NU 185 Medical Surgical Nursing II Exam 3
Preparation Exam 3 Practice Questions & Rationa,
Exams of Nursing
1. A patient with heart failure is prescribed furosemide. Which laboratory value should the
nurse monitor most closely to detect a common adverse effect?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Answer: B
Rationale: Loop diuretics like furosemide cause potassium loss, leading to hypokalemia.
Monitoring serum potassium is essential to prevent dysrhythmias. While sodium and magnesium
can also be affected, potassium is the most critical and commonly monitored electrolyte.
2. Which finding in a patient with a new tracheostomy requires immediate nursing
intervention?
A. Coughing after suctioning
B. Oxygen saturation of 94%
C. Copious secretions
D. Tracheal cuff pressure of 30 cm H2O
Answer: D
Rationale: Tracheal cuff pressure should be maintained between 20-25 cm H2O to prevent
tracheal mucosal damage. A pressure of 30 cm H2O is too high and requires immediate
adjustment. The other findings are expected or within normal limits.
3. A patient with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which
initial prescription should the nurse question?
A. 0.9% sodium chloride IV infusion
B. Regular insulin IV bolus
C. Sodium bicarbonate IV push
D. Potassium chloride added to IV fluids
Answer: C
Rationale: Sodium bicarbonate is not routinely recommended in DKA unless pH is severely low
(<6.9). It can worsen hypokalemia and cause paradoxical acidosis. The other interventions are
standard initial treatments for DKA.
Page 1
,4. Following a motor vehicle crash, a patient has a suspected cervical spine injury. Which
action should the nurse take first?
A. Perform a neurological assessment
B. Apply a cervical collar
C. Obtain a lateral cervical spine X-ray
D. Administer pain medication
Answer: B
Rationale: Immobilization with a cervical collar is the priority to prevent further spinal cord
injury. Neurological assessment and imaging follow after stabilization. Pain medication is not
the first priority.
5. Which assessment finding in a patient receiving heparin therapy indicates a need for
immediate action?
A. Platelet count of 150,000/mm³
B. Hemoglobin of 12 g/dL
C. New onset of black, tarry stools
D. aPTT of 60 seconds
Answer: C
Rationale: Black, tarry stools indicate gastrointestinal bleeding, a serious adverse effect of
heparin. The other values are within normal limits or therapeutic range. Immediate action
includes holding heparin and notifying the provider.
6. A patient with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
intervention should the nurse anticipate?
A. Administering sodium polystyrene sulfonate
B. Administering potassium chloride
C. Encouraging a high-potassium diet
D. Restricting fluid intake
Answer: A
Rationale: Sodium polystyrene sulfonate is a cation-exchange resin that removes potassium via
the gastrointestinal tract. Potassium chloride and high-potassium diet would worsen
hyperkalemia. Fluid restriction does not directly lower potassium.
7. A patient is one day postoperative from a total hip arthroplasty. Which action should the
nurse include in the plan of care to prevent dislocation?
A. Place a pillow between the legs when turning
B. Flex the hip beyond 90 degrees
C. Cross the legs when sitting
D. Turn to the operative side
Answer: A
Page 2
, Rationale: Using an abduction pillow prevents adduction and flexion beyond 90 degrees, reducing the risk of dislocation.
The other actions increase the risk of dislocation.
8. A patient with an acute exacerbation of asthma has a peak expiratory flow rate at 50%
of personal best. Which medication should the nurse administer first?
A. Inhaled corticosteroid
B. Short-acting beta-2 agonist
C. Long-acting beta-2 agonist
D. Oral leukotriene modifier
Answer: B
Rationale: A short-acting beta-2 agonist (e.g., albuterol) is the rescue medication of choice for
acute bronchospasm. Inhaled corticosteroids and long-acting beta-2 agonists are for
maintenance, not acute relief. Leukotriene modifiers are also for long-term control.
9. The nurse is reviewing a prescription for a patient with a new colostomy. Which
instruction should the nurse include about colostomy care?
A. Change the pouch every day
B. Clean the stoma with alcohol
C. Measure the stoma each time the pouch is changed
D. Apply the pouch while the stoma is dry
Answer: C
Rationale: The stoma shrinks over time, so measuring ensures a proper fit to prevent leakage.
The pouch is changed every 3-7 days, not daily. Alcohol is irritating to the stoma. The pouch
should be applied when the stoma is clean and dry, but measuring is a key ongoing assessment.
10. A patient with a traumatic brain injury has an intracranial pressure (ICP) monitor.
Which finding should the nurse report immediately?
A. ICP of 10 mm Hg
B. ICP of 20 mm Hg
C. Cerebral perfusion pressure (CPP) of 70 mm Hg
D. Mean arterial pressure (MAP) of 80 mm Hg
Answer: B
Rationale: Normal ICP is 0-15 mm Hg; an ICP of 20 mm Hg indicates increased intracranial
pressure and requires immediate intervention. The other values are within acceptable ranges.
11. A patient with acute decompensated heart failure is receiving IV furosemide. Which
assessment finding best indicates the medication is producing the desired therapeutic
effect?
