NUR 170 Exam 4 V1 | NUR 170 Medical-Surgical
Nursing | Actual Q&A with Rationale (NUR 170
Exam 4) | Galen
1. Mr. Henderson is a 45-year-old client admitted to the emergency department with a blood
glucose level of 685 mg/dL, fruity breath odor, and Kussmaul respirations. The nurse notes
the client is drowsy but follows commands. Which prescription should the nurse implement
first?
A. Initiate an intravenous infusion of 0.9% normal saline.
B. Administer 10 units of regular insulin intravenously.
C. Obtain an arterial blood gas (ABG) to check for acidosis.
D. Insert an indwelling urinary catheter for output monitoring.
Correct Answer: A
Explanation: In Diabetic Ketoacidosis (DKA), the priority is restoring circulating volume to
prevent hypovolemic shock. Fluid resuscitation with normal saline is essential before or
concurrent with insulin therapy to address the profound dehydration caused by osmotic
diuresis. While insulin is necessary to lower blood sugar, starting fluids is the immediate
life-saving intervention.
,2. Ms. Rivera is 12 hours post-operative following a subtotal thyroidectomy. During the
assessment, the nurse notes that the client has a positive Trousseau sign and reports tingling
around her mouth. Which medication should the nurse have readily available?
A. Levothyroxine sodium
B. Calcium gluconate
C. Potassium chloride
D. Sodium bicarbonate
Correct Answer: B
Explanation: A positive Trousseau sign and circumoral paresthesia indicate hypocalcemia,
which can occur after thyroid surgery if the parathyroid glands are accidentally damaged
or removed. Calcium gluconate is the drug of choice for treating acute hypocalcemic tetany
to prevent seizures or laryngospasm. The nurse must monitor the client closely for
respiratory distress and have emergency equipment at the bedside.
3. A nurse is caring for Mr. Thompson, who sustained thermal burns to his entire chest and
the anterior surface of both arms. Using the Rule of Nines, what percentage of the total body
surface area (TBSA) should the nurse document as being burned?
A. 18%
B. 36%
C. 27%
D. 45%
,Correct Answer: C
Explanation: According to the Rule of Nines, the entire anterior trunk (chest and
abdomen) is 18%, and the chest alone is roughly 9%. However, standard charting for the
‘entire chest’ often implies the whole anterior torso in some clinical scenarios, but
specifically, the anterior trunk is 18% and each entire arm is 9%. If the anterior of both
arms is burned (4.5% + 4.5% = 9%) plus the entire anterior trunk (18%), the total is 27%.
This assessment is critical for calculating fluid resuscitation requirements.
4. Mrs. Baker is receiving peritoneal dialysis for chronic kidney disease (CKD). During a fluid
exchange, the nurse observes that the returning dialysate is cloudy. What is the nurse’s
priority action?
A. Notify the healthcare provider immediately.
B. Document the finding as a normal expected occurrence.
C. Flush the peritoneal catheter with heparinized saline.
D. Warm the next bag of dialysate before infusion.
Correct Answer: A
Explanation: Cloudy effluent is the earliest sign of peritonitis, a serious complication of
peritoneal dialysis. The nurse must notify the provider so that cultures can be obtained and
antibiotic therapy can be initiated. Failure to treat peritonitis promptly can lead to sepsis
and the loss of the peritoneal membrane’s function.
, 5. Mr. Davis is being discharged following a cataract extraction with an intraocular lens
implant. Which statement by the client indicates that the discharge teaching was effective?
A. ‘I should lay on the side of my surgery to help the eye drain.’
B. ‘I will call the doctor if I experience any mild itching in the eye.’
C. ‘I will keep my head down and chin to my chest when I am sitting.’
D. ‘I will avoid lifting my 20-pound grandson for the next few weeks.’
Correct Answer: D
Explanation: Post-cataract surgery, it is vital to avoid activities that increase intraocular
pressure (IOP), such as heavy lifting, bending at the waist, or straining. Sleeping on the
operative side or keeping the head down also increases pressure and should be avoided.
Mild itching is normal, but severe pain or vision changes must be reported immediately.
6. A nurse is caring for a client with Addison’s disease who is experiencing nausea, vomiting,
and a blood pressure of 82/50 mmHg. Which intervention should the nurse prioritize?
