NUR 242 Exam 3 () | Med
Surg Nursing | Galen College (A+
Guarantee) | PDF
1. A nurse is assessing a client who is 2 days postoperative following an
abdominal hysterectomy. The client reports a sudden onset of shortness of
breath and chest pain. The nurse should suspect which of the following
complications?
• A. Atelectasis
• B. Pneumonia
• C. Pulmonary embolism
• D. Pulmonary embolism
• Rationale: A sudden onset of shortness of breath and pleuritic chest
pain in a postoperative client is a classic presentation of a pulmonary
embolism (PE). While atelectasis and pneumonia are postoperative risks,
they typically present with a more gradual onset of symptoms like fever,
cough, and decreased breath sounds. A PE is a medical emergency.
2. A client with type 1 diabetes mellitus is admitted with diabetic ketoacidosis
(DKA). Which of the following findings should the nurse expect?
• A. Blood glucose of 480 mg/dL
• B. Respiratory rate of 10/min
• C. Blood pH of 7.45
• D. Serum potassium of 5.8 mEq/L
• Rationale: DKA is characterized by hyperglycemia (blood glucose >250
mg/dL), metabolic acidosis (pH <7.35), and ketonuria. Clients often present
, with Kussmaul respirations (deep, rapid breathing) to blow off CO2. Serum
potassium may be normal or high initially due to the shift of potassium out
of the cells, but total body potassium is depleted.
3. A nurse is caring for a client who has heart failure and is prescribed
furosemide. Which of the following foods should the nurse instruct the client to
include in their diet?
• A. Canned soup
• B. White bread
• C. Bananas
• D. Cheese
• Rationale: Furosemide is a loop diuretic that causes potassium loss.
Clients should be instructed to increase their intake of potassium-rich foods,
such as bananas, oranges, potatoes, and spinach. Canned soup and cheese
are high in sodium and should be limited.
4. A client is admitted with an acute exacerbation of chronic obstructive
pulmonary disease (COPD). Which of the following oxygen delivery systems
should the nurse anticipate using?
• A. Simple face mask at 8 L/min
• B. Nasal cannula at 2 L/min
• C. Non-rebreather mask at 10 L/min
• D. Venturi mask at 6 L/min
• Rationale: Clients with COPD have a hypoxic drive to breathe.
Administering too much oxygen can suppress their respiratory drive, leading
to CO2 retention and respiratory failure. Therefore, low-flow oxygen,
typically via nasal cannula at 1-3 L/min, is the safest initial intervention to
maintain SpO2 between 88-92%.
,5. A nurse is teaching a client who has a new prescription for warfarin. Which of
the following statements by the client indicates an understanding of the
teaching?
• A. "I will increase my intake of green, leafy vegetables."
• B. "I will take ibuprofen for my headaches."
• C. "I will use a soft toothbrush to brush my teeth."
• D. "I will double my dose if I miss one."
• Rationale: Warfarin is an anticoagulant that increases the risk of
bleeding. Using a soft toothbrush helps prevent bleeding gums. Clients
should maintain a consistent intake of Vitamin K (found in green, leafy
vegetables), not increase it. Ibuprofen increases bleeding risk and should be
avoided. Clients should never double a dose of warfarin.
6. A client is 6 hours postoperative following a total hip arthroplasty. Which of
the following actions should the nurse take?
• A. Place a pillow under the client's knee.
• B. Encourage the client to cross their legs.
• C. Maintain the client's hip in abduction.
• D. Keep the client's hip in a flexed position.
• Rationale: After a total hip arthroplasty, it is crucial to prevent
dislocation of the new joint. The hip should be kept in abduction (using a
pillow or wedge between the legs) and should not be flexed beyond 90
degrees, adducted (crossed), or internally rotated.
7. A nurse is assessing a client with acute pancreatitis. Which of the following
findings is a priority for the nurse to report?
• A. Nausea and vomiting
• B. Jaundice
, • C. Turner's sign
• D. Weight loss
• Rationale: Turner's sign (ecchymosis of the flank) and Cullen's sign
(ecchymosis around the umbilicus) are signs of retroperitoneal bleeding,
which indicates severe hemorrhagic pancreatitis. This is a life-threatening
complication and must be reported immediately. Nausea, vomiting, and
jaundice are common but less acute findings.
8. A client with chronic kidney disease (CKD) has a serum potassium level of 6.5
mEq/L. Which of the following medications should the nurse anticipate
administering?
• A. Calcium gluconate
• B. Regular insulin with dextrose
• C. Sodium polystyrene sulfonate
• D. Furosemide
• Rationale: Regular insulin, administered with dextrose to prevent
hypoglycemia, drives potassium from the extracellular fluid back into the
cells, rapidly lowering serum potassium levels. Calcium gluconate is used to
protect the heart from the effects of hyperkalemia but does not lower
potassium levels. Sodium polystyrene sulfonate and furosemide are used to
eliminate potassium from the body but have a slower onset of action. The
priority is to shift the potassium intracellularly.
9. A nurse is providing discharge teaching to a client who has a new colostomy.
Which of the following instructions should the nurse include?
• A. "You should empty the pouch when it is one-third full."
• B. "You should clean the skin around the stoma with warm water."
• C. "You should change the pouch every day."
• D. "You should expect your stoma to be pale and dry."
