PNR 206/PNR206 Exam 3 V1 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who underwent a subtotal thyroidectomy. Which of the
following findings should the nurse report to the provider immediately?
A. Laryngeal stridor
B. Pain at the incision site
C. Hoarseness of voice
D. Serum calcium of 9.2 mg/dL
Correct Answer: A
Explanation: Laryngeal stridor is a harsh, high-pitched sound heard on inspiration that
indicates acute airway obstruction. This is a medical emergency that requires immediate
intervention to maintain a patent airway. While hoarseness and pain are common
postoperatively, stridor suggests glottic edema or tetany from hypocalcemia.
2. A client is admitted with a diagnosis of Addison’s disease. Which of the following
electrolyte imbalances should the nurse expect to find?
A. Hypernatremia and hypokalemia
B. Hypocalcemia and hyperphosphatemia
C. Hyponatremia and hyperkalemia
D. Hypermagnesemia and hypocalcemia
,Correct Answer: C
Explanation: Addison’s disease involves the deficiency of cortisol and aldosterone from
the adrenal cortex. Aldosterone deficiency leads to the excretion of sodium and the
retention of potassium. Consequently, the nurse should expect to see decreased sodium
levels and elevated potassium levels in the client’s lab results.
3. The nurse is providing discharge teaching for a client with Type 1 Diabetes Mellitus
regarding exercise. Which instruction should the nurse include?
A. Exercise only when blood glucose is above 300 mg/dL
B. Inject insulin into the muscle group that will be exercised
C. Avoid consuming carbohydrates before starting physical activity
D. Check blood glucose levels before, during, and after exercise
Correct Answer: D
Explanation: Exercise increases glucose uptake by the muscles, which can lead to
hypoglycemia during or after the activity. Checking blood glucose levels frequently helps
the client manage their levels and adjust their carbohydrate intake as needed. The client
should avoid exercise if ketones are present in the urine or if blood glucose is excessively
high.
4. A client with Cushing’s syndrome is being monitored for complications. Which of the
following clinical manifestations is consistent with this diagnosis?
A. Thinning of the skin and bruising
, B. Weight loss and hypotension
C. Increased muscle mass in the extremities
D. Decreased blood glucose levels
Correct Answer: A
Explanation: Cushing’s syndrome is caused by an excess of corticosteroids, which leads to
protein catabolism. This results in thinning of the skin, easy bruising, and striae on the
abdomen. Other classic signs include a ‘moon face,’ ‘buffalo hump,’ and truncal obesity with
thin extremities.
5. The nurse is caring for a client who is post-operative following a transurethral resection of
the prostate (TURP). The client has a continuous bladder irrigation (CBI) running. Which
finding should the nurse investigate?
A. Pink-tinged drainage in the collection bag
B. The client reporting a strong urge to urinate
C. Output that is significantly less than the amount of irritant instilled
D. Occasional small blood clots in the drainage tubing
Correct Answer: C
Explanation: If the output in the drainage bag is less than the volume of irrigation fluid
instilled, it indicates an obstruction in the catheter system. Obstructions are often caused
by blood clots and require immediate manual irrigation to prevent bladder distension and
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who underwent a subtotal thyroidectomy. Which of the
following findings should the nurse report to the provider immediately?
A. Laryngeal stridor
B. Pain at the incision site
C. Hoarseness of voice
D. Serum calcium of 9.2 mg/dL
Correct Answer: A
Explanation: Laryngeal stridor is a harsh, high-pitched sound heard on inspiration that
indicates acute airway obstruction. This is a medical emergency that requires immediate
intervention to maintain a patent airway. While hoarseness and pain are common
postoperatively, stridor suggests glottic edema or tetany from hypocalcemia.
2. A client is admitted with a diagnosis of Addison’s disease. Which of the following
electrolyte imbalances should the nurse expect to find?
A. Hypernatremia and hypokalemia
B. Hypocalcemia and hyperphosphatemia
C. Hyponatremia and hyperkalemia
D. Hypermagnesemia and hypocalcemia
,Correct Answer: C
Explanation: Addison’s disease involves the deficiency of cortisol and aldosterone from
the adrenal cortex. Aldosterone deficiency leads to the excretion of sodium and the
retention of potassium. Consequently, the nurse should expect to see decreased sodium
levels and elevated potassium levels in the client’s lab results.
3. The nurse is providing discharge teaching for a client with Type 1 Diabetes Mellitus
regarding exercise. Which instruction should the nurse include?
A. Exercise only when blood glucose is above 300 mg/dL
B. Inject insulin into the muscle group that will be exercised
C. Avoid consuming carbohydrates before starting physical activity
D. Check blood glucose levels before, during, and after exercise
Correct Answer: D
Explanation: Exercise increases glucose uptake by the muscles, which can lead to
hypoglycemia during or after the activity. Checking blood glucose levels frequently helps
the client manage their levels and adjust their carbohydrate intake as needed. The client
should avoid exercise if ketones are present in the urine or if blood glucose is excessively
high.
4. A client with Cushing’s syndrome is being monitored for complications. Which of the
following clinical manifestations is consistent with this diagnosis?
A. Thinning of the skin and bruising
, B. Weight loss and hypotension
C. Increased muscle mass in the extremities
D. Decreased blood glucose levels
Correct Answer: A
Explanation: Cushing’s syndrome is caused by an excess of corticosteroids, which leads to
protein catabolism. This results in thinning of the skin, easy bruising, and striae on the
abdomen. Other classic signs include a ‘moon face,’ ‘buffalo hump,’ and truncal obesity with
thin extremities.
5. The nurse is caring for a client who is post-operative following a transurethral resection of
the prostate (TURP). The client has a continuous bladder irrigation (CBI) running. Which
finding should the nurse investigate?
A. Pink-tinged drainage in the collection bag
B. The client reporting a strong urge to urinate
C. Output that is significantly less than the amount of irritant instilled
D. Occasional small blood clots in the drainage tubing
Correct Answer: C
Explanation: If the output in the drainage bag is less than the volume of irrigation fluid
instilled, it indicates an obstruction in the catheter system. Obstructions are often caused
by blood clots and require immediate manual irrigation to prevent bladder distension and
