PNR 206/PNR206 Final Exam V1 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A patient is admitted with suspected increased intracranial pressure (ICP) following a head
injury. Which assessment finding should the nurse identify as part of Cushing’s Triad?
A. Tachycardia, hypotension, and rapid respirations
B. Hypotension, bradycardia, and Cheyne-Stokes respirations
C. Narrowed pulse pressure, tachycardia, and bradypnea
D. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
Correct Answer: D
Explanation: Cushing’s triad is a late sign of increased intracranial pressure and
represents a loss of compensatory mechanisms. It is characterized by a rise in systolic
blood pressure with a widening pulse pressure, a decrease in heart rate, and irregular
respiratory patterns. Immediate intervention is required as this indicates potential
brainstem herniation.
2. The nurse is caring for a patient who underwent a thyroidectomy 6 hours ago. The patient
reports tingling in the fingers and around the mouth. Which action should the nurse take
first?
A. Assess for Chvostek’s or Trousseau’s sign
B. Check the patient’s blood glucose level
,C. Administer a dose of levothyroxine as ordered
D. Encourage the patient to cough and deep breathe
Correct Answer: A
Explanation: Tingling in the extremities and perioral area are early indicators of
hypocalcemia, which can occur if the parathyroid glands are accidentally damaged or
removed during a thyroidectomy. The nurse should immediately assess for neuromuscular
irritability using Chvostek’s or Trousseau’s signs. Prompt identification allows for the
timely administration of calcium gluconate to prevent tetany or seizures.
3. A patient with Type 1 Diabetes is found unconscious and clammy. The nurse suspects
hypoglycemia. Which intervention is the priority if the patient cannot swallow?
A. Administer 15 grams of simple carbohydrates orally
B. Wait 15 minutes and recheck the blood glucose level
C. Provide 4 ounces of orange juice via a straw
D. Inject 1 mg of glucagon subcutaneously or intramuscularly
Correct Answer: D
Explanation: When a patient is unconscious or unable to swallow, oral carbohydrates are
contraindicated due to the high risk of aspiration. Glucagon is the emergency treatment of
choice to stimulate the liver to release stored glucose. Once the patient regains
consciousness and can swallow, a complex carbohydrate and protein snack should be
provided to maintain glucose levels.
, 4. A nurse is teaching a patient with Chronic Kidney Disease (CKD) about a low-potassium
diet. Which food choice indicates that the patient understands the teaching?
A. Baked potato with skin
B. Fresh bananas
C. Spinach salad
D. Apple juice
Correct Answer: D
Explanation: Apple juice is relatively low in potassium compared to other fruit and
vegetable options. Potatoes, bananas, and spinach are all high-potassium foods that must
be restricted in patients with CKD to prevent life-threatening hyperkalemia. The nurse
must ensure the patient can distinguish between high and low potassium sources to
manage their condition effectively at home.
5. Which clinical manifestation should the nurse expect to observe in a patient experiencing
autonomic dysreflexia?
A. Hypotension and tachycardia
B. Severe pounding headache and profuse sweating above the level of injury
C. Pale, cool skin above the level of injury
D. Extreme lethargy and bradypnea
Correct Answer: B
Nursing II Q&A with Rationale | Fortis College
1. A patient is admitted with suspected increased intracranial pressure (ICP) following a head
injury. Which assessment finding should the nurse identify as part of Cushing’s Triad?
A. Tachycardia, hypotension, and rapid respirations
B. Hypotension, bradycardia, and Cheyne-Stokes respirations
C. Narrowed pulse pressure, tachycardia, and bradypnea
D. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
Correct Answer: D
Explanation: Cushing’s triad is a late sign of increased intracranial pressure and
represents a loss of compensatory mechanisms. It is characterized by a rise in systolic
blood pressure with a widening pulse pressure, a decrease in heart rate, and irregular
respiratory patterns. Immediate intervention is required as this indicates potential
brainstem herniation.
2. The nurse is caring for a patient who underwent a thyroidectomy 6 hours ago. The patient
reports tingling in the fingers and around the mouth. Which action should the nurse take
first?
A. Assess for Chvostek’s or Trousseau’s sign
B. Check the patient’s blood glucose level
,C. Administer a dose of levothyroxine as ordered
D. Encourage the patient to cough and deep breathe
Correct Answer: A
Explanation: Tingling in the extremities and perioral area are early indicators of
hypocalcemia, which can occur if the parathyroid glands are accidentally damaged or
removed during a thyroidectomy. The nurse should immediately assess for neuromuscular
irritability using Chvostek’s or Trousseau’s signs. Prompt identification allows for the
timely administration of calcium gluconate to prevent tetany or seizures.
3. A patient with Type 1 Diabetes is found unconscious and clammy. The nurse suspects
hypoglycemia. Which intervention is the priority if the patient cannot swallow?
A. Administer 15 grams of simple carbohydrates orally
B. Wait 15 minutes and recheck the blood glucose level
C. Provide 4 ounces of orange juice via a straw
D. Inject 1 mg of glucagon subcutaneously or intramuscularly
Correct Answer: D
Explanation: When a patient is unconscious or unable to swallow, oral carbohydrates are
contraindicated due to the high risk of aspiration. Glucagon is the emergency treatment of
choice to stimulate the liver to release stored glucose. Once the patient regains
consciousness and can swallow, a complex carbohydrate and protein snack should be
provided to maintain glucose levels.
, 4. A nurse is teaching a patient with Chronic Kidney Disease (CKD) about a low-potassium
diet. Which food choice indicates that the patient understands the teaching?
A. Baked potato with skin
B. Fresh bananas
C. Spinach salad
D. Apple juice
Correct Answer: D
Explanation: Apple juice is relatively low in potassium compared to other fruit and
vegetable options. Potatoes, bananas, and spinach are all high-potassium foods that must
be restricted in patients with CKD to prevent life-threatening hyperkalemia. The nurse
must ensure the patient can distinguish between high and low potassium sources to
manage their condition effectively at home.
5. Which clinical manifestation should the nurse expect to observe in a patient experiencing
autonomic dysreflexia?
A. Hypotension and tachycardia
B. Severe pounding headache and profuse sweating above the level of injury
C. Pale, cool skin above the level of injury
D. Extreme lethargy and bradypnea
Correct Answer: B