A. Serum potassium rises from 3.2 to 4.0 mEq/L
B. Urine output increases with a 1.5 kg weight loss over 24 hours
Page 3
Preparation Exam 3 Practice Questions & Rationa,
Exams of Nursing
1. A patient with heart failure is prescribed furosemide. Which laboratory value should the
nurse monitor most closely to detect a common adverse effect?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Answer: B
Rationale: Loop diuretics like furosemide cause potassium loss, leading to hypokalemia.
Monitoring serum potassium is essential to prevent dysrhythmias. While sodium and magnesium
can also be affected, potassium is the most critical and commonly monitored electrolyte.
2. Which finding in a patient with a new tracheostomy requires immediate nursing
intervention?
A. Coughing after suctioning
B. Oxygen saturation of 94%
C. Copious secretions
D. Tracheal cuff pressure of 30 cm H2O
Answer: D
Rationale: Tracheal cuff pressure should be maintained between 20-25 cm H2O to prevent
tracheal mucosal damage. A pressure of 30 cm H2O is too high and requires immediate
adjustment. The other findings are expected or within normal limits.
3. A patient with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which
initial prescription should the nurse question?
A. 0.9% sodium chloride IV infusion
B. Regular insulin IV bolus
C. Sodium bicarbonate IV push
D. Potassium chloride added to IV fluids
Answer: C
Rationale: Sodium bicarbonate is not routinely recommended in DKA unless pH is severely low
(<6.9). It can worsen hypokalemia and cause paradoxical acidosis. The other interventions are
standard initial treatments for DKA.
Page 1
,4. Following a motor vehicle crash, a patient has a suspected cervical spine injury. Which
action should the nurse take first?
A. Perform a neurological assessment
B. Apply a cervical collar
C. Obtain a lateral cervical spine X-ray
D. Administer pain medication
Answer: B
Rationale: Immobilization with a cervical collar is the priority to prevent further spinal cord
injury. Neurological assessment and imaging follow after stabilization. Pain medication is not
the first priority.
5. Which assessment finding in a patient receiving heparin therapy indicates a need for
immediate action?
A. Platelet count of 150,000/mm³
B. Hemoglobin of 12 g/dL
C. New onset of black, tarry stools
D. aPTT of 60 seconds
Answer: C
Rationale: Black, tarry stools indicate gastrointestinal bleeding, a serious adverse effect of
heparin. The other values are within normal limits or therapeutic range. Immediate action
includes holding heparin and notifying the provider.
6. A patient with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
intervention should the nurse anticipate?
A. Administering sodium polystyrene sulfonate
B. Administering potassium chloride
C. Encouraging a high-potassium diet
D. Restricting fluid intake
Answer: A
Rationale: Sodium polystyrene sulfonate is a cation-exchange resin that removes potassium via
the gastrointestinal tract. Potassium chloride and high-potassium diet would worsen
hyperkalemia. Fluid restriction does not directly lower potassium.
7. A patient is one day postoperative from a total hip arthroplasty. Which action should the
nurse include in the plan of care to prevent dislocation?
A. Place a pillow between the legs when turning
B. Flex the hip beyond 90 degrees
C. Cross the legs when sitting
D. Turn to the operative side
Answer: A
Page 2
, Rationale: Using an abduction pillow prevents adduction and flexion beyond 90 degrees, reducing the risk of dislocation.
The other actions increase the risk of dislocation.
8. A patient with an acute exacerbation of asthma has a peak expiratory flow rate at 50%
of personal best. Which medication should the nurse administer first?
A. Inhaled corticosteroid
B. Short-acting beta-2 agonist
C. Long-acting beta-2 agonist
D. Oral leukotriene modifier
Answer: B
Rationale: A short-acting beta-2 agonist (e.g., albuterol) is the rescue medication of choice for
acute bronchospasm. Inhaled corticosteroids and long-acting beta-2 agonists are for
maintenance, not acute relief. Leukotriene modifiers are also for long-term control.
9. The nurse is reviewing a prescription for a patient with a new colostomy. Which
instruction should the nurse include about colostomy care?
A. Change the pouch every day
B. Clean the stoma with alcohol
C. Measure the stoma each time the pouch is changed
D. Apply the pouch while the stoma is dry
Answer: C
Rationale: The stoma shrinks over time, so measuring ensures a proper fit to prevent leakage.
The pouch is changed every 3-7 days, not daily. Alcohol is irritating to the stoma. The pouch
should be applied when the stoma is clean and dry, but measuring is a key ongoing assessment.
10. A patient with a traumatic brain injury has an intracranial pressure (ICP) monitor.
Which finding should the nurse report immediately?
A. ICP of 10 mm Hg
B. ICP of 20 mm Hg
C. Cerebral perfusion pressure (CPP) of 70 mm Hg
D. Mean arterial pressure (MAP) of 80 mm Hg
Answer: B
Rationale: Normal ICP is 0-15 mm Hg; an ICP of 20 mm Hg indicates increased intracranial
pressure and requires immediate intervention. The other values are within acceptable ranges.
11. A patient with acute decompensated heart failure is receiving IV furosemide. Which
assessment finding best indicates the medication is producing the desired therapeutic
effect?
A. Serum potassium rises from 3.2 to 4.0 mEq/L
B. Urine output increases with a 1.5 kg weight loss over 24 hours
Page 3
