NRSG 110 Exam 2 V2 | NRSG 110 Medical Surgical
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 2) | Ivy Tech
1. A nurse is caring for a patient who is 24 hours post-operative following a subtotal
thyroidectomy. Which of the following assessment findings is the most critical to report to
the provider?
A. Calcium level of 9.2 mg/dL
B. Pain level of 5 on a scale of 0 to 10 at the incision site
C. Hoarseness when speaking
D. Laryngeal stridor heard on inspiration
Correct Answer: D
Explanation: Laryngeal stridor indicates an acute airway obstruction, which is a life-
threatening emergency following thyroid surgery. The nurse must monitor for respiratory
distress caused by edema or tetany. Immediate intervention is required to maintain airway
patency and oxygenation.
2. A client with a history of chronic cholecystitis is admitted with right upper quadrant pain
that radiates to the right shoulder. Which nutritional instruction should the nurse prioritize
during discharge teaching?
A. Increase intake of fat-soluble vitamins
B. Consume three large meals a day to maintain energy levels
,C. Adhere to a low-fat diet to minimize gallbladder stimulation
D. Limit fluid intake to 1500 mL per day
Correct Answer: C
Explanation: Patients with cholecystitis should follow a low-fat diet to prevent gallbladder
contraction and subsequent biliary colic. Small, frequent meals are often better tolerated
than large meals. This dietary modification helps manage symptoms and prevents further
inflammation of the gallbladder.
3. The nurse is reviewing the laboratory results of a client suspected of having acute
pancreatitis. Which of the following elevations is most diagnostic for this condition?
A. Serum amylase and lipase
B. Serum potassium
C. Serum creatinine
D. Serum bilirubin
Correct Answer: A
Explanation: Serum amylase and lipase are the primary enzymes released when the
pancreas is inflamed. Amylase rises early, while lipase stays elevated longer and is more
specific to pancreatic damage. These markers are essential for confirming a diagnosis of
acute pancreatitis in the clinical setting.
, 4. A client is diagnosed with Diverticulitis and is experiencing an acute exacerbation. Which of
the following dietary recommendations is appropriate for the client during this acute phase?
A. High-fiber diet with whole grains
B. Full liquid diet including milk and puddings
C. Clear liquid diet to allow the bowel to rest
D. Low-sodium diet to prevent edema
E. Low-protein diet to decrease nitrogenous waste
Correct Answer: C
Explanation: During an acute flare-up of diverticulitis, the bowel requires rest to allow
inflammation to subside. A clear liquid diet is initiated first and progressed as the client’s
condition improves. Once the acute phase resolves, a high-fiber diet is recommended to
prevent future occurrences.
5. A nurse is preparing to administer levothyroxine to a client with hypothyroidism. Which of
the following findings would cause the nurse to hold the medication?
A. Heart rate of 62 bpm
B. Weight gain of 2 lbs in a week
C. Blood pressure of 110/70 mmHg
D. Temperature of 98.6 F
E. Respiratory rate of 16 bpm
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 2) | Ivy Tech
1. A nurse is caring for a patient who is 24 hours post-operative following a subtotal
thyroidectomy. Which of the following assessment findings is the most critical to report to
the provider?
A. Calcium level of 9.2 mg/dL
B. Pain level of 5 on a scale of 0 to 10 at the incision site
C. Hoarseness when speaking
D. Laryngeal stridor heard on inspiration
Correct Answer: D
Explanation: Laryngeal stridor indicates an acute airway obstruction, which is a life-
threatening emergency following thyroid surgery. The nurse must monitor for respiratory
distress caused by edema or tetany. Immediate intervention is required to maintain airway
patency and oxygenation.
2. A client with a history of chronic cholecystitis is admitted with right upper quadrant pain
that radiates to the right shoulder. Which nutritional instruction should the nurse prioritize
during discharge teaching?
A. Increase intake of fat-soluble vitamins
B. Consume three large meals a day to maintain energy levels
,C. Adhere to a low-fat diet to minimize gallbladder stimulation
D. Limit fluid intake to 1500 mL per day
Correct Answer: C
Explanation: Patients with cholecystitis should follow a low-fat diet to prevent gallbladder
contraction and subsequent biliary colic. Small, frequent meals are often better tolerated
than large meals. This dietary modification helps manage symptoms and prevents further
inflammation of the gallbladder.
3. The nurse is reviewing the laboratory results of a client suspected of having acute
pancreatitis. Which of the following elevations is most diagnostic for this condition?
A. Serum amylase and lipase
B. Serum potassium
C. Serum creatinine
D. Serum bilirubin
Correct Answer: A
Explanation: Serum amylase and lipase are the primary enzymes released when the
pancreas is inflamed. Amylase rises early, while lipase stays elevated longer and is more
specific to pancreatic damage. These markers are essential for confirming a diagnosis of
acute pancreatitis in the clinical setting.
, 4. A client is diagnosed with Diverticulitis and is experiencing an acute exacerbation. Which of
the following dietary recommendations is appropriate for the client during this acute phase?
A. High-fiber diet with whole grains
B. Full liquid diet including milk and puddings
C. Clear liquid diet to allow the bowel to rest
D. Low-sodium diet to prevent edema
E. Low-protein diet to decrease nitrogenous waste
Correct Answer: C
Explanation: During an acute flare-up of diverticulitis, the bowel requires rest to allow
inflammation to subside. A clear liquid diet is initiated first and progressed as the client’s
condition improves. Once the acute phase resolves, a high-fiber diet is recommended to
prevent future occurrences.
5. A nurse is preparing to administer levothyroxine to a client with hypothyroidism. Which of
the following findings would cause the nurse to hold the medication?
A. Heart rate of 62 bpm
B. Weight gain of 2 lbs in a week
C. Blood pressure of 110/70 mmHg
D. Temperature of 98.6 F
E. Respiratory rate of 16 bpm
