HERZING UNIVERSITY NSG 223 MED SURG II FINAL
EXAM 300 MULTIPLE CHOICE QUESTIONS WITH
CORRECT ANSWERS AND RATIONALES
Question 1
A client scheduled for surgery has a potassium level of 2.4 mEq/L. Which action
should the nurse take first?
A) Document the finding in the chart
B) Notify the healthcare provider immediately
C) Prepare to administer potassium supplements
D) Reassure the client that this is a normal finding
Correct Answer: B
Rationale: A potassium level of 2.4 mEq/L is critically low and requires
immediate intervention. Potassium is essential for cardiac and muscle function,
and severe hypokalemia can lead to lifethreatening cardiac dysrhythmias. The
healthcare provider must be notified STAT for prompt correction .
Question 2
,During a preoperative assessment, a male client states, "I am allergic to
codeine." What should the nurse do first?
A) Apply an allergy bracelet on the client's wrist
B) Label the allergies on the front of the chart
C) Ask the client what happens when he takes codeine
D) Document the allergy on the medication administration record
Correct Answer: C
Rationale: The nurse should first assess the reaction the client experiences
when taking codeine, as many clients mistake side effects such as nausea for
true allergic reactions. Accurate assessment is essential before labeling the
allergy .
Question 3
The circulating nurse observes the surgical scrub technician remove a sponge
from the edge of the sterile field with a clamp and place it in a designated area.
What action should the nurse take?
A) Place the sponge back where it was
B) Tell the technician not to waste supplies
C) Do nothing because this is the correct procedure
D) Take the sponge out of the room immediately
Correct Answer: C
,Rationale: The scrub technician followed the correct procedure. All sponges
must be kept together and counted to maintain client safety; sponges removed
from the field are placed in a designated area to be counted later before the
incision is sutured .
Question 4
The circulating nurse and scrub technician find a discrepancy in the sponge
count. What action should the circulating nurse take first?
A) Notify the client's surgeon
B) Complete an occurrence report
C) Contact the surgical manager
D) Continue searching for the missing sponge
Correct Answer: A
Rationale: The surgeon must be notified immediately when a sponge count
discrepancy occurs because this may delay wound closure or require further
investigation. Client safety is the priority .
Question 5
An elderly client has a decrease in T cells and B cells. What nursing action is a
priority?
, A) Monitor for altered kidney function
B) Monitor regularly for blood loss
C) Monitor for joint swelling and tenderness
D) Monitor regularly for signs of infection
Correct Answer: D
Rationale: As clients age, there is a decrease in T cells and B cells, increasing the
risk for infection. The client should be monitored regularly for signs of infection
to enable early intervention and reduce complications .
Question 6
A client arrives in the emergency department after being bitten by a raccoon.
What nursing action does the nurse anticipate?
A) Administering a rabies vaccine to provide naturally acquired active
immunity
B) Administering a rabies vaccine to provide artificially acquired passive
immunity
C) Administering a rabies vaccine to create antibodymediated immunity
D) Administering a rabies vaccine to provide naturally acquired passive
immunity
Correct Answer: B
EXAM 300 MULTIPLE CHOICE QUESTIONS WITH
CORRECT ANSWERS AND RATIONALES
Question 1
A client scheduled for surgery has a potassium level of 2.4 mEq/L. Which action
should the nurse take first?
A) Document the finding in the chart
B) Notify the healthcare provider immediately
C) Prepare to administer potassium supplements
D) Reassure the client that this is a normal finding
Correct Answer: B
Rationale: A potassium level of 2.4 mEq/L is critically low and requires
immediate intervention. Potassium is essential for cardiac and muscle function,
and severe hypokalemia can lead to lifethreatening cardiac dysrhythmias. The
healthcare provider must be notified STAT for prompt correction .
Question 2
,During a preoperative assessment, a male client states, "I am allergic to
codeine." What should the nurse do first?
A) Apply an allergy bracelet on the client's wrist
B) Label the allergies on the front of the chart
C) Ask the client what happens when he takes codeine
D) Document the allergy on the medication administration record
Correct Answer: C
Rationale: The nurse should first assess the reaction the client experiences
when taking codeine, as many clients mistake side effects such as nausea for
true allergic reactions. Accurate assessment is essential before labeling the
allergy .
Question 3
The circulating nurse observes the surgical scrub technician remove a sponge
from the edge of the sterile field with a clamp and place it in a designated area.
What action should the nurse take?
A) Place the sponge back where it was
B) Tell the technician not to waste supplies
C) Do nothing because this is the correct procedure
D) Take the sponge out of the room immediately
Correct Answer: C
,Rationale: The scrub technician followed the correct procedure. All sponges
must be kept together and counted to maintain client safety; sponges removed
from the field are placed in a designated area to be counted later before the
incision is sutured .
Question 4
The circulating nurse and scrub technician find a discrepancy in the sponge
count. What action should the circulating nurse take first?
A) Notify the client's surgeon
B) Complete an occurrence report
C) Contact the surgical manager
D) Continue searching for the missing sponge
Correct Answer: A
Rationale: The surgeon must be notified immediately when a sponge count
discrepancy occurs because this may delay wound closure or require further
investigation. Client safety is the priority .
Question 5
An elderly client has a decrease in T cells and B cells. What nursing action is a
priority?
, A) Monitor for altered kidney function
B) Monitor regularly for blood loss
C) Monitor for joint swelling and tenderness
D) Monitor regularly for signs of infection
Correct Answer: D
Rationale: As clients age, there is a decrease in T cells and B cells, increasing the
risk for infection. The client should be monitored regularly for signs of infection
to enable early intervention and reduce complications .
Question 6
A client arrives in the emergency department after being bitten by a raccoon.
What nursing action does the nurse anticipate?
A) Administering a rabies vaccine to provide naturally acquired active
immunity
B) Administering a rabies vaccine to provide artificially acquired passive
immunity
C) Administering a rabies vaccine to create antibodymediated immunity
D) Administering a rabies vaccine to provide naturally acquired passive
immunity
Correct Answer: B
