PNR 206/PNR206 Exam 2 V1 | 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 prescribed Lispro insulin.
When should the nurse administer this medication?
A. 30 to 60 minutes before meals
B. Immediately after the client finishes eating
C. At bedtime with a snack
D. 15 minutes before a meal
Correct Answer: D
Explanation: Lispro is a rapid-acting insulin with an onset of 15 to 30 minutes.
Administering it 15 minutes before a meal ensures the insulin peaks as blood glucose levels
rise from food intake. Giving it too early or too late can lead to significant hypoglycemic or
hyperglycemic events respectively.
2. A client is diagnosed with Cushing’s syndrome. Which clinical manifestation should the
nurse expect to observe?
A. Buffalo hump and moon face
B. Hypotension and weight loss
C. Hyperpigmentation of the skin
D. Tremors and tachycardia
,Correct Answer: A
Explanation: Cushing’s syndrome is caused by an excess of cortisol, leading to
characteristic fat redistribution such as a buffalo hump and moon face. Clients also
commonly experience trunkal obesity and thin extremities. Monitoring for hypertension
and hyperglycemia is also a priority for these patients.
3. A nurse is preparing to administer levothyroxine to a client with hypothyroidism. Which
vital sign is most important to check before administration?
A. Respiratory rate
B. Blood pressure
C. Heart rate
D. Temperature
Correct Answer: C
Explanation: Levothyroxine increases the metabolic rate and can cause tachycardia or
palpitations if the dose is too high. The nurse must assess the apical pulse and hold the
medication if the heart rate exceeds 100 beats per minute. This assessment helps prevent
cardiovascular complications related to thyroid hormone replacement therapy.
4. Which of the following interventions is a priority for a client following a thyroidectomy?
A. Placing a tracheostomy tray at the bedside
B. Encouraging the client to cough and deep breathe every hour
, C. Assessing for Chvostek’s sign every 8 hours
D. Administering oral fluids as soon as the client is awake
Correct Answer: A
Explanation: Post-thyroidectomy patients are at risk for airway obstruction due to edema
or laryngeal nerve damage. Having a tracheostomy tray at the bedside is a critical safety
measure for emergency airway management. The nurse should also monitor for signs of
respiratory distress and hematoma formation.
5. A client with cirrhosis has a high ammonia level and is receiving lactulose. What is the
desired therapeutic effect of this medication?
A. Improved mental status
B. Increased serum potassium levels
C. Reduced abdominal girth
D. Decreased frequency of bowel movements
Correct Answer: A
Explanation: Lactulose works by trapping ammonia in the gut and expelling it through the
stool to treat hepatic encephalopathy. As ammonia levels decrease, the client’s cognitive
function and mental status should improve. The nurse should expect the client to have two
to three soft stools per day while on this therapy.
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client with Type 1 Diabetes Mellitus who is prescribed Lispro insulin.
When should the nurse administer this medication?
A. 30 to 60 minutes before meals
B. Immediately after the client finishes eating
C. At bedtime with a snack
D. 15 minutes before a meal
Correct Answer: D
Explanation: Lispro is a rapid-acting insulin with an onset of 15 to 30 minutes.
Administering it 15 minutes before a meal ensures the insulin peaks as blood glucose levels
rise from food intake. Giving it too early or too late can lead to significant hypoglycemic or
hyperglycemic events respectively.
2. A client is diagnosed with Cushing’s syndrome. Which clinical manifestation should the
nurse expect to observe?
A. Buffalo hump and moon face
B. Hypotension and weight loss
C. Hyperpigmentation of the skin
D. Tremors and tachycardia
,Correct Answer: A
Explanation: Cushing’s syndrome is caused by an excess of cortisol, leading to
characteristic fat redistribution such as a buffalo hump and moon face. Clients also
commonly experience trunkal obesity and thin extremities. Monitoring for hypertension
and hyperglycemia is also a priority for these patients.
3. A nurse is preparing to administer levothyroxine to a client with hypothyroidism. Which
vital sign is most important to check before administration?
A. Respiratory rate
B. Blood pressure
C. Heart rate
D. Temperature
Correct Answer: C
Explanation: Levothyroxine increases the metabolic rate and can cause tachycardia or
palpitations if the dose is too high. The nurse must assess the apical pulse and hold the
medication if the heart rate exceeds 100 beats per minute. This assessment helps prevent
cardiovascular complications related to thyroid hormone replacement therapy.
4. Which of the following interventions is a priority for a client following a thyroidectomy?
A. Placing a tracheostomy tray at the bedside
B. Encouraging the client to cough and deep breathe every hour
, C. Assessing for Chvostek’s sign every 8 hours
D. Administering oral fluids as soon as the client is awake
Correct Answer: A
Explanation: Post-thyroidectomy patients are at risk for airway obstruction due to edema
or laryngeal nerve damage. Having a tracheostomy tray at the bedside is a critical safety
measure for emergency airway management. The nurse should also monitor for signs of
respiratory distress and hematoma formation.
5. A client with cirrhosis has a high ammonia level and is receiving lactulose. What is the
desired therapeutic effect of this medication?
A. Improved mental status
B. Increased serum potassium levels
C. Reduced abdominal girth
D. Decreased frequency of bowel movements
Correct Answer: A
Explanation: Lactulose works by trapping ammonia in the gut and expelling it through the
stool to treat hepatic encephalopathy. As ammonia levels decrease, the client’s cognitive
function and mental status should improve. The nurse should expect the client to have two
to three soft stools per day while on this therapy.
