Final Exam: NUR201 / NUR 201 (Latest 2026 /
2027 Update) Medical-Surgical Nursing I |
Questions and Verified Answers 100% Correct |
Grade A – Fortis
Question 1
A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. Which
finding shows the treatment is effective?
A. Respiratory rate 32/min
B. SpO₂ 95%
C. Use of accessory muscles
D. Cyanosis
Correct Answer: B. SpO₂ 95%
Rationale: SpO₂ ≥ 94% indicates improved oxygenation. Tachypnea (>20 breaths/min),
accessory muscle use, and cyanosis indicate worsening respiratory status .
Question 2
A patient with heart failure reports sudden weight gain of 4 lbs in 24 hours. What
should the nurse do first?
A. Teach sodium restriction
B. Notify the provider
C. Encourage fluids
D. Document and recheck tomorrow
Correct Answer: B. Notify the provider
Rationale: A gain of >2 lbs in 24 hours indicates acute fluid retention and requires
provider notification for potential medication adjustment. This is a sign of worsening
heart failure .
,Question 3
Which lab value is most important before giving furosemide?
A. Hemoglobin
B. Sodium
C. Potassium
D. Calcium
Correct Answer: C. Potassium
Rationale: Furosemide is a loop diuretic that can cause severe hypokalemia. Potassium
should be checked before administration. Hypokalemia increases the risk of cardiac
arrhythmias .
Question 4
A client with COPD has a PaCO₂ of 58 mmHg. What is the priority nursing
intervention?
A. Increase oxygen to 6 L/min
B. Encourage pursed-lip breathing
C. Position in supine
D. Restrict fluids
Correct Answer: B. Encourage pursed-lip breathing
Rationale: Pursed-lip breathing improves CO₂ elimination by creating positive pressure
in the airways during exhalation, preventing airway collapse. High oxygen flow may
worsen CO₂ retention in COPD patients by suppressing the hypoxic drive .
Question 5
The nurse hears crackles in the lower lobes. What is the most likely cause?
A. Bronchospasm
B. Air in pleural space
C. Fluid in alveoli
D. Upper airway obstruction
,Correct Answer: C. Fluid in alveoli
Rationale: Crackles (rales) are caused by air passing through fluid-filled or collapsed
alveoli. Common causes include heart failure (pulmonary edema) and pneumonia .
Question 6
Which diet is best for a patient with hypertension?
A. Canned soup and cold cuts
B. Fresh fruits, vegetables, grilled fish
C. Fast-food burger and fries
D. Processed snacks
Correct Answer: B. Fresh fruits, vegetables, grilled fish
Rationale: The DASH diet (Dietary Approaches to Stop Hypertension) is rich in fruits,
vegetables, and low-fat dairy products, and low in saturated fat and sodium. This diet
lowers blood pressure .
Question 7
The nurse assesses a patient with a new cast on the lower extremity. Which finding
requires immediate notification of the provider?
A. Mild swelling of the toes
B. Capillary refill of 2 seconds
C. Complaints of severe, unrelieved pain
D. Slight discoloration of the cast
Correct Answer: C. Complaints of severe, unrelieved pain
Rationale: Severe, unrelieved pain in a casted extremity may indicate compartment
syndrome. This is a medical emergency that requires immediate intervention .
Question 8
, A post-operative patient with a PCA pump has a respiratory rate of 8 and is
difficult to arouse. What is the priority action?
A. Increase the PCA dose
B. Administer naloxone and notify the provider
C. Turn off the PCA pump and reassess
D. Encourage the patient to take deep breaths
Correct Answer: B. Administer naloxone and notify the provider
Rationale: Respiratory depression is a sign of opioid overdose requiring immediate
intervention with naloxone. The PCA pump should be stopped .
Question 9
Which ECG change indicates hyperkalemia?
A. Flat T waves
B. ST depression
C. Tall peaked T waves
D. U waves
Correct Answer: C. Tall peaked T waves
Rationale: Tall, peaked T waves are the classic ECG finding in hyperkalemia. Flat T waves
and U waves are seen in hypokalemia .
Question 10
A client on digoxin shows nausea, bradycardia, and vision changes. What should
the nurse do?
