NU 185 Medical Surgical Nursing II Exam 4
Comprehensive Prep Exam 4 Practice Questions &,
Exams of Nursing
1. A patient with acute decompensated heart failure is receiving IV furosemide. Which
assessment finding best indicates a therapeutic response?
A. Serum potassium of 3.1 mEq/L
B. Urine output of 1,200 mL over 8 hours with decreased dyspnea
C. B-type natriuretic peptide (BNP) level unchanged from admission
D. Weight loss of 0.5 kg over 24 hours
Answer: B
Rationale: Therapeutic response to loop diuretics includes increased urine output and reduced
dyspnea from decreased preload. Hypokalemia (A) is an adverse effect, not a therapeutic
response. Unchanged BNP (C) does not reflect diuresis, and 0.5 kg (D) is less than the expected
0.5-1 kg/day fluid loss goal but alone is not the best indicator.
2. Which finding in a patient receiving hemodialysis requires immediate intervention?
A. Blood pressure 102/68 mm Hg pre-dialysis
B. Temperature 37.2°C (99°F) orally
C. Arteriovenous fistula thrill and bruit present
D. Serum potassium 6.8 mEq/L
Answer: D
Rationale: A potassium level of 6.8 mEq/L is a life-threatening hyperkalemia that can cause
lethal dysrhythmias and requires immediate treatment. The other findings (A, B, C) are within
expected parameters for a hemodialysis patient.
3. A patient with type 1 diabetes is found unresponsive with a blood glucose of 38 mg/dL.
After administering IV dextrose, which action is most important?
A. Recheck blood glucose in 15 minutes
B. Administer a dose of long-acting insulin
C. Place the patient in a lateral position
D. Document the episode and continue monitoring
Answer: A
Rationale: After treating hypoglycemia with IV dextrose, the nurse must recheck blood glucose in
15 minutes to evaluate response and prevent recurrence. Administering insulin (B) would
worsen hypoglycemia. Positioning (C) and documentation (D) are important but not the priority
over reassessment.
Page 1
,4. Which laboratory result is most concerning in a patient receiving chemotherapy?
A. Hemoglobin 10.2 g/dL
B. Platelet count 20,000/mm³
C. White blood cell count 3,500/mm³
D. Creatinine 1.1 mg/dL
Answer: B
Rationale: A platelet count of 20,000/mm³ indicates severe thrombocytopenia and risk for
spontaneous bleeding, requiring immediate intervention. Hemoglobin 10.2 g/dL (A) and WBC
3,500/mm³ (C) are low but less acutely dangerous. Creatinine 1.1 mg/dL (D) is normal.
5. A patient with a new ileostomy is being taught about dietary management. Which
statement indicates correct understanding?
A. I should eat foods high in fiber to thicken my stool.
B. I should avoid drinking fluids with meals to prevent diarrhea.
C. I should chew food thoroughly and avoid high-fiber foods initially.
D. I should take a laxative daily to regulate output.
Answer: C
Rationale: Initially after ileostomy, high-fiber foods can cause obstruction; thorough chewing
and a low-fiber diet are recommended. Fiber (A) may be added gradually later. Avoiding fluids
(B) can lead to dehydration. Laxatives (D) are contraindicated.
6. A patient is admitted with an acute ischemic stroke and is within the 4.5-hour treatment
window. Which finding would contraindicate IV thrombolytic therapy?
A. Blood pressure 180/100 mm Hg
B. Platelet count 150,000/mm³
C. INR 1.0
D. Blood glucose 120 mg/dL
Answer: A
Rationale: Blood pressure >185/110 mm Hg is a contraindication to IV thrombolytics because of
increased risk of intracranial hemorrhage. Platelet count 150,000/mm³ (B), INR 1.0 (C), and
glucose 120 mg/dL (D) are within acceptable limits.
7. Which assessment finding in a patient with a chest tube indicates a possible air leak?
A. Continuous bubbling in the water seal chamber
B. Fluctuation (tidaling) in the water seal chamber
C. Drainage of 50 mL serosanguineous fluid in the first hour
D. Subcutaneous emphysema at the insertion site
Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system.
Tidaling (B) is normal with respiration. Drainage (C) is expected initially. Subcutaneous
emphysema (D) may occur but is not the primary indicator of an air leak.
