NRSG 201 Exam 3 V2 | NRSG 201 Med Surg 1 |
Actual Q&A with Rationale (NRSG201 Exam 3) | Ivy
Tech
1. A nurse is caring for a postoperative patient who begins to experience muscle rigidity and a
rapid rise in body temperature. What is the priority nursing intervention?
A. Administer acetaminophen rectally to reduce the fever.
B. Notify the surgeon that the patient is likely developing a wound infection.
C. Apply a cooling blanket and increase the IV fluid rate.
D. Prepare to administer dantrolene sodium as ordered.
Correct Answer: D
Explanation: Muscle rigidity and hyperpyrexia are classic late signs of malignant
hyperthermia, a life-threatening anesthetic complication. The priority intervention is the
administration of dantrolene sodium to stop the calcium release from the sarcoplasmic
reticulum. The nurse must also coordinate cooling measures and provide 100% oxygen to
support the patient during this hypermetabolic state.
2. When obtaining informed consent from a patient scheduled for elective surgery, which role
is strictly the responsibility of the nurse?
A. Explaining the risks and benefits of the procedure to the patient.
B. Determining if the patient has any alternative treatment options.
,C. Witnessing the signature and ensuring the patient is competent.
D. Describing the surgical technique that will be utilized during the operation.
Correct Answer: C
Explanation: The nurse’s role in informed consent is to act as a witness to the patient’s
signature and verify that the patient is signing voluntarily. It is the surgeon’s legal
responsibility to explain the procedure, risks, benefits, and alternatives. If the nurse notes
that the patient does not understand the procedure, the surgeon must be notified to return
and provide further explanation before the signature is obtained.
3. A patient with COPD is receiving oxygen therapy. Which assessment finding should the
nurse report immediately to the healthcare provider?
A. Oxygen saturation of 91% on 2 liters per nasal cannula.
B. Pursed-lip breathing during ambulation.
C. A decrease in respiratory rate to 8 breaths per minute.
D. Presence of a productive cough with clear sputum.
Correct Answer: C
Explanation: Patients with chronic hypercapnia may rely on a hypoxic drive to breathe,
where low oxygen levels stimulate respiration. Providing excessive oxygen can suppress
this drive, leading to respiratory depression or arrest as evidenced by a significantly low
respiratory rate. The nurse must monitor for oxygen-induced hypoventilation and adjust
flow rates according to specific provider orders for COPD patients.
,4. Which clinical manifestation should the nurse recognize as an early sign of hypoxia in a
patient with pneumonia?
A. Cyanosis of the lips and nail beds.
B. A heart rate of 50 beats per minute.
C. Restlessness and agitation.
D. Bradypnea and shallow respirations.
Correct Answer: C
Explanation: Restlessness, agitation, and apprehension are early compensatory signs of
hypoxia as the brain responds to decreased oxygen levels. Cyanosis is a late and unreliable
sign that indicates severe deoxygenation. Tachycardia and tachypnea are also early signs,
whereas bradycardia and bradypnea typically indicate impending respiratory failure.
5. The nurse is providing discharge teaching for a patient diagnosed with Tuberculosis (TB).
Which statement by the patient indicates a need for further instruction?
A. I will need to take these medications for at least six months.
B. I should cover my mouth with a tissue when I sneeze or cough.
C. I can stop taking the pills once my cough goes away and I feel better.
D. I will have my sputum tested regularly to see if the treatment is working.
Correct Answer: C
, Explanation: Treatment for TB requires strict adherence to a multi-drug regimen for an
extended period, often six to nine months, to ensure the bacteria are eradicated. Stopping
medication early leads to drug-resistant TB strains and treatment failure. Patients must be
taught that clinical improvement does not mean the infection is cured.
6. A patient returns to the unit following a bronchoscopy. Which nursing action is the highest
priority?
A. Maintaining NPO status until the gag reflex returns.
B. Administering prescribed prophylactic antibiotics.
C. Encouraging the patient to cough and deep breathe every two hours.
D. Applying warm compresses to the neck to relieve soreness.
Correct Answer: A
Explanation: During a bronchoscopy, the throat is numbed with a topical anesthetic, which
suppresses the gag reflex. Patients are at high risk for aspiration if they consume liquids or
solids before the reflex returns. The nurse must verify the return of the gag reflex by
touching the back of the throat with a tongue depressor before allowing oral intake.
7. A nurse is assessing a patient 24 hours post-surgery and notes diminished breath sounds at
the lung bases and a low-grade fever. What is the most likely cause?
