,NUR201 Medical-Surgical Nursing I Exam 2
Study Guide & 150 Practice Questions Fortis
College 2026/2027
1. A 72-year-old woman is admitted to the medical unit after three days of severe vomiting and
diarrhea at home. Her blood pressure is 96/58 mmHg lying and 78/44 mmHg standing, heart
rate is 112 bpm, and her mucous membranes are dry with furrowed tongue. Her skin turgor
remains tented for five seconds after being pinched. Based on these findings, what is the
priority nursing intervention?
A. Initiate intravenous access and administer isotonic fluids as prescribed.
B. Administer a prescribed antiemetic and encourage oral sips of clear liquid.
C. Obtain a stool specimen for culture and begin contact precautions.
D. Apply compression stockings and instruct the patient to perform leg exercises.
Correct Answer: A. Initiate intravenous access and administer isotonic fluids as prescribed.
Rationale: Fluid volume deficit with hypotension and tachycardia requires immediate
intravenous fluid resuscitation to restore circulating volume and prevent shock. Oral rehydration
is insufficient when the patient is hemodynamically unstable and continues to lose fluid through
vomiting. The nurse should anticipate orders for isotonic fluids such as 0.9% sodium chloride or
Lactated Ringer's and monitor the patient's response closely.
,2. A 65-year-old man with a history of heart failure receives 2 L of normal saline over four hours
in the emergency department for suspected sepsis. He now has jugular venous distention,
bilateral crackles at the lung bases, and a weight gain of 2 kg since yesterday. His oxygen
saturation has dropped to 89% on room air. What nursing action is most appropriate at this
time?
A. Restrict dietary sodium to less than 2 g per day and provide a low-protein meal tray.
B. Elevate the head of the bed, apply oxygen, and notify the provider about the findings.
C. Encourage the patient to ambulate in the hallway to promote venous return and diuresis.
D. Administer a prescribed stool softener and monitor for abdominal distension.
Correct Answer: B. Elevate the head of the bed, apply oxygen, and notify the provider about the
findings.
Rationale: Fluid volume excess is evident from crackles, jugular venous distention, weight gain,
and desaturation. Elevating the head of the bed and applying oxygen improve respiratory status
immediately while the provider is notified to adjust fluid management. Ambulation could
worsen respiratory distress in a hypoxic patient. The nurse should anticipate orders for diuretics
and strict intake and output monitoring.
3. A 58-year-old woman with syndrome of inappropriate antidiuretic hormone secretion (SIADH)
secondary to small cell lung cancer reports a persistent headache, nausea, and generalized
weakness. Her serum sodium is 121 mEq/L, and she is oriented to person but confused about
place and time. The provider has prescribed fluid restriction to 800 mL per day. Which
assessment finding requires immediate notification of the provider?
, A. Serum sodium of 123 mEq/L after 24 hours of fluid restriction.
B. Urine output of 40 mL/hr with a specific gravity of 1.025.
C. New onset of seizure activity.
D. Patient reports decreased headache.
Correct Answer: C. New onset of seizure activity.
Rationale: Severe hyponatremia (serum sodium <125 mEq/L) can cause cerebral edema, leading
to seizures, coma, and death. The onset of seizure activity indicates a neurologic emergency
requiring immediate intervention, including possible administration of hypertonic saline (3%
sodium chloride). The other findings do not require immediate notification.
4. A 45-year-old man with chronic kidney disease is admitted with muscle weakness,
palpitations, and a serum potassium level of 6.8 mEq/L. An ECG reveals tall, peaked T waves and
a widened QRS complex. Which medication should the nurse anticipate administering first?
A. Sodium polystyrene sulfonate (Kayexalate).
B. Insulin and glucose.
C. Calcium gluconate.
Study Guide & 150 Practice Questions Fortis
College 2026/2027
1. A 72-year-old woman is admitted to the medical unit after three days of severe vomiting and
diarrhea at home. Her blood pressure is 96/58 mmHg lying and 78/44 mmHg standing, heart
rate is 112 bpm, and her mucous membranes are dry with furrowed tongue. Her skin turgor
remains tented for five seconds after being pinched. Based on these findings, what is the
priority nursing intervention?
A. Initiate intravenous access and administer isotonic fluids as prescribed.
B. Administer a prescribed antiemetic and encourage oral sips of clear liquid.
C. Obtain a stool specimen for culture and begin contact precautions.
D. Apply compression stockings and instruct the patient to perform leg exercises.
Correct Answer: A. Initiate intravenous access and administer isotonic fluids as prescribed.
Rationale: Fluid volume deficit with hypotension and tachycardia requires immediate
intravenous fluid resuscitation to restore circulating volume and prevent shock. Oral rehydration
is insufficient when the patient is hemodynamically unstable and continues to lose fluid through
vomiting. The nurse should anticipate orders for isotonic fluids such as 0.9% sodium chloride or
Lactated Ringer's and monitor the patient's response closely.
,2. A 65-year-old man with a history of heart failure receives 2 L of normal saline over four hours
in the emergency department for suspected sepsis. He now has jugular venous distention,
bilateral crackles at the lung bases, and a weight gain of 2 kg since yesterday. His oxygen
saturation has dropped to 89% on room air. What nursing action is most appropriate at this
time?
A. Restrict dietary sodium to less than 2 g per day and provide a low-protein meal tray.
B. Elevate the head of the bed, apply oxygen, and notify the provider about the findings.
C. Encourage the patient to ambulate in the hallway to promote venous return and diuresis.
D. Administer a prescribed stool softener and monitor for abdominal distension.
Correct Answer: B. Elevate the head of the bed, apply oxygen, and notify the provider about the
findings.
Rationale: Fluid volume excess is evident from crackles, jugular venous distention, weight gain,
and desaturation. Elevating the head of the bed and applying oxygen improve respiratory status
immediately while the provider is notified to adjust fluid management. Ambulation could
worsen respiratory distress in a hypoxic patient. The nurse should anticipate orders for diuretics
and strict intake and output monitoring.
3. A 58-year-old woman with syndrome of inappropriate antidiuretic hormone secretion (SIADH)
secondary to small cell lung cancer reports a persistent headache, nausea, and generalized
weakness. Her serum sodium is 121 mEq/L, and she is oriented to person but confused about
place and time. The provider has prescribed fluid restriction to 800 mL per day. Which
assessment finding requires immediate notification of the provider?
, A. Serum sodium of 123 mEq/L after 24 hours of fluid restriction.
B. Urine output of 40 mL/hr with a specific gravity of 1.025.
C. New onset of seizure activity.
D. Patient reports decreased headache.
Correct Answer: C. New onset of seizure activity.
Rationale: Severe hyponatremia (serum sodium <125 mEq/L) can cause cerebral edema, leading
to seizures, coma, and death. The onset of seizure activity indicates a neurologic emergency
requiring immediate intervention, including possible administration of hypertonic saline (3%
sodium chloride). The other findings do not require immediate notification.
4. A 45-year-old man with chronic kidney disease is admitted with muscle weakness,
palpitations, and a serum potassium level of 6.8 mEq/L. An ECG reveals tall, peaked T waves and
a widened QRS complex. Which medication should the nurse anticipate administering first?
A. Sodium polystyrene sulfonate (Kayexalate).
B. Insulin and glucose.
C. Calcium gluconate.
