NURS 480 Final Exam: Medical-Surgical Nursing
Comprehensive Review
Advanced Medical-Surgical Nursing Examination
QUESTION 1
A 68-year-old male with a history of heart failure is admitted with acute shortness of breath,
orthopnea, and 3+ pitting edema. Vital signs: BP 162/94, HR 118, RR 30, SpO2 86% on room air.
Lung auscultation reveals crackles in both lung bases. What is the priority nursing intervention?
Answer: Position the patient in high Fowler's position and administer supplemental oxygen at
4-6 L/min via nasal cannula or non-rebreather mask
Rationale: The patient is experiencing acute decompensated heart failure with severe
pulmonary congestion and hypoxia. High Fowler's position maximizes lung expansion, reduces
venous return (preload), and decreases pulmonary congestion. Supplemental oxygen should be
administered to maintain SpO2 >92%. The nurse should also assess for signs of respiratory
distress, monitor vital signs, and prepare for diuretic therapy (furosemide) and other
interventions. The underlying cause of the exacerbation should be identified (e.g., medication
non-adherence, dietary indiscretion, infection). Continuous monitoring of fluid balance, daily
weights, and intake/output is essential. The nurse should also prepare for potential need for
non-invasive positive pressure ventilation (BiPAP) if respiratory status does not improve.
QUESTION 2
A 72-year-old female is 2 days post-operative following a total hip replacement. She reports
sudden onset of chest pain and shortness of breath. Her vital signs are: HR 124, RR 28, BP
130/78, SpO2 85% on 2L O2. What is the most likely complication and priority nursing action?
Answer: Pulmonary embolism (PE); administer supplemental oxygen, notify the healthcare
provider immediately, and prepare for diagnostic studies
Rationale: The patient is at high risk for venous thromboembolism (VTE) due to recent major
orthopedic surgery and immobility. Sudden onset of chest pain, dyspnea, tachycardia, and
hypoxia are classic signs of pulmonary embolism (PE). The priority nursing intervention is to
administer supplemental oxygen, notify the healthcare provider immediately, and prepare for
diagnostic studies (CT pulmonary angiography, V/Q scan). The patient should be maintained on
bed rest and monitored for hemodynamic instability. Anticoagulation therapy (heparin or
,LMWH) should be initiated as ordered. The nurse should also assess for signs of deep vein
thrombosis (DVT) in the lower extremities, such as unilateral leg swelling, pain, and warmth.
VTE prophylaxis should have been implemented pre-operatively.
QUESTION 3
A 55-year-old male with a history of type 2 diabetes presents with a 3-day history of fever,
chills, and productive cough with purulent sputum. He has been non-compliant with his
diabetes medications. Vital signs: T 102.4°F, HR 118, RR 26, BP 154/96, SpO2 88% on room air.
Lung auscultation reveals crackles in the right lower lobe. What is the priority nursing diagnosis
and intervention?
Answer: Ineffective airway clearance related to excessive mucus production; administer
bronchodilators and antibiotics as ordered
Rationale: The patient is presenting with community-acquired pneumonia with signs of infection
and hypoxia. The priority nursing diagnosis is ineffective airway clearance due to the productive
cough and sputum production. Nursing interventions include promoting effective coughing and
deep breathing, maintaining adequate hydration (IV or oral), administering bronchodilators and
antibiotics as ordered, and monitoring respiratory status. The patient's diabetes should also be
managed, as hyperglycemia can impair immune function and increase susceptibility to infection.
The patient should be monitored for signs of sepsis and respiratory failure. A chest X-ray and
sputum culture should be obtained to guide treatment. The patient should be placed on contact
and droplet precautions if infection is suspected.
QUESTION 4
A 60-year-old female with chronic kidney disease (CKD) stage 4 is admitted with hyperkalemia
(K+ 7.2 mEq/L). Which ECG finding would the nurse expect to observe, and what is the priority
intervention?
Answer: Peaked T waves; administer calcium gluconate and insulin with glucose
Rationale: Hyperkalemia (potassium >5.5 mEq/L) causes characteristic ECG changes, with
peaked T waves being the earliest and most common finding. As potassium levels rise further,
PR interval prolongation, QRS widening, and eventually sinusoidal waves and ventricular
fibrillation may occur. The patient is at high risk for cardiac arrhythmias. Immediate
interventions for severe hyperkalemia include calcium gluconate (to stabilize cardiac
membranes), insulin with glucose (to shift potassium intracellularly), albuterol nebulization, and
sodium bicarbonate. Hemodialysis is the definitive treatment for CKD patients. The nurse should
place the patient on continuous telemetry and monitor for changes in cardiac rhythm. Serum
,potassium should be rechecked frequently to assess response to treatment. The patient should
be assessed for signs of muscle weakness and paralysis.
