Galen College NU 189 Exam 4 (pdf) | 2026/2027 | Med-Surg II Q&A |
Medical-Surgical Nursing
1. Which position should the nurse place a patient in to relieve chest pain
associated with acute pericarditis?
A) Supine with legs elevated
B) Sitting upright and leaning forward
C) Left lateral recumbent
D) Trendelenburg
Correct Answer: Sitting upright and leaning forward
Rationale: Leaning forward reduces pressure on the inflamed pericardium,
relieving pain in acute pericarditis. Supine worsens pain, and Trendelenburg
or lateral positions do not provide the same relief. This position also
facilitates easier breathing by reducing cardiac compression.
2. The nurse is teaching a patient with angina about sublingual nitroglycerin.
Which statement by the patient indicates correct understanding?
A) "I should swallow the tablet with water."
B) "I can take up to three doses, 5 minutes apart, and call 911 if pain
persists."
C) "I can take as many doses as I need."
D) "I should take nitroglycerin only if my blood pressure is high."
Correct Answer: "I can take up to three doses, 5 minutes apart, and call 911
if pain persists."
Rationale: Standard guidelines recommend up to three doses at 5-minute
intervals. If pain is unrelieved, emergency services must be activated.
,Swallowing the tablet prevents rapid absorption, and unlimited dosing is
unsafe.
3. The nurse is assessing a patient with cirrhosis and notes hand flapping
when the wrists are extended. This finding is known as:
A) Asterixis
B) Fasciculations
C) Myoclonus
D) Tremor at rest
Correct Answer: Asterixis
Rationale: Asterixis (flapping tremor) is a characteristic sign of hepatic
encephalopathy, caused by the brain's inability to metabolize ammonia and
other toxins. It indicates worsening liver function and requires prompt
intervention to prevent progression to coma.
4. Which cardiac biomarker is the most specific indicator of myocardial
injury?
A) C-reactive protein
B) B-type natriuretic peptide
C) Troponin
D) Creatine kinase-MB
Correct Answer: Troponin
Rationale: Troponin is the most specific and sensitive cardiac biomarker for
myocardial injury. It rises within 3-4 hours of infarction and remains elevated
for up to 10-14 days. BNP indicates heart failure, and CK-MB is less specific.
,5. The nurse is caring for a patient with an epidural catheter. The patient
reports dizziness. What is the priority nursing action?
A) Administer IV fluids
B) Assess blood pressure and ensure the patient does not get up
C) Notify the provider immediately
D) Place the patient in Trendelenburg position
Correct Answer: Assess blood pressure and ensure the patient does not get
up
Rationale: Dizziness after epidural analgesia may indicate hypotension. The
patient is at high risk for falls. The nurse should assess vital signs and
prevent the patient from ambulating until further assessment is completed.
6. A patient with a below-knee amputation (BKA) from a traumatic injury is at
risk for which complication?
A) Infection at the surgical site
B) Phantom limb pain
C) Hemorrhage and hypovolemic shock
D) Contractures of the remaining limb
Correct Answer: Hemorrhage and hypovolemic shock
Rationale: With traumatic amputations, there is a significant risk of
hemorrhage, which can lead to hypovolemic shock. Immediate hemorrhage
control is a priority in the emergency setting. Phantom limb pain and
contractures are later complications.
, 7. A patient has a chest tube in place. The nurse observes fluctuation of the
water level in the water seal chamber with each respiration. Which action is
required?
A) Clamp the chest tube immediately
B) Notify the health care provider
C) Continue to monitor; this is a normal finding
D) Prepare for chest tube removal
Correct Answer: Continue to monitor; this is a normal finding
Rationale: Tidaling (fluctuation of the water level with breathing) indicates
that the chest tube is patent and the system is functioning properly. No
intervention is needed. Clamping or notifying the provider is unnecessary for
expected function.
8. A patient with a chest tube suddenly becomes disconnected from the
drainage system. What is the priority action?
A) Clamp the chest tube immediately
B) Place the end of the chest tube in a container of sterile water
C) Reconnect the tube to the drainage system and tape it
D) Notify the provider and prepare for a new chest tube insertion
Correct Answer: Place the end of the chest tube in a container of sterile
water
Rationale: Placing the disconnected end under sterile water creates an
underwater seal, preventing air from entering the pleural space and causing
a tension pneumothorax. Clamping can lead to tension pneumothorax if air is
trapped.
