NU 185 Medical Surgical Nursing II Exam 4 (2026)
Exam 4 Practice Questions & Rationales 2, Exams of
Nursing
1. A patient with heart failure is prescribed sacubitril/valsartan. Which assessment finding
requires immediate follow-up?
A. Blood pressure 102/64 mm Hg
B. Heart rate 88 beats/min
C. Angioedema of the tongue
D. Serum potassium 4.2 mEq/L
Answer: C
Rationale: Angioedema is a life-threatening adverse effect of sacubitril/valsartan, requiring
immediate discontinuation and emergency treatment. The other findings are within normal limits
or expected. Blood pressure of 102/64 is acceptable, heart rate 88 is normal, and potassium 4.2
is normal.
2. Which intervention is most appropriate for a patient with an acute exacerbation of
asthma who has a peak expiratory flow rate at 50% of personal best?
A. Administer a short-acting beta2-agonist via nebulizer
B. Administer a long-acting beta2-agonist inhaler
C. Initiate oral corticosteroid therapy
D. Perform chest physiotherapy
Answer: A
Rationale: A peak flow at 50% of personal best indicates a moderate asthma exacerbation;
immediate treatment with a short-acting beta2-agonist is the first-line intervention. Long-acting
beta2-agonists are for maintenance, not acute relief. Oral corticosteroids may be added but are
not the first immediate action. Chest physiotherapy is not indicated for acute bronchospasm.
3. A patient with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
prescribed medication should the nurse question?
A. Sodium polystyrene sulfonate
B. Spironolactone
C. Calcium acetate
D. Epoetin alfa
Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic that can worsen hyperkalemia; it
should be questioned in a patient with potassium 6.2 mEq/L. Sodium polystyrene sulfonate is
Page 1
,used to treat hyperkalemia. Calcium acetate is a phosphate binder. Epoetin alfa treats anemia of
CKD and does not affect potassium.
4. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8. Which
nursing action is the priority?
A. Perform oral care every 4 hours
B. Prepare for endotracheal intubation
C. Administer mannitol as prescribed
D. Elevate the head of the bed to 30 degrees
Answer: B
Rationale: A GCS of 8 indicates severe neurological impairment and imminent risk of airway
compromise; endotracheal intubation is the priority to secure the airway. Oral care, mannitol
administration, and head elevation are important but secondary to airway management.
Mannitol may be given to reduce intracranial pressure, but airway takes precedence.
5. Which finding in a patient receiving chemotherapy for leukemia requires immediate
notification of the provider?
A. Temperature of 38.3°C (101°F)
B. Hemoglobin 10.5 g/dL
C. Platelet count 75,000/mm³
D. Nausea and vomiting
Answer: A
Rationale: A temperature of 38.3°C in a neutropenic patient after chemotherapy indicates
possible neutropenic fever, a medical emergency requiring immediate provider notification and
broad-spectrum antibiotics. Hemoglobin 10.5 is mildly low but not urgent. Platelet count 75,000
is low but not critically; nausea is expected and manageable.
6. A patient with cirrhosis and ascites is scheduled for a paracentesis. Which pre-procedure
assessment is most important?
A. Serum albumin level
B. Bladder emptying
C. Coagulation studies
D. Body weight
Answer: C
Rationale: Coagulation studies are critical before paracentesis because cirrhosis causes
coagulopathy, increasing bleeding risk. Serum albumin, bladder emptying, and body weight are
relevant but not the priority for safety. Bladder emptying prevents bladder puncture but
coagulation status is the most important to prevent hemorrhage.
Page 2
, 7. A patient with a new below-the-knee amputation reports a sharp, burning sensation in
the missing foot. Which intervention is most appropriate?
A. Apply a cold pack to the residual limb
B. Administer prescribed gabapentin
C. Elevate the residual limb on a pillow
D. Perform range-of-motion exercises
Answer: B
Rationale: Phantom limb pain is neuropathic and treated with medications like gabapentin. Cold
packs, elevation, and ROM exercises do not address neuropathic pain. Elevation is for edema,
not phantom pain.
8. A patient with type 1 diabetes has a blood glucose of 52 mg/dL and is conscious. Which
action should the nurse take first?
A. Administer 15 g of oral glucose
B. Give glucagon subcutaneously
C. Start an IV infusion of dextrose 5%
D. Recheck blood glucose in 15 minutes
Answer: A
Rationale: For a conscious patient with hypoglycemia, the first step is to administer 15 g of
rapid-acting oral carbohydrate. Glucagon is for unconscious patients or when oral intake is not
possible. IV dextrose is for severe cases. Rechecking glucose is done after treatment, not before.
9. Which assessment finding in a patient with a cervical spinal cord injury indicates
neurogenic shock?
A. Hypertension and tachycardia
B. Hypotension and bradycardia
C. Warm, dry skin and fever
D. Flaccid paralysis and hyperreflexia
Answer: B
Rationale: Neurogenic shock results from loss of sympathetic tone, causing hypotension and
bradycardia. Hypertension and tachycardia indicate spinal shock or autonomic dysreflexia.
Warm, dry skin and fever are not typical. Flaccid paralysis and hyperreflexia are not specific to
neurogenic shock.
10. A patient with a new colostomy has a stoma that is dark purple and dusky. What is the
nurse's priority action?