Surg Nursing | Galen College (A+
Guarantee) | PDF
1. A nurse is assessing a client who is 2 days postoperative following an
abdominal hysterectomy. The client reports a sudden onset of shortness of
breath and chest pain. The nurse should suspect which of the following
complications?
• A. Atelectasis
• B. Pneumonia
• C. Pulmonary embolism
• D. Pulmonary embolism
• Rationale: A sudden onset of shortness of breath and pleuritic chest
pain in a postoperative client is a classic presentation of a pulmonary
embolism (PE). While atelectasis and pneumonia are postoperative risks,
they typically present with a more gradual onset of symptoms like fever,
cough, and decreased breath sounds. A PE is a medical emergency.
2. A client with type 1 diabetes mellitus is admitted with diabetic ketoacidosis
(DKA). Which of the following findings should the nurse expect?
• A. Blood glucose of 480 mg/dL
• B. Respiratory rate of 10/min
• C. Blood pH of 7.45
• D. Serum potassium of 5.8 mEq/L
• Rationale: DKA is characterized by hyperglycemia (blood glucose >250
mg/dL), metabolic acidosis (pH <7.35), and ketonuria. Clients often present
, with Kussmaul respirations (deep, rapid breathing) to blow off CO2. Serum
potassium may be normal or high initially due to the shift of potassium out
of the cells, but total body potassium is depleted.
3. A nurse is caring for a client who has heart failure and is prescribed
furosemide. Which of the following foods should the nurse instruct the client to
include in their diet?
• A. Canned soup
• B. White bread
• C. Bananas
• D. Cheese
• Rationale: Furosemide is a loop diuretic that causes potassium loss.
Clients should be instructed to increase their intake of potassium-rich foods,
such as bananas, oranges, potatoes, and spinach. Canned soup and cheese
are high in sodium and should be limited.
4. A client is admitted with an acute exacerbation of chronic obstructive
pulmonary disease (COPD). Which of the following oxygen delivery systems
should the nurse anticipate using?
• A. Simple face mask at 8 L/min
• B. Nasal cannula at 2 L/min
• C. Non-rebreather mask at 10 L/min
• D. Venturi mask at 6 L/min
• Rationale: Clients with COPD have a hypoxic drive to breathe.
Administering too much oxygen can suppress their respiratory drive, leading
to CO2 retention and respiratory failure. Therefore, low-flow oxygen,
typically via nasal cannula at 1-3 L/min, is the safest initial intervention to
maintain SpO2 between 88-92%.
,5. A nurse is teaching a client who has a new prescription for warfarin. Which of
the following statements by the client indicates an understanding of the
teaching?
• A. "I will increase my intake of green, leafy vegetables."
• B. "I will take ibuprofen for my headaches."
• C. "I will use a soft toothbrush to brush my teeth."
• D. "I will double my dose if I miss one."
• Rationale: Warfarin is an anticoagulant that increases the risk of
bleeding. Using a soft toothbrush helps prevent bleeding gums. Clients
should maintain a consistent intake of Vitamin K (found in green, leafy
vegetables), not increase it. Ibuprofen increases bleeding risk and should be
avoided. Clients should never double a dose of warfarin.
6. A client is 6 hours postoperative following a total hip arthroplasty. Which of
the following actions should the nurse take?
• A. Place a pillow under the client's knee.
• B. Encourage the client to cross their legs.
• C. Maintain the client's hip in abduction.
• D. Keep the client's hip in a flexed position.
• Rationale: After a total hip arthroplasty, it is crucial to prevent
dislocation of the new joint. The hip should be kept in abduction (using a
pillow or wedge between the legs) and should not be flexed beyond 90
degrees, adducted (crossed), or internally rotated.
7. A nurse is assessing a client with acute pancreatitis. Which of the following
findings is a priority for the nurse to report?
• A. Nausea and vomiting
• B. Jaundice
, • C. Turner's sign
• D. Weight loss
• Rationale: Turner's sign (ecchymosis of the flank) and Cullen's sign
(ecchymosis around the umbilicus) are signs of retroperitoneal bleeding,
which indicates severe hemorrhagic pancreatitis. This is a life-threatening
complication and must be reported immediately. Nausea, vomiting, and
jaundice are common but less acute findings.
8. A client with chronic kidney disease (CKD) has a serum potassium level of 6.5
mEq/L. Which of the following medications should the nurse anticipate
administering?
• A. Calcium gluconate
• B. Regular insulin with dextrose
• C. Sodium polystyrene sulfonate
• D. Furosemide
• Rationale: Regular insulin, administered with dextrose to prevent
hypoglycemia, drives potassium from the extracellular fluid back into the
cells, rapidly lowering serum potassium levels. Calcium gluconate is used to
protect the heart from the effects of hyperkalemia but does not lower
potassium levels. Sodium polystyrene sulfonate and furosemide are used to
eliminate potassium from the body but have a slower onset of action. The
priority is to shift the potassium intracellularly.
9. A nurse is providing discharge teaching to a client who has a new colostomy.
Which of the following instructions should the nurse include?
• A. "You should empty the pouch when it is one-third full."
• B. "You should clean the skin around the stoma with warm water."
• C. "You should change the pouch every day."
• D. "You should expect your stoma to be pale and dry."