Page 2
, 8. A patient with acute pancreatitis is prescribed enteral feeding. Which intervention is
most appropriate to prevent aspiration?
A. Place the patient in a supine position during feeding
B. Elevate the head of the bed to 30-45 degrees during and after feeding
C. Administer a bolus feeding rapidly
D. Check residual volume every 8 hours
Answer: B
Rationale: Elevating the head of the bed 30–45 degrees reduces aspiration risk during enteral
feeding. Supine position (A) increases risk. Rapid bolus (C) is not recommended. Checking
residual (D) is no longer routinely recommended but is not the primary aspiration prevention
measure.
9. A patient with chronic kidney disease has a serum calcium of 7.8 mg/dL and phosphate
of 6.5 mg/dL. Which medication does the nurse anticipate administering?
A. Calcium carbonate
B. Aluminum hydroxide
C. Calcitriol
D. Sodium polystyrene sulfonate
Answer: A
Rationale: Calcium carbonate is a phosphate binder and also provides calcium, addressing both
hypocalcemia and hyperphosphatemia. Aluminum hydroxide (B) binds phosphate but does not
correct calcium. Calcitriol (C) increases calcium but not phosphate binding. Sodium polystyrene
sulfonate (D) treats hyperkalemia.
10. A patient receiving continuous IV heparin for venous thromboembolism has an aPTT
of 105 seconds (therapeutic range 60-80 seconds). Which action should the nurse
anticipate?
A. Continue the infusion at the current rate and recheck aPTT in 6 hours.
B. Hold the heparin infusion and prepare to administer protamine sulfate.
C. Increase the infusion rate and recheck aPTT in 6 hours.
D. Administer vitamin K subcutaneously and recheck aPTT in 12 hours.
Answer: B
Rationale: An aPTT of 105 seconds exceeds the therapeutic range and signals excessive
anticoagulation, so the infusion must be held and protamine sulfate given as the antidote.
Continuing or increasing the rate worsens bleeding risk, and vitamin K reverses warfarin, not
heparin.
11. A patient with acute decompensated heart failure is prescribed IV furosemide. Which
assessment finding best indicates the medication is achieving its intended therapeutic
effect?
Page 3
Comprehensive Prep Exam 4 Practice Questions &,
Exams of Nursing
1. A patient with acute decompensated heart failure is receiving IV furosemide. Which
assessment finding best indicates a therapeutic response?
A. Serum potassium of 3.1 mEq/L
B. Urine output of 1,200 mL over 8 hours with decreased dyspnea
C. B-type natriuretic peptide (BNP) level unchanged from admission
D. Weight loss of 0.5 kg over 24 hours
Answer: B
Rationale: Therapeutic response to loop diuretics includes increased urine output and reduced
dyspnea from decreased preload. Hypokalemia (A) is an adverse effect, not a therapeutic
response. Unchanged BNP (C) does not reflect diuresis, and 0.5 kg (D) is less than the expected
0.5-1 kg/day fluid loss goal but alone is not the best indicator.
2. Which finding in a patient receiving hemodialysis requires immediate intervention?
A. Blood pressure 102/68 mm Hg pre-dialysis
B. Temperature 37.2°C (99°F) orally
C. Arteriovenous fistula thrill and bruit present
D. Serum potassium 6.8 mEq/L
Answer: D
Rationale: A potassium level of 6.8 mEq/L is a life-threatening hyperkalemia that can cause
lethal dysrhythmias and requires immediate treatment. The other findings (A, B, C) are within
expected parameters for a hemodialysis patient.
3. A patient with type 1 diabetes is found unresponsive with a blood glucose of 38 mg/dL.
After administering IV dextrose, which action is most important?
A. Recheck blood glucose in 15 minutes
B. Administer a dose of long-acting insulin
C. Place the patient in a lateral position
D. Document the episode and continue monitoring
Answer: A
Rationale: After treating hypoglycemia with IV dextrose, the nurse must recheck blood glucose in
15 minutes to evaluate response and prevent recurrence. Administering insulin (B) would
worsen hypoglycemia. Positioning (C) and documentation (D) are important but not the priority
over reassessment.
Page 1
,4. Which laboratory result is most concerning in a patient receiving chemotherapy?