A. Atelectasis.
B. Pulmonary embolism.
C. Hospital-acquired pneumonia.
Actual Q&A with Rationale (NRSG201 Exam 3) | Ivy
Tech
1. A nurse is caring for a postoperative patient who begins to experience muscle rigidity and a
rapid rise in body temperature. What is the priority nursing intervention?
A. Administer acetaminophen rectally to reduce the fever.
B. Notify the surgeon that the patient is likely developing a wound infection.
C. Apply a cooling blanket and increase the IV fluid rate.
D. Prepare to administer dantrolene sodium as ordered.
Correct Answer: D
Explanation: Muscle rigidity and hyperpyrexia are classic late signs of malignant
hyperthermia, a life-threatening anesthetic complication. The priority intervention is the
administration of dantrolene sodium to stop the calcium release from the sarcoplasmic
reticulum. The nurse must also coordinate cooling measures and provide 100% oxygen to
support the patient during this hypermetabolic state.
2. When obtaining informed consent from a patient scheduled for elective surgery, which role
is strictly the responsibility of the nurse?
A. Explaining the risks and benefits of the procedure to the patient.
B. Determining if the patient has any alternative treatment options.
,C. Witnessing the signature and ensuring the patient is competent.
D. Describing the surgical technique that will be utilized during the operation.
Correct Answer: C
Explanation: The nurse’s role in informed consent is to act as a witness to the patient’s
signature and verify that the patient is signing voluntarily. It is the surgeon’s legal
responsibility to explain the procedure, risks, benefits, and alternatives. If the nurse notes
that the patient does not understand the procedure, the surgeon must be notified to return
and provide further explanation before the signature is obtained.
3. A patient with COPD is receiving oxygen therapy. Which assessment finding should the
nurse report immediately to the healthcare provider?
A. Oxygen saturation of 91% on 2 liters per nasal cannula.
B. Pursed-lip breathing during ambulation.
C. A decrease in respiratory rate to 8 breaths per minute.
D. Presence of a productive cough with clear sputum.
Correct Answer: C
Explanation: Patients with chronic hypercapnia may rely on a hypoxic drive to breathe,
where low oxygen levels stimulate respiration. Providing excessive oxygen can suppress
this drive, leading to respiratory depression or arrest as evidenced by a significantly low
respiratory rate. The nurse must monitor for oxygen-induced hypoventilation and adjust
flow rates according to specific provider orders for COPD patients.
,4. Which clinical manifestation should the nurse recognize as an early sign of hypoxia in a
patient with pneumonia?
A. Cyanosis of the lips and nail beds.
B. A heart rate of 50 beats per minute.
C. Restlessness and agitation.
D. Bradypnea and shallow respirations.
Correct Answer: C
Explanation: Restlessness, agitation, and apprehension are early compensatory signs of
hypoxia as the brain responds to decreased oxygen levels. Cyanosis is a late and unreliable
sign that indicates severe deoxygenation. Tachycardia and tachypnea are also early signs,
whereas bradycardia and bradypnea typically indicate impending respiratory failure.
5. The nurse is providing discharge teaching for a patient diagnosed with Tuberculosis (TB).
Which statement by the patient indicates a need for further instruction?
A. I will need to take these medications for at least six months.
B. I should cover my mouth with a tissue when I sneeze or cough.
C. I can stop taking the pills once my cough goes away and I feel better.
D. I will have my sputum tested regularly to see if the treatment is working.
Correct Answer: C
, Explanation: Treatment for TB requires strict adherence to a multi-drug regimen for an
extended period, often six to nine months, to ensure the bacteria are eradicated. Stopping
medication early leads to drug-resistant TB strains and treatment failure. Patients must be
taught that clinical improvement does not mean the infection is cured.
6. A patient returns to the unit following a bronchoscopy. Which nursing action is the highest
priority?
A. Maintaining NPO status until the gag reflex returns.
B. Administering prescribed prophylactic antibiotics.
C. Encouraging the patient to cough and deep breathe every two hours.
D. Applying warm compresses to the neck to relieve soreness.
Correct Answer: A
Explanation: During a bronchoscopy, the throat is numbed with a topical anesthetic, which
suppresses the gag reflex. Patients are at high risk for aspiration if they consume liquids or
solids before the reflex returns. The nurse must verify the return of the gag reflex by
touching the back of the throat with a tongue depressor before allowing oral intake.
7. A nurse is assessing a patient 24 hours post-surgery and notes diminished breath sounds at
the lung bases and a low-grade fever. What is the most likely cause?
A. Atelectasis.
B. Pulmonary embolism.
C. Hospital-acquired pneumonia.
