NUR 425 Exam 3: Medical Surgical V1 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. Which clinical manifestation is most characteristic of a patient experiencing hypovolemic shock?
A. Increased urine output and hypertension
B. Bradycardia and warm, dry skin
C. Tachycardia and cool, clammy skin
D. Decreased respiratory rate and bounding pulses
Ans: C
Explanation: Hypovolemic shock occurs when there is a significant loss of blood or fluid volume. The
body compensates by increasing the heart rate to maintain cardiac output. Peripheral vasoconstriction
occurs to divert blood to vital organs, causing the skin to feel cool and clammy. This physiological
response is a hallmark sign of early to mid-stage shock. Monitoring these vital signs is crucial for early
intervention and stabilization.
2. A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations. What is the primary cause
of this breathing pattern?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Ans: C
,Explanation: Kussmaul respirations are deep and rapid breaths typically seen in Diabetic Ketoacidosis.
This breathing pattern is the body’s attempt to blow off excess carbon dioxide. By reducing CO2, the body
tries to compensate for the metabolic acidosis present. This is a critical compensatory mechanism to help
restore a normal pH balance. Nurses must recognize this sign as an indicator of severe metabolic distress.
3. What is the primary goal of administering a loop diuretic like Furosemide to a patient with heart failure?
A. To increase heart rate
B. To reduce systemic vascular resistance
C. To increase blood glucose levels
D. To reduce fluid volume overload
Ans: D
Explanation: Heart failure often leads to the accumulation of excess fluid in the lungs and tissues. Loop
diuretics work by inhibiting sodium reabsorption in the kidneys, leading to increased diuresis. This
reduction in fluid volume decreases the workload on the failing heart. It also helps alleviate symptoms
such as dyspnea and peripheral edema. Patients must be monitored for electrolyte imbalances,
particularly potassium loss, during therapy.
4. Which laboratory value is most important to monitor in a patient receiving Heparin therapy?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Ans: C
, Explanation: Heparin is an anticoagulant used to prevent and treat blood clots. The aPTT test measures
the time it takes for blood to clot and guides dosage adjustments. Maintaining the aPTT within a
therapeutic range ensures the drug is effective without causing excessive bleeding. Regular monitoring is
essential to provide safe and effective individualized care for the patient. Nurses must follow hospital
protocols for weight-based dosing and laboratory timing.
5. A patient is scheduled for surgery. What is the primary purpose of the ‘Time Out’ before the procedure
starts?
A. To allow the surgeon to take a break
B. To administer the final dose of anesthesia
C. To count the number of instruments used
D. To ensure correct patient, site, and procedure
Ans: D
Explanation: The ‘Time Out’ is a mandatory safety protocol performed immediately before the first
incision. All members of the surgical team must participate and agree on the details. It serves to verify the
patient’s identity, the surgical site, and the specific procedure being performed. This practice is vital for
preventing ‘wrong-site’ or ‘wrong-patient’ surgical errors. It represents a critical component of the Joint
Commission’s National Patient Safety Goals.
6. What is the priority nursing intervention for a patient with a suspected spinal cord injury?
A. Assessing for bowel sounds
B. Administering pain medication
C. Immobilizing the spine
D. Checking the patient’s blood pressure
Updated and Latest Questions and Correct Answers with
Rationale
1. Which clinical manifestation is most characteristic of a patient experiencing hypovolemic shock?
A. Increased urine output and hypertension
B. Bradycardia and warm, dry skin
C. Tachycardia and cool, clammy skin
D. Decreased respiratory rate and bounding pulses
Ans: C
Explanation: Hypovolemic shock occurs when there is a significant loss of blood or fluid volume. The
body compensates by increasing the heart rate to maintain cardiac output. Peripheral vasoconstriction
occurs to divert blood to vital organs, causing the skin to feel cool and clammy. This physiological
response is a hallmark sign of early to mid-stage shock. Monitoring these vital signs is crucial for early
intervention and stabilization.
2. A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations. What is the primary cause
of this breathing pattern?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Ans: C
,Explanation: Kussmaul respirations are deep and rapid breaths typically seen in Diabetic Ketoacidosis.
This breathing pattern is the body’s attempt to blow off excess carbon dioxide. By reducing CO2, the body
tries to compensate for the metabolic acidosis present. This is a critical compensatory mechanism to help
restore a normal pH balance. Nurses must recognize this sign as an indicator of severe metabolic distress.
3. What is the primary goal of administering a loop diuretic like Furosemide to a patient with heart failure?
A. To increase heart rate
B. To reduce systemic vascular resistance
C. To increase blood glucose levels
D. To reduce fluid volume overload
Ans: D
Explanation: Heart failure often leads to the accumulation of excess fluid in the lungs and tissues. Loop
diuretics work by inhibiting sodium reabsorption in the kidneys, leading to increased diuresis. This
reduction in fluid volume decreases the workload on the failing heart. It also helps alleviate symptoms
such as dyspnea and peripheral edema. Patients must be monitored for electrolyte imbalances,
particularly potassium loss, during therapy.
4. Which laboratory value is most important to monitor in a patient receiving Heparin therapy?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Ans: C
, Explanation: Heparin is an anticoagulant used to prevent and treat blood clots. The aPTT test measures
the time it takes for blood to clot and guides dosage adjustments. Maintaining the aPTT within a
therapeutic range ensures the drug is effective without causing excessive bleeding. Regular monitoring is
essential to provide safe and effective individualized care for the patient. Nurses must follow hospital
protocols for weight-based dosing and laboratory timing.
5. A patient is scheduled for surgery. What is the primary purpose of the ‘Time Out’ before the procedure
starts?
A. To allow the surgeon to take a break
B. To administer the final dose of anesthesia
C. To count the number of instruments used
D. To ensure correct patient, site, and procedure
Ans: D
Explanation: The ‘Time Out’ is a mandatory safety protocol performed immediately before the first
incision. All members of the surgical team must participate and agree on the details. It serves to verify the
patient’s identity, the surgical site, and the specific procedure being performed. This practice is vital for
preventing ‘wrong-site’ or ‘wrong-patient’ surgical errors. It represents a critical component of the Joint
Commission’s National Patient Safety Goals.
6. What is the priority nursing intervention for a patient with a suspected spinal cord injury?
A. Assessing for bowel sounds
B. Administering pain medication
C. Immobilizing the spine
D. Checking the patient’s blood pressure