A. Hemoglobin 10.2 g/dL
B. Platelet count 20,000/mm³
C. White blood cell count 3,500/mm³
D. Creatinine 1.1 mg/dL
Answer: B
Rationale: A platelet count of 20,000/mm³ indicates severe thrombocytopenia and risk for
spontaneous bleeding, requiring immediate intervention. Hemoglobin 10.2 g/dL (A) and WBC
3,500/mm³ (C) are low but less acutely dangerous. Creatinine 1.1 mg/dL (D) is normal.
5. A patient with a new ileostomy is being taught about dietary management. Which
statement indicates correct understanding?
A. I should eat foods high in fiber to thicken my stool.
B. I should avoid drinking fluids with meals to prevent diarrhea.
C. I should chew food thoroughly and avoid high-fiber foods initially.
D. I should take a laxative daily to regulate output.
Answer: C
Rationale: Initially after ileostomy, high-fiber foods can cause obstruction; thorough chewing
and a low-fiber diet are recommended. Fiber (A) may be added gradually later. Avoiding fluids
(B) can lead to dehydration. Laxatives (D) are contraindicated.
6. A patient is admitted with an acute ischemic stroke and is within the 4.5-hour treatment
window. Which finding would contraindicate IV thrombolytic therapy?
A. Blood pressure 180/100 mm Hg
B. Platelet count 150,000/mm³
C. INR 1.0
D. Blood glucose 120 mg/dL
Answer: A
Rationale: Blood pressure >185/110 mm Hg is a contraindication to IV thrombolytics because of
increased risk of intracranial hemorrhage. Platelet count 150,000/mm³ (B), INR 1.0 (C), and
glucose 120 mg/dL (D) are within acceptable limits.
7. Which assessment finding in a patient with a chest tube indicates a possible air leak?
A. Continuous bubbling in the water seal chamber
B. Fluctuation (tidaling) in the water seal chamber
C. Drainage of 50 mL serosanguineous fluid in the first hour
D. Subcutaneous emphysema at the insertion site
Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system.
Tidaling (B) is normal with respiration. Drainage (C) is expected initially. Subcutaneous
emphysema (D) may occur but is not the primary indicator of an air leak.
Page 2
, 8. A patient with acute pancreatitis is prescribed enteral feeding. Which intervention is
most appropriate to prevent aspiration?
A. Place the patient in a supine position during feeding
B. Elevate the head of the bed to 30-45 degrees during and after feeding
C. Administer a bolus feeding rapidly
D. Check residual volume every 8 hours
Answer: B
Rationale: Elevating the head of the bed 30–45 degrees reduces aspiration risk during enteral
feeding. Supine position (A) increases risk. Rapid bolus (C) is not recommended. Checking
residual (D) is no longer routinely recommended but is not the primary aspiration prevention
measure.
9. A patient with chronic kidney disease has a serum calcium of 7.8 mg/dL and phosphate
of 6.5 mg/dL. Which medication does the nurse anticipate administering?
A. Calcium carbonate
B. Aluminum hydroxide
C. Calcitriol
D. Sodium polystyrene sulfonate
Answer: A
Rationale: Calcium carbonate is a phosphate binder and also provides calcium, addressing both
hypocalcemia and hyperphosphatemia. Aluminum hydroxide (B) binds phosphate but does not
correct calcium. Calcitriol (C) increases calcium but not phosphate binding. Sodium polystyrene
sulfonate (D) treats hyperkalemia.
10. A patient receiving continuous IV heparin for venous thromboembolism has an aPTT
of 105 seconds (therapeutic range 60-80 seconds). Which action should the nurse
anticipate?
A. Continue the infusion at the current rate and recheck aPTT in 6 hours.
B. Hold the heparin infusion and prepare to administer protamine sulfate.
C. Increase the infusion rate and recheck aPTT in 6 hours.
D. Administer vitamin K subcutaneously and recheck aPTT in 12 hours.
Answer: B
Rationale: An aPTT of 105 seconds exceeds the therapeutic range and signals excessive
anticoagulation, so the infusion must be held and protamine sulfate given as the antidote.
Continuing or increasing the rate worsens bleeding risk, and vitamin K reverses warfarin, not
heparin.
11. A patient with acute decompensated heart failure is prescribed IV furosemide. Which
assessment finding best indicates the medication is achieving its intended therapeutic
effect?
Page 3