A. Providing a diet high in potassium and low in sodium.
B. Checking the client’s blood glucose level.
C. Administering high-dose intravenous hydrocortisone.
D. Encouraging oral fluid intake to increase blood pressure.
Correct Answer: C
Nursing | Actual Q&A with Rationale (NUR 170
Exam 4) | Galen
1. Mr. Henderson is a 45-year-old client admitted to the emergency department with a blood
glucose level of 685 mg/dL, fruity breath odor, and Kussmaul respirations. The nurse notes
the client is drowsy but follows commands. Which prescription should the nurse implement
first?
A. Initiate an intravenous infusion of 0.9% normal saline.
B. Administer 10 units of regular insulin intravenously.
C. Obtain an arterial blood gas (ABG) to check for acidosis.
D. Insert an indwelling urinary catheter for output monitoring.
Correct Answer: A
Explanation: In Diabetic Ketoacidosis (DKA), the priority is restoring circulating volume to
prevent hypovolemic shock. Fluid resuscitation with normal saline is essential before or
concurrent with insulin therapy to address the profound dehydration caused by osmotic
diuresis. While insulin is necessary to lower blood sugar, starting fluids is the immediate
life-saving intervention.
,2. Ms. Rivera is 12 hours post-operative following a subtotal thyroidectomy. During the
assessment, the nurse notes that the client has a positive Trousseau sign and reports tingling
around her mouth. Which medication should the nurse have readily available?
A. Levothyroxine sodium
B. Calcium gluconate
C. Potassium chloride
D. Sodium bicarbonate
Correct Answer: B
Explanation: A positive Trousseau sign and circumoral paresthesia indicate hypocalcemia,
which can occur after thyroid surgery if the parathyroid glands are accidentally damaged
or removed. Calcium gluconate is the drug of choice for treating acute hypocalcemic tetany
to prevent seizures or laryngospasm. The nurse must monitor the client closely for
respiratory distress and have emergency equipment at the bedside.
3. A nurse is caring for Mr. Thompson, who sustained thermal burns to his entire chest and
the anterior surface of both arms. Using the Rule of Nines, what percentage of the total body
surface area (TBSA) should the nurse document as being burned?
A. 18%
B. 36%
C. 27%
D. 45%
,Correct Answer: C
Explanation: According to the Rule of Nines, the entire anterior trunk (chest and
abdomen) is 18%, and the chest alone is roughly 9%. However, standard charting for the
‘entire chest’ often implies the whole anterior torso in some clinical scenarios, but
specifically, the anterior trunk is 18% and each entire arm is 9%. If the anterior of both
arms is burned (4.5% + 4.5% = 9%) plus the entire anterior trunk (18%), the total is 27%.
This assessment is critical for calculating fluid resuscitation requirements.
4. Mrs. Baker is receiving peritoneal dialysis for chronic kidney disease (CKD). During a fluid
exchange, the nurse observes that the returning dialysate is cloudy. What is the nurse’s
priority action?
A. Notify the healthcare provider immediately.
B. Document the finding as a normal expected occurrence.
C. Flush the peritoneal catheter with heparinized saline.
D. Warm the next bag of dialysate before infusion.
Correct Answer: A
Explanation: Cloudy effluent is the earliest sign of peritonitis, a serious complication of
peritoneal dialysis. The nurse must notify the provider so that cultures can be obtained and
antibiotic therapy can be initiated. Failure to treat peritonitis promptly can lead to sepsis
and the loss of the peritoneal membrane’s function.
, 5. Mr. Davis is being discharged following a cataract extraction with an intraocular lens
implant. Which statement by the client indicates that the discharge teaching was effective?
A. ‘I should lay on the side of my surgery to help the eye drain.’
B. ‘I will call the doctor if I experience any mild itching in the eye.’
C. ‘I will keep my head down and chin to my chest when I am sitting.’
D. ‘I will avoid lifting my 20-pound grandson for the next few weeks.’
Correct Answer: D
Explanation: Post-cataract surgery, it is vital to avoid activities that increase intraocular
pressure (IOP), such as heavy lifting, bending at the waist, or straining. Sleeping on the
operative side or keeping the head down also increases pressure and should be avoided.
Mild itching is normal, but severe pain or vision changes must be reported immediately.
6. A nurse is caring for a client with Addison’s disease who is experiencing nausea, vomiting,
and a blood pressure of 82/50 mmHg. Which intervention should the nurse prioritize?
A. Providing a diet high in potassium and low in sodium.
B. Checking the client’s blood glucose level.
C. Administering high-dose intravenous hydrocortisone.
D. Encouraging oral fluid intake to increase blood pressure.
Correct Answer: C
