribution of body fat resulting in a ‘moon face’ and truncal obesity. Clients also often
exhibit a ‘buffalo hump’ and thin extremities. Conversely, hypotension and bronze skin are
typical signs of Addison’s disease, which is an adrenal insufficiency.
4. A nurse is preparing to administer insulin glargine to a client. Which of the following
actions is correct regarding the administration of this medication?
A. Do not mix it with any other insulin.
, B. Administer it 15 minutes before breakfast.
C. Mix it with regular insulin in the same syringe.
D. Monitor for a peak effect in 2 to 4 hours.
Correct Answer: A
Explanation: Insulin glargine is a long-acting insulin that is clear and must not be mixed
with other insulins in the same syringe because it can alter its onset and duration. It does
not have a distinct peak and provides a steady level of insulin over 24 hours. The nurse
must always use a separate syringe if the client also requires short-acting insulin.
5. Which of the following interventions should the nurse include in the plan of care for a
client who had a total thyroidectomy 4 hours ago?
A. Place the client in a supine position.
B. Keep a tracheostomy tray at the bedside.
C. Encourage the client to cough and deep breathe every hour.
D. Assess for Homan’s sign every shift.
Correct Answer: B
Explanation: Post-thyroidectomy, the nurse must monitor for airway obstruction caused
by edema or laryngeal nerve damage. Having a tracheostomy tray at the bedside is a critical
safety precaution for emergency use. The client should be kept in a semi-Fowler’s position