Medical-Surgical Nursing
1. Which position should the nurse place a patient in to relieve chest pain
associated with acute pericarditis?
A) Supine with legs elevated
B) Sitting upright and leaning forward
C) Left lateral recumbent
D) Trendelenburg
Correct Answer: Sitting upright and leaning forward
Rationale: Leaning forward reduces pressure on the inflamed pericardium,
relieving pain in acute pericarditis. Supine worsens pain, and Trendelenburg
or lateral positions do not provide the same relief. This position also
facilitates easier breathing by reducing cardiac compression.
2. The nurse is teaching a patient with angina about sublingual nitroglycerin.
Which statement by the patient indicates correct understanding?
A) "I should swallow the tablet with water."
B) "I can take up to three doses, 5 minutes apart, and call 911 if pain
persists."
C) "I can take as many doses as I need."
D) "I should take nitroglycerin only if my blood pressure is high."
Correct Answer: "I can take up to three doses, 5 minutes apart, and call 911
if pain persists."
Rationale: Standard guidelines recommend up to three doses at 5-minute
intervals. If pain is unrelieved, emergency services must be activated.
,Swallowing the tablet prevents rapid absorption, and unlimited dosing is
unsafe.
3. The nurse is assessing a patient with cirrhosis and notes hand flapping
when the wrists are extended. This finding is known as:
A) Asterixis
B) Fasciculations
C) Myoclonus
D) Tremor at rest
Correct Answer: Asterixis
Rationale: Asterixis (flapping tremor) is a characteristic sign of hepatic
encephalopathy, caused by the brain's inability to metabolize ammonia and
other toxins. It indicates worsening liver function and requires prompt
intervention to prevent progression to coma.
4. Which cardiac biomarker is the most specific indicator of myocardial
injury?
A) C-reactive protein
B) B-type natriuretic peptide
C) Troponin
D) Creatine kinase-MB
Correct Answer: Troponin
Rationale: Troponin is the most specific and sensitive cardiac biomarker for
myocardial injury. It rises within 3-4 hours of infarction and remains elevated
for up to 10-14 days. BNP indicates heart failure, and CK-MB is less specific.
,5. The nurse is caring for a patient with an epidural catheter. The patient
reports dizziness. What is the priority nursing action?
A) Administer IV fluids
B) Assess blood pressure and ensure the patient does not get up
C) Notify the provider immediately
D) Place the patient in Trendelenburg position
Correct Answer: Assess blood pressure and ensure the patient does not get
up
Rationale: Dizziness after epidural analgesia may indicate hypotension. The
patient is at high risk for falls. The nurse should assess vital signs and
prevent the patient from ambulating until further assessment is completed.
6. A patient with a below-knee amputation (BKA) from a traumatic injury is at
risk for which complication?
A) Infection at the surgical site
B) Phantom limb pain
C) Hemorrhage and hypovolemic shock
D) Contractures of the remaining limb
Correct Answer: Hemorrhage and hypovolemic shock
Rationale: With traumatic amputations, there is a significant risk of
hemorrhage, which can lead to hypovolemic shock. Immediate hemorrhage
control is a priority in the emergency setting. Phantom limb pain and
contractures are later complications.
, 7. A patient has a chest tube in place. The nurse observes fluctuation of the
water level in the water seal chamber with each respiration. Which action is
required?
A) Clamp the chest tube immediately
B) Notify the health care provider
C) Continue to monitor; this is a normal finding
D) Prepare for chest tube removal
Correct Answer: Continue to monitor; this is a normal finding
Rationale: Tidaling (fluctuation of the water level with breathing) indicates
that the chest tube is patent and the system is functioning properly. No
intervention is needed. Clamping or notifying the provider is unnecessary for
expected function.
8. A patient with a chest tube suddenly becomes disconnected from the
drainage system. What is the priority action?
A) Clamp the chest tube immediately
B) Place the end of the chest tube in a container of sterile water
C) Reconnect the tube to the drainage system and tape it
D) Notify the provider and prepare for a new chest tube insertion
Correct Answer: Place the end of the chest tube in a container of sterile
water
Rationale: Placing the disconnected end under sterile water creates an
underwater seal, preventing air from entering the pleural space and causing
a tension pneumothorax. Clamping can lead to tension pneumothorax if air is
trapped.