QUESTION 5
A 45-year-old male presents with acute abdominal pain that started in the periumbilical region
and migrated to the right lower quadrant. He reports nausea, vomiting, and anorexia. Vital
signs: T 100.8°F, HR 106, RR 20, BP 142/88. On exam, there is rebound tenderness and guarding
in the right lower quadrant. What is the most appropriate nursing action?
Answer: Maintain the patient NPO, initiate IV fluids, and prepare for surgical consultation
Rationale: The patient presents with classic signs of acute appendicitis: pain migrating from the
periumbilical to the right lower quadrant, nausea, vomiting, anorexia, fever, and rebound
tenderness with guarding. The most appropriate initial action is to maintain the patient NPO,
initiate IV fluids, and prepare for surgical consultation. A CT scan of the abdomen and pelvis
with contrast can confirm the diagnosis. Antibiotics are typically administered pre-operatively.
Surgery (appendectomy) is the definitive treatment. The nurse should monitor for signs of
perforation (rigid abdomen, worsening pain, sepsis). The patient should be assessed for signs of
peritonitis, which would require emergency surgery. Pain management should be provided as
ordered, but opioids should be used cautiously to avoid masking symptoms.
QUESTION 6
A 75-year-old male with a history of benign prostatic hyperplasia (BPH) presents with acute
urinary retention. He is unable to void and is experiencing severe suprapubic pain. His bladder
is distended on palpation. What is the priority nursing intervention?
Answer: Insert a Foley catheter to relieve the obstruction
Rationale: Acute urinary retention is a urological emergency. The immediate priority is to relieve
the obstruction by inserting a Foley catheter to drain the bladder. This will relieve pain, prevent
bladder distension, and prevent acute kidney injury. The nurse should use sterile technique and
assess the amount and character of urine output. After the bladder is drained, the patient
should be evaluated for the cause of the obstruction (usually BPH in elderly males). The patient
may be started on an alpha-blocker (e.g., tamsulosin) to relax the prostate. A voiding trial may
be attempted after the catheter is removed. The nurse should monitor for signs of post-
obstructive diuresis, which can occur after relief of obstruction and may require IV fluid
replacement.
, QUESTION 7
A 62-year-old female with a history of hypertension presents with a 30-minute episode of right-
sided weakness and slurred speech that resolved completely. She reports a similar episode 3
days ago. What is the most likely diagnosis and nursing action?
Answer: Transient ischemic attack (TIA); initiate antiplatelet therapy and evaluate risk factors
Rationale: A transient ischemic attack (TIA) is a temporary episode of neurological deficit that
resolves within 24 hours. It is a warning sign for a future stroke. The patient's symptoms (right-
sided weakness, slurred speech) suggest involvement of the left hemisphere. The most
appropriate nursing actions include a thorough neurological assessment, evaluation of risk
factors (hypertension, hyperlipidemia, smoking), and initiation of antiplatelet therapy (aspirin)
as ordered. The patient should be educated on stroke warning signs and the importance of
seeking immediate medical attention. Diagnostic studies (carotid ultrasound, echocardiogram,
brain imaging) may be ordered to identify the cause. The ABCD2 score can be used to assess
stroke risk. The patient should be counseled on lifestyle modifications, including diet, exercise,
and smoking cessation.
QUESTION 8
A 58-year-old male with a 30-pack-year smoking history presents with a 3-month history of
progressive hoarseness and a sensation of a lump in his throat. He has a history of
gastroesophageal reflux disease (GERD). What is the priority nursing action?
Answer: Refer the patient for otolaryngology evaluation and possible laryngoscopy
Rationale: Persistent hoarseness (>3 weeks) in a patient with risk factors for laryngeal cancer
(smoking, GERD) requires prompt evaluation. The priority is to refer the patient to an
otolaryngologist for a laryngoscopy to visualize the vocal cords and assess for lesions.
Hoarseness can also be caused by GERD, vocal cord nodules, or infection, but malignancy must
be ruled out. Nursing care includes providing emotional support, educating the patient on
smoking cessation, and preparing for possible biopsy. Early diagnosis and treatment are critical
for a good prognosis. The patient should be counseled on the importance of follow-up. The
patient should also be evaluated for other risk factors, such as alcohol use. The nurse should
assess for signs of respiratory distress, which may indicate airway compromise.
