MEDICAL SURGICAL NURSING II -
EXAM 2 PRACTICE QUESTIONS AND
ANSWERS
1. A patient with a T4 spinal cord injury reports a sudden, severe headache and nasal
congestion. The blood pressure is 185/100 mmHg. What is the nurse’s priority action?
A. Administer an antihypertensive medication.
B. Place the patient in a high-Fowler’s position.
C. Check for a full bladder or fecal impaction.
D. Notify the healthcare provider immediately.
Answer: B
Conceptual Explanation: Autonomic dysreflexia is a medical emergency. The first action is
to sit the patient up (high-Fowler’s) to lower blood pressure through orthostatic changes
before identifying the trigger.
2. A patient’s ABG results are pH 7.28, PaCO2 55 mmHg, and HCO3 24 mEq/L. Which
condition do these values indicate?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Conceptual Explanation: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg
indicates a respiratory cause. Since the bicarbonate is normal, it is uncompensated
respiratory acidosis.
3. When assessing a patient with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What does this suggest?
A. The lung has fully re-expanded.
B. An air leak is present in the system.
C. This is a normal finding for a patient with a pneumothorax.
D. The suction level is set too high.
Answer: B
Conceptual Explanation: Intermittent bubbling is normal in a patient with a
pneumothorax, but continuous bubbling in the water-seal chamber indicates an air leak in
the drainage system or at the insertion site.
4. Which electrolyte imbalance is a patient with chronic kidney disease (CKD) most at risk for
developing?
A. Hyperkalemia
, B. Hypernatremia
C. Hypokalemia
D. Hypophosphatemia
Answer: A
Conceptual Explanation: CKD reduces the kidneys’ ability to excrete potassium, leading to
hyperkalemia, which can cause life-threatening cardiac arrhythmias.
5. A nurse is caring for a patient in the ICU who is on a ventilator. The high-pressure alarm
sounds. Which of the following could be the cause?
A. Disconnection of the ventilator tubing
B. A leak in the endotracheal tube cuff
C. The patient is biting the endotracheal tube
D. Extubation of the patient
Answer: C
Conceptual Explanation: High-pressure alarms are triggered by increased resistance,
such as secretions, bronchospasm, or the patient biting the tube. Disconnections and leaks
trigger low-pressure alarms.
6. Which medication is typically administered to treat a patient with hyperkalemia and visible
EKG changes?
A. Furosemide
EXAM 2 PRACTICE QUESTIONS AND
ANSWERS
1. A patient with a T4 spinal cord injury reports a sudden, severe headache and nasal
congestion. The blood pressure is 185/100 mmHg. What is the nurse’s priority action?
A. Administer an antihypertensive medication.
B. Place the patient in a high-Fowler’s position.
C. Check for a full bladder or fecal impaction.
D. Notify the healthcare provider immediately.
Answer: B
Conceptual Explanation: Autonomic dysreflexia is a medical emergency. The first action is
to sit the patient up (high-Fowler’s) to lower blood pressure through orthostatic changes
before identifying the trigger.
2. A patient’s ABG results are pH 7.28, PaCO2 55 mmHg, and HCO3 24 mEq/L. Which
condition do these values indicate?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Conceptual Explanation: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg
indicates a respiratory cause. Since the bicarbonate is normal, it is uncompensated
respiratory acidosis.
3. When assessing a patient with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What does this suggest?
A. The lung has fully re-expanded.
B. An air leak is present in the system.
C. This is a normal finding for a patient with a pneumothorax.
D. The suction level is set too high.
Answer: B
Conceptual Explanation: Intermittent bubbling is normal in a patient with a
pneumothorax, but continuous bubbling in the water-seal chamber indicates an air leak in
the drainage system or at the insertion site.
4. Which electrolyte imbalance is a patient with chronic kidney disease (CKD) most at risk for
developing?
A. Hyperkalemia
, B. Hypernatremia
C. Hypokalemia
D. Hypophosphatemia
Answer: A
Conceptual Explanation: CKD reduces the kidneys’ ability to excrete potassium, leading to
hyperkalemia, which can cause life-threatening cardiac arrhythmias.
5. A nurse is caring for a patient in the ICU who is on a ventilator. The high-pressure alarm
sounds. Which of the following could be the cause?
A. Disconnection of the ventilator tubing
B. A leak in the endotracheal tube cuff
C. The patient is biting the endotracheal tube
D. Extubation of the patient
Answer: C
Conceptual Explanation: High-pressure alarms are triggered by increased resistance,
such as secretions, bronchospasm, or the patient biting the tube. Disconnections and leaks
trigger low-pressure alarms.
6. Which medication is typically administered to treat a patient with hyperkalemia and visible
EKG changes?
A. Furosemide