A. Document the finding as normal
B. Apply a moist dressing
C. Notify the surgeon immediately
D. Increase fluid intake
Page 3
Exam 4 Practice Questions & Rationales 2, Exams of
Nursing
1. A patient with heart failure is prescribed sacubitril/valsartan. Which assessment finding
requires immediate follow-up?
A. Blood pressure 102/64 mm Hg
B. Heart rate 88 beats/min
C. Angioedema of the tongue
D. Serum potassium 4.2 mEq/L
Answer: C
Rationale: Angioedema is a life-threatening adverse effect of sacubitril/valsartan, requiring
immediate discontinuation and emergency treatment. The other findings are within normal limits
or expected. Blood pressure of 102/64 is acceptable, heart rate 88 is normal, and potassium 4.2
is normal.
2. Which intervention is most appropriate for a patient with an acute exacerbation of
asthma who has a peak expiratory flow rate at 50% of personal best?
A. Administer a short-acting beta2-agonist via nebulizer
B. Administer a long-acting beta2-agonist inhaler
C. Initiate oral corticosteroid therapy
D. Perform chest physiotherapy
Answer: A
Rationale: A peak flow at 50% of personal best indicates a moderate asthma exacerbation;
immediate treatment with a short-acting beta2-agonist is the first-line intervention. Long-acting
beta2-agonists are for maintenance, not acute relief. Oral corticosteroids may be added but are
not the first immediate action. Chest physiotherapy is not indicated for acute bronchospasm.
3. A patient with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
prescribed medication should the nurse question?
A. Sodium polystyrene sulfonate
B. Spironolactone
C. Calcium acetate
D. Epoetin alfa
Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic that can worsen hyperkalemia; it
should be questioned in a patient with potassium 6.2 mEq/L. Sodium polystyrene sulfonate is
Page 1
,used to treat hyperkalemia. Calcium acetate is a phosphate binder. Epoetin alfa treats anemia of
CKD and does not affect potassium.
4. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8. Which
nursing action is the priority?
A. Perform oral care every 4 hours
B. Prepare for endotracheal intubation
C. Administer mannitol as prescribed
D. Elevate the head of the bed to 30 degrees
Answer: B
Rationale: A GCS of 8 indicates severe neurological impairment and imminent risk of airway
compromise; endotracheal intubation is the priority to secure the airway. Oral care, mannitol
administration, and head elevation are important but secondary to airway management.
Mannitol may be given to reduce intracranial pressure, but airway takes precedence.
5. Which finding in a patient receiving chemotherapy for leukemia requires immediate
notification of the provider?
A. Temperature of 38.3°C (101°F)
B. Hemoglobin 10.5 g/dL
C. Platelet count 75,000/mm³
D. Nausea and vomiting
Answer: A
Rationale: A temperature of 38.3°C in a neutropenic patient after chemotherapy indicates
possible neutropenic fever, a medical emergency requiring immediate provider notification and
broad-spectrum antibiotics. Hemoglobin 10.5 is mildly low but not urgent. Platelet count 75,000
is low but not critically; nausea is expected and manageable.
6. A patient with cirrhosis and ascites is scheduled for a paracentesis. Which pre-procedure
assessment is most important?
A. Serum albumin level
B. Bladder emptying
C. Coagulation studies
D. Body weight
Answer: C
Rationale: Coagulation studies are critical before paracentesis because cirrhosis causes
coagulopathy, increasing bleeding risk. Serum albumin, bladder emptying, and body weight are
relevant but not the priority for safety. Bladder emptying prevents bladder puncture but
coagulation status is the most important to prevent hemorrhage.
Page 2
, 7. A patient with a new below-the-knee amputation reports a sharp, burning sensation in
the missing foot. Which intervention is most appropriate?
A. Apply a cold pack to the residual limb
B. Administer prescribed gabapentin
C. Elevate the residual limb on a pillow
D. Perform range-of-motion exercises
Answer: B
Rationale: Phantom limb pain is neuropathic and treated with medications like gabapentin. Cold
packs, elevation, and ROM exercises do not address neuropathic pain. Elevation is for edema,
not phantom pain.
8. A patient with type 1 diabetes has a blood glucose of 52 mg/dL and is conscious. Which
action should the nurse take first?
A. Administer 15 g of oral glucose
B. Give glucagon subcutaneously
C. Start an IV infusion of dextrose 5%
D. Recheck blood glucose in 15 minutes
Answer: A
Rationale: For a conscious patient with hypoglycemia, the first step is to administer 15 g of
rapid-acting oral carbohydrate. Glucagon is for unconscious patients or when oral intake is not
possible. IV dextrose is for severe cases. Rechecking glucose is done after treatment, not before.
9. Which assessment finding in a patient with a cervical spinal cord injury indicates
neurogenic shock?
A. Hypertension and tachycardia
B. Hypotension and bradycardia
C. Warm, dry skin and fever
D. Flaccid paralysis and hyperreflexia
Answer: B
Rationale: Neurogenic shock results from loss of sympathetic tone, causing hypotension and
bradycardia. Hypertension and tachycardia indicate spinal shock or autonomic dysreflexia.
Warm, dry skin and fever are not typical. Flaccid paralysis and hyperreflexia are not specific to
neurogenic shock.
10. A patient with a new colostomy has a stoma that is dark purple and dusky. What is the
nurse's priority action?
A. Document the finding as normal
B. Apply a moist dressing
C. Notify the surgeon immediately
D. Increase fluid intake
Page 3
