PNR 206/PNR206 Final Exam V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with type 1 diabetes mellitus who plans to start an exercise
program. Which instruction should the nurse provide to prevent hypoglycemia?
A. Administer an extra dose of rapid-acting insulin before exercise.
B. Check blood glucose levels only after completing the exercise.
C. Exercise during the peak action time of the morning insulin dose.
D. Consume a carbohydrate snack if blood glucose is less than 100 mg/dL prior to exercise.
Answer: D
Rationale: Exercise increases glucose uptake by the muscles and can lead to hypoglycemia
in clients with type 1 diabetes. Consuming a carbohydrate snack when blood glucose is low
before activity helps maintain stable levels. The nurse must also emphasize monitoring
glucose before, during, and after exercise to ensure safety.
2. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment
finding should the nurse report immediately regarding the client’s arteriovenous (AV) fistula?
A. Presence of a palpable thrill over the site.
B. Presence of a loud bruit upon auscultation.
C. Absence of a thrill or bruit.
,D. A blood pressure of 130/80 mmHg in the opposite arm.
Answer: C
Rationale: The presence of a thrill and bruit indicates that the AV fistula is patent and
blood flow is adequate. The absence of these findings suggests a clot or occlusion, which is
a medical emergency for a dialysis patient. Prompt notification of the healthcare provider is
required to prevent permanent loss of the access site.
3. Which clinical manifestation should the nurse prioritize when assessing a client suspected
of having increased intracranial pressure (ICP)?
A. Increased heart rate and decreased blood pressure.
B. Normal pupillary reaction to light.
C. A localized headache that improves with movement.
D. Altered level of consciousness (LOC).
Answer: D
Rationale: Altered level of consciousness is often the earliest and most sensitive indicator
of increasing intracranial pressure. As pressure rises, brain tissue perfusion decreases,
leading to irritability, restlessness, or lethargy. Nurses must monitor LOC closely to detect
neurological deterioration before more severe signs like Cushing’s triad occur.
4. A nurse is providing discharge instructions to a client following a subtotal gastrectomy.
Which dietary modification should be included to prevent dumping syndrome?
A. Drink at least 240 mL of water with every meal.
, B. Eat small, frequent meals and lie down for 30 minutes after eating.
C. Consume high-carbohydrate, sugary foods for energy.
D. Increase the intake of high-fiber raw vegetables.
Answer: B
Rationale: Dumping syndrome occurs when food moves too rapidly from the stomach into
the small intestine. Eating small, frequent meals prevents over-distension, and lying down
after meals slows the transit of food. Clients should also be advised to avoid fluids with
meals and limit concentrated sweets to reduce osmotic shifts.
5. A client is diagnosed with Myxedema coma. Which intervention is the highest priority for
the nurse to implement?
A. Administering intravenous levothyroxine as prescribed.
B. Maintaining a patent airway and monitoring respiratory status.
C. Applying a cooling blanket to reduce body temperature.
D. Restricting fluid intake to 1000 mL per day.
Answer: B
Rationale: Myxedema coma is a life-threatening complication of severe hypothyroidism
characterized by extreme metabolic slowdown. Maintaining the airway is the priority
because respiratory failure is a common cause of death in these clients. Once the airway is
secure, intravenous thyroid hormones and rewarming measures can be initiated.
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with type 1 diabetes mellitus who plans to start an exercise
program. Which instruction should the nurse provide to prevent hypoglycemia?
A. Administer an extra dose of rapid-acting insulin before exercise.
B. Check blood glucose levels only after completing the exercise.
C. Exercise during the peak action time of the morning insulin dose.
D. Consume a carbohydrate snack if blood glucose is less than 100 mg/dL prior to exercise.
Answer: D
Rationale: Exercise increases glucose uptake by the muscles and can lead to hypoglycemia
in clients with type 1 diabetes. Consuming a carbohydrate snack when blood glucose is low
before activity helps maintain stable levels. The nurse must also emphasize monitoring
glucose before, during, and after exercise to ensure safety.
2. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment
finding should the nurse report immediately regarding the client’s arteriovenous (AV) fistula?
A. Presence of a palpable thrill over the site.
B. Presence of a loud bruit upon auscultation.
C. Absence of a thrill or bruit.
,D. A blood pressure of 130/80 mmHg in the opposite arm.
Answer: C
Rationale: The presence of a thrill and bruit indicates that the AV fistula is patent and
blood flow is adequate. The absence of these findings suggests a clot or occlusion, which is
a medical emergency for a dialysis patient. Prompt notification of the healthcare provider is
required to prevent permanent loss of the access site.
3. Which clinical manifestation should the nurse prioritize when assessing a client suspected
of having increased intracranial pressure (ICP)?
A. Increased heart rate and decreased blood pressure.
B. Normal pupillary reaction to light.
C. A localized headache that improves with movement.
D. Altered level of consciousness (LOC).
Answer: D
Rationale: Altered level of consciousness is often the earliest and most sensitive indicator
of increasing intracranial pressure. As pressure rises, brain tissue perfusion decreases,
leading to irritability, restlessness, or lethargy. Nurses must monitor LOC closely to detect
neurological deterioration before more severe signs like Cushing’s triad occur.
4. A nurse is providing discharge instructions to a client following a subtotal gastrectomy.
Which dietary modification should be included to prevent dumping syndrome?
A. Drink at least 240 mL of water with every meal.
, B. Eat small, frequent meals and lie down for 30 minutes after eating.
C. Consume high-carbohydrate, sugary foods for energy.
D. Increase the intake of high-fiber raw vegetables.
Answer: B
Rationale: Dumping syndrome occurs when food moves too rapidly from the stomach into
the small intestine. Eating small, frequent meals prevents over-distension, and lying down
after meals slows the transit of food. Clients should also be advised to avoid fluids with
meals and limit concentrated sweets to reduce osmotic shifts.
5. A client is diagnosed with Myxedema coma. Which intervention is the highest priority for
the nurse to implement?
A. Administering intravenous levothyroxine as prescribed.
B. Maintaining a patent airway and monitoring respiratory status.
C. Applying a cooling blanket to reduce body temperature.
D. Restricting fluid intake to 1000 mL per day.
Answer: B
Rationale: Myxedema coma is a life-threatening complication of severe hypothyroidism
characterized by extreme metabolic slowdown. Maintaining the airway is the priority
because respiratory failure is a common cause of death in these clients. Once the airway is
secure, intravenous thyroid hormones and rewarming measures can be initiated.