QUESTION 9
A 65-year-old female with a history of osteoporosis presents with acute, severe lower back pain
after lifting a heavy object. The pain is worsened by movement and relieved by lying supine. On
Comprehensive Review
Advanced Medical-Surgical Nursing Examination
QUESTION 1
A 68-year-old male with a history of heart failure is admitted with acute shortness of breath,
orthopnea, and 3+ pitting edema. Vital signs: BP 162/94, HR 118, RR 30, SpO2 86% on room air.
Lung auscultation reveals crackles in both lung bases. What is the priority nursing intervention?
Answer: Position the patient in high Fowler's position and administer supplemental oxygen at
4-6 L/min via nasal cannula or non-rebreather mask
Rationale: The patient is experiencing acute decompensated heart failure with severe
pulmonary congestion and hypoxia. High Fowler's position maximizes lung expansion, reduces
venous return (preload), and decreases pulmonary congestion. Supplemental oxygen should be
administered to maintain SpO2 >92%. The nurse should also assess for signs of respiratory
distress, monitor vital signs, and prepare for diuretic therapy (furosemide) and other
interventions. The underlying cause of the exacerbation should be identified (e.g., medication
non-adherence, dietary indiscretion, infection). Continuous monitoring of fluid balance, daily
weights, and intake/output is essential. The nurse should also prepare for potential need for
non-invasive positive pressure ventilation (BiPAP) if respiratory status does not improve.
QUESTION 2
A 72-year-old female is 2 days post-operative following a total hip replacement. She reports
sudden onset of chest pain and shortness of breath. Her vital signs are: HR 124, RR 28, BP
130/78, SpO2 85% on 2L O2. What is the most likely complication and priority nursing action?
Answer: Pulmonary embolism (PE); administer supplemental oxygen, notify the healthcare
provider immediately, and prepare for diagnostic studies
Rationale: The patient is at high risk for venous thromboembolism (VTE) due to recent major
orthopedic surgery and immobility. Sudden onset of chest pain, dyspnea, tachycardia, and
hypoxia are classic signs of pulmonary embolism (PE). The priority nursing intervention is to
administer supplemental oxygen, notify the healthcare provider immediately, and prepare for
diagnostic studies (CT pulmonary angiography, V/Q scan). The patient should be maintained on
bed rest and monitored for hemodynamic instability. Anticoagulation therapy (heparin or
,LMWH) should be initiated as ordered. The nurse should also assess for signs of deep vein
thrombosis (DVT) in the lower extremities, such as unilateral leg swelling, pain, and warmth.
VTE prophylaxis should have been implemented pre-operatively.
QUESTION 3
A 55-year-old male with a history of type 2 diabetes presents with a 3-day history of fever,
chills, and productive cough with purulent sputum. He has been non-compliant with his
diabetes medications. Vital signs: T 102.4°F, HR 118, RR 26, BP 154/96, SpO2 88% on room air.
Lung auscultation reveals crackles in the right lower lobe. What is the priority nursing diagnosis
and intervention?
Answer: Ineffective airway clearance related to excessive mucus production; administer
bronchodilators and antibiotics as ordered
Rationale: The patient is presenting with community-acquired pneumonia with signs of infection
and hypoxia. The priority nursing diagnosis is ineffective airway clearance due to the productive
cough and sputum production. Nursing interventions include promoting effective coughing and
deep breathing, maintaining adequate hydration (IV or oral), administering bronchodilators and
antibiotics as ordered, and monitoring respiratory status. The patient's diabetes should also be
managed, as hyperglycemia can impair immune function and increase susceptibility to infection.
The patient should be monitored for signs of sepsis and respiratory failure. A chest X-ray and
sputum culture should be obtained to guide treatment. The patient should be placed on contact
and droplet precautions if infection is suspected.
QUESTION 4
A 60-year-old female with chronic kidney disease (CKD) stage 4 is admitted with hyperkalemia
(K+ 7.2 mEq/L). Which ECG finding would the nurse expect to observe, and what is the priority
intervention?
Answer: Peaked T waves; administer calcium gluconate and insulin with glucose
Rationale: Hyperkalemia (potassium >5.5 mEq/L) causes characteristic ECG changes, with
peaked T waves being the earliest and most common finding. As potassium levels rise further,
PR interval prolongation, QRS widening, and eventually sinusoidal waves and ventricular
fibrillation may occur. The patient is at high risk for cardiac arrhythmias. Immediate
interventions for severe hyperkalemia include calcium gluconate (to stabilize cardiac
membranes), insulin with glucose (to shift potassium intracellularly), albuterol nebulization, and
sodium bicarbonate. Hemodialysis is the definitive treatment for CKD patients. The nurse should
place the patient on continuous telemetry and monitor for changes in cardiac rhythm. Serum
,potassium should be rechecked frequently to assess response to treatment. The patient should
be assessed for signs of muscle weakness and paralysis.