A. Give next dose
B. Document only
C. Hold medication and notify provider
D. Increase potassium intake immediately
Correct Answer: C. Hold medication and notify provider
2027 Update) Medical-Surgical Nursing I |
Questions and Verified Answers 100% Correct |
Grade A – Fortis
Question 1
A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. Which
finding shows the treatment is effective?
A. Respiratory rate 32/min
B. SpO₂ 95%
C. Use of accessory muscles
D. Cyanosis
Correct Answer: B. SpO₂ 95%
Rationale: SpO₂ ≥ 94% indicates improved oxygenation. Tachypnea (>20 breaths/min),
accessory muscle use, and cyanosis indicate worsening respiratory status .
Question 2
A patient with heart failure reports sudden weight gain of 4 lbs in 24 hours. What
should the nurse do first?
A. Teach sodium restriction
B. Notify the provider
C. Encourage fluids
D. Document and recheck tomorrow
Correct Answer: B. Notify the provider
Rationale: A gain of >2 lbs in 24 hours indicates acute fluid retention and requires
provider notification for potential medication adjustment. This is a sign of worsening
heart failure .
,Question 3
Which lab value is most important before giving furosemide?
A. Hemoglobin
B. Sodium
C. Potassium
D. Calcium
Correct Answer: C. Potassium
Rationale: Furosemide is a loop diuretic that can cause severe hypokalemia. Potassium
should be checked before administration. Hypokalemia increases the risk of cardiac
arrhythmias .
Question 4
A client with COPD has a PaCO₂ of 58 mmHg. What is the priority nursing
intervention?
A. Increase oxygen to 6 L/min
B. Encourage pursed-lip breathing
C. Position in supine
D. Restrict fluids
Correct Answer: B. Encourage pursed-lip breathing
Rationale: Pursed-lip breathing improves CO₂ elimination by creating positive pressure
in the airways during exhalation, preventing airway collapse. High oxygen flow may
worsen CO₂ retention in COPD patients by suppressing the hypoxic drive .
Question 5
The nurse hears crackles in the lower lobes. What is the most likely cause?
A. Bronchospasm
B. Air in pleural space
C. Fluid in alveoli
D. Upper airway obstruction
,Correct Answer: C. Fluid in alveoli
Rationale: Crackles (rales) are caused by air passing through fluid-filled or collapsed
alveoli. Common causes include heart failure (pulmonary edema) and pneumonia .
Question 6
Which diet is best for a patient with hypertension?
A. Canned soup and cold cuts
B. Fresh fruits, vegetables, grilled fish
C. Fast-food burger and fries
D. Processed snacks
Correct Answer: B. Fresh fruits, vegetables, grilled fish
Rationale: The DASH diet (Dietary Approaches to Stop Hypertension) is rich in fruits,
vegetables, and low-fat dairy products, and low in saturated fat and sodium. This diet
lowers blood pressure .
Question 7
The nurse assesses a patient with a new cast on the lower extremity. Which finding
requires immediate notification of the provider?
A. Mild swelling of the toes
B. Capillary refill of 2 seconds
C. Complaints of severe, unrelieved pain
D. Slight discoloration of the cast
Correct Answer: C. Complaints of severe, unrelieved pain
Rationale: Severe, unrelieved pain in a casted extremity may indicate compartment
syndrome. This is a medical emergency that requires immediate intervention .
Question 8
, A post-operative patient with a PCA pump has a respiratory rate of 8 and is
difficult to arouse. What is the priority action?
A. Increase the PCA dose
B. Administer naloxone and notify the provider
C. Turn off the PCA pump and reassess
D. Encourage the patient to take deep breaths
Correct Answer: B. Administer naloxone and notify the provider
Rationale: Respiratory depression is a sign of opioid overdose requiring immediate
intervention with naloxone. The PCA pump should be stopped .
Question 9
Which ECG change indicates hyperkalemia?
A. Flat T waves
B. ST depression
C. Tall peaked T waves
D. U waves
Correct Answer: C. Tall peaked T waves
Rationale: Tall, peaked T waves are the classic ECG finding in hyperkalemia. Flat T waves
and U waves are seen in hypokalemia .
Question 10
A client on digoxin shows nausea, bradycardia, and vision changes. What should
the nurse do?
A. Give next dose
B. Document only
C. Hold medication and notify provider
D. Increase potassium intake immediately
Correct Answer: C. Hold medication and notify provider
