PNR 206/PNR206 Exam 3 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A client with Type 1 Diabetes Mellitus presents with diaphoresis, tremors, and a blood
glucose level of 52 mg/dL. Which action should the nurse take first?
A. Administer 10 units of regular insulin.
B. Administer 15 grams of simple carbohydrates.
C. Notify the healthcare provider immediately.
D. Provide a complex carbohydrate snack like a sandwich.
Answer: B
Rationale: The client is exhibiting signs of hypoglycemia, which requires immediate
intervention to raise blood glucose levels. Following the 15-15 rule, the nurse should
provide 15 grams of simple carbohydrates such as 4 ounces of orange juice. After the
intervention, the nurse must re-evaluate the blood glucose in 15 minutes to ensure it has
returned to a safe range.
2. The nurse is assessing a client post-thyroidectomy. Which assessment finding is the most
critical to report to the surgeon?
A. Laryngospasms and positive Chvostek’s sign.
B. Pain level of 4 on a scale of 0 to 10.
,C. Negative Trousseau’s sign.
D. Laryngeal nerve damage manifested by hoarseness.
Answer: A
Rationale: A positive Chvostek’s sign and laryngospasms indicate hypocalcemia, which is a
potential complication if the parathyroid glands are accidentally damaged or removed.
Hypocalcemia can lead to tetany and respiratory distress, making it a life-threatening
priority. The nurse must ensure calcium gluconate is readily available at the bedside for
emergency administration.
3. A client is diagnosed with Cushing’s Syndrome. Which clinical manifestation should the
nurse expect to find during the physical assessment?
A. Weight loss and hypotension.
B. Truncal obesity and a ‘buffalo hump’.
C. Hyperpigmentation of the skin and bronze color.
D. Thin, frail appearance with sunken eyes.
Answer: B
Rationale: Cushing’s Syndrome results from an excess of corticosteroids, which causes a
characteristic redistribution of fat. This leads to truncal obesity, a fatty pad between the
shoulders known as a buffalo hump, and a rounded ‘moon face’. Monitoring for
hypertension and hyperglycemia is also essential for these clients due to the systemic
effects of cortisol.
, 4. The nurse is providing discharge instructions to a client with Addison’s Disease. Which
statement by the client indicates a need for further teaching?
A. ‘I should wear a medical alert bracelet at all times.’
B. ‘I will need to take my hormone replacement for the rest of my life.’
C. ‘I should stop taking my medication if I feel nauseated.’
D. ‘I need to increase my salt intake during hot weather.’}],
Answer: C
Rationale: Clients with Addison’s disease must never abruptly stop their corticosteroid
medication as it can trigger a life-threatening Addisonian crisis. If the client is unable to
tolerate oral medications due to vomiting, they must seek medical attention for parenteral
administration. Education should emphasize that hormone replacement therapy is lifelong
and doses may need adjustment during periods of stress.
5. A client with Diabetes Insipidus (DI) is receiving Desmopressin (DDAVP). Which finding
indicates the medication is effective?
A. Decreased urine output and increased urine specific gravity.
B. Increased thirst and increased urine output.
C. Increased blood glucose levels.
D. Decreased serum sodium levels below 130 mEq/L.
Answer: A
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A client with Type 1 Diabetes Mellitus presents with diaphoresis, tremors, and a blood
glucose level of 52 mg/dL. Which action should the nurse take first?
A. Administer 10 units of regular insulin.
B. Administer 15 grams of simple carbohydrates.
C. Notify the healthcare provider immediately.
D. Provide a complex carbohydrate snack like a sandwich.
Answer: B
Rationale: The client is exhibiting signs of hypoglycemia, which requires immediate
intervention to raise blood glucose levels. Following the 15-15 rule, the nurse should
provide 15 grams of simple carbohydrates such as 4 ounces of orange juice. After the
intervention, the nurse must re-evaluate the blood glucose in 15 minutes to ensure it has
returned to a safe range.
2. The nurse is assessing a client post-thyroidectomy. Which assessment finding is the most
critical to report to the surgeon?
A. Laryngospasms and positive Chvostek’s sign.
B. Pain level of 4 on a scale of 0 to 10.
,C. Negative Trousseau’s sign.
D. Laryngeal nerve damage manifested by hoarseness.
Answer: A
Rationale: A positive Chvostek’s sign and laryngospasms indicate hypocalcemia, which is a
potential complication if the parathyroid glands are accidentally damaged or removed.
Hypocalcemia can lead to tetany and respiratory distress, making it a life-threatening
priority. The nurse must ensure calcium gluconate is readily available at the bedside for
emergency administration.
3. A client is diagnosed with Cushing’s Syndrome. Which clinical manifestation should the
nurse expect to find during the physical assessment?
A. Weight loss and hypotension.
B. Truncal obesity and a ‘buffalo hump’.
C. Hyperpigmentation of the skin and bronze color.
D. Thin, frail appearance with sunken eyes.
Answer: B
Rationale: Cushing’s Syndrome results from an excess of corticosteroids, which causes a
characteristic redistribution of fat. This leads to truncal obesity, a fatty pad between the
shoulders known as a buffalo hump, and a rounded ‘moon face’. Monitoring for
hypertension and hyperglycemia is also essential for these clients due to the systemic
effects of cortisol.
, 4. The nurse is providing discharge instructions to a client with Addison’s Disease. Which
statement by the client indicates a need for further teaching?
A. ‘I should wear a medical alert bracelet at all times.’
B. ‘I will need to take my hormone replacement for the rest of my life.’
C. ‘I should stop taking my medication if I feel nauseated.’
D. ‘I need to increase my salt intake during hot weather.’}],
Answer: C
Rationale: Clients with Addison’s disease must never abruptly stop their corticosteroid
medication as it can trigger a life-threatening Addisonian crisis. If the client is unable to
tolerate oral medications due to vomiting, they must seek medical attention for parenteral
administration. Education should emphasize that hormone replacement therapy is lifelong
and doses may need adjustment during periods of stress.
5. A client with Diabetes Insipidus (DI) is receiving Desmopressin (DDAVP). Which finding
indicates the medication is effective?
A. Decreased urine output and increased urine specific gravity.
B. Increased thirst and increased urine output.
C. Increased blood glucose levels.
D. Decreased serum sodium levels below 130 mEq/L.
Answer: A