QUESTION 5
A 45-year-old male presents with acute abdominal pain that started in the periumbilical region
and migrated to the right lower quadrant. He reports nausea, vomiting, and anorexia. Vital
signs: T 100.8°F, HR 106, RR 20, BP 142/88. On exam, there is rebound tenderness and guarding
in the right lower quadrant. What is the most appropriate nursing action?
Answer: Maintain the patient NPO, initiate IV fluids, and prepare for surgical consultation
Rationale: The patient presents with classic signs of acute appendicitis: pain migrating from the
periumbilical to the right lower quadrant, nausea, vomiting, anorexia, fever, and rebound
tenderness with guarding. The most appropriate initial action is to maintain the patient NPO,
initiate IV fluids, and prepare for surgical consultation. A CT scan of the abdomen and pelvis
with contrast can confirm the diagnosis. Antibiotics are typically administered pre-operatively.
Surgery (appendectomy) is the definitive treatment. The nurse should monitor for signs of
perforation (rigid abdomen, worsening pain, sepsis). The patient should be assessed for signs of
peritonitis, which would require emergency surgery. Pain management should be provided as
ordered, but opioids should be used cautiously to avoid masking symptoms.
QUESTION 6
A 75-year-old male with a history of benign prostatic hyperplasia (BPH) presents with acute
urinary retention. He is unable to void and is experiencing severe suprapubic pain. His bladder
is distended on palpation. What is the priority nursing intervention?
Answer: Insert a Foley catheter to relieve the obstruction
Rationale: Acute urinary retention is a urological emergency. The immediate priority is to relieve
the obstruction by inserting a Foley catheter to drain the bladder. This will relieve pain, prevent
bladder distension, and prevent acute kidney injury. The nurse should use sterile technique and
assess the amount and character of urine output. After the bladder is drained, the patient
should be evaluated for the cause of the obstruction (usually BPH in elderly males). The patient
may be started on an alpha-blocker (e.g., tamsulosin) to relax the prostate. A voiding trial may
be attempted after the catheter is removed. The nurse should monitor for signs of post-
obstructive diuresis, which can occur after relief of obstruction and may require IV fluid
replacement.
, QUESTION 7
A 62-year-old female with a history of hypertension presents with a 30-minute episode of right-
sided weakness and slurred speech that resolved completely. She reports a similar episode 3
days ago. What is the most likely diagnosis and nursing action?
Answer: Transient ischemic attack (TIA); initiate antiplatelet therapy and evaluate risk factors
Rationale: A transient ischemic attack (TIA) is a temporary episode of neurological deficit that
resolves within 24 hours. It is a warning sign for a future stroke. The patient's symptoms (right-
sided weakness, slurred speech) suggest involvement of the left hemisphere. The most
appropriate nursing actions include a thorough neurological assessment, evaluation of risk
factors (hypertension, hyperlipidemia, smoking), and initiation of antiplatelet therapy (aspirin)
as ordered. The patient should be educated on stroke warning signs and the importance of
seeking immediate medical attention. Diagnostic studies (carotid ultrasound, echocardiogram,
brain imaging) may be ordered to identify the cause. The ABCD2 score can be used to assess
stroke risk. The patient should be counseled on lifestyle modifications, including diet, exercise,
and smoking cessation.
QUESTION 8
A 58-year-old male with a 30-pack-year smoking history presents with a 3-month history of
progressive hoarseness and a sensation of a lump in his throat. He has a history of
gastroesophageal reflux disease (GERD). What is the priority nursing action?
Answer: Refer the patient for otolaryngology evaluation and possible laryngoscopy
Rationale: Persistent hoarseness (>3 weeks) in a patient with risk factors for laryngeal cancer
(smoking, GERD) requires prompt evaluation. The priority is to refer the patient to an
otolaryngologist for a laryngoscopy to visualize the vocal cords and assess for lesions.
Hoarseness can also be caused by GERD, vocal cord nodules, or infection, but malignancy must
be ruled out. Nursing care includes providing emotional support, educating the patient on
smoking cessation, and preparing for possible biopsy. Early diagnosis and treatment are critical
for a good prognosis. The patient should be counseled on the importance of follow-up. The
patient should also be evaluated for other risk factors, such as alcohol use. The nurse should
assess for signs of respiratory distress, which may indicate airway compromise.
QUESTION 9
A 65-year-old female with a history of osteoporosis presents with acute, severe lower back pain
after lifting a heavy object. The pain is worsened by movement and relieved by lying supine. On
