PNR 206/PNR206 Final Exam V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient with hepatic encephalopathy. Which medication should the
nurse anticipate administering to reduce the patient’s ammonia levels?
A. Lactulose
B. Furosemide
C. Spironolactone
D. Metoprolol
Answer: A
Rationale: Lactulose works by trapping ammonia in the gut and expelling it through bowel
movements. It is the primary treatment for hepatic encephalopathy caused by liver failure.
The nurse must monitor the patient for frequent stools and potential electrolyte
imbalances.
2. Which of the following findings is considered an early sign of increased intracranial
pressure (ICP)?
A. Widening pulse pressure
B. Bradycardia
C. Decreased level of consciousness
,D. Fixed and dilated pupils
Answer: C
Rationale: A change in the level of consciousness is the most sensitive and earliest
indicator of neurological decline. Late signs include Cushing’s triad, which consists of
bradycardia, hypertension, and irregular respirations. The nurse should perform frequent
neurological assessments to detect subtle changes early.
3. A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations and a fruity
breath odor. What condition does the nurse suspect?
A. Diabetic Ketoacidosis (DKA)
B. Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
C. Hypoglycemia
D. Metabolic Alkalosis
Answer: A
Rationale: DKA is characterized by hyperglycemia, ketosis, and metabolic acidosis.
Kussmaul respirations are the body’s attempt to compensate for acidosis by blowing off
carbon dioxide. This condition is a medical emergency requiring insulin therapy and fluid
resuscitation.
4. When caring for a patient with Grave’s disease, which clinical manifestation should the
nurse expect?
A. Weight gain
, B. Cold intolerance
C. Bradycardia
D. Exophthalmos
Answer: D
Rationale: Exophthalmos is the protrusion of the eyeballs frequently seen in
hyperthyroidism or Grave’s disease. This occurs due to edema and fat deposits in the retro-
orbital tissues. The nurse should advise the patient to use artificial tears and wear
sunglasses for protection.
5. Which assessment finding is most indicative of a tension pneumothorax?
A. Bilateral breath sounds
B. Tracheal deviation to the unaffected side
C. Flattened neck veins
D. Resonance on percussion
Answer: B
Rationale: Tracheal deviation is a late and life-threatening sign of a tension pneumothorax.
It occurs as pressure builds in the pleural space, shifting the mediastinum toward the
healthy lung. Immediate needle decompression or chest tube insertion is required to save
the patient’s life.
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient with hepatic encephalopathy. Which medication should the
nurse anticipate administering to reduce the patient’s ammonia levels?
A. Lactulose
B. Furosemide
C. Spironolactone
D. Metoprolol
Answer: A
Rationale: Lactulose works by trapping ammonia in the gut and expelling it through bowel
movements. It is the primary treatment for hepatic encephalopathy caused by liver failure.
The nurse must monitor the patient for frequent stools and potential electrolyte
imbalances.
2. Which of the following findings is considered an early sign of increased intracranial
pressure (ICP)?
A. Widening pulse pressure
B. Bradycardia
C. Decreased level of consciousness
,D. Fixed and dilated pupils
Answer: C
Rationale: A change in the level of consciousness is the most sensitive and earliest
indicator of neurological decline. Late signs include Cushing’s triad, which consists of
bradycardia, hypertension, and irregular respirations. The nurse should perform frequent
neurological assessments to detect subtle changes early.
3. A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations and a fruity
breath odor. What condition does the nurse suspect?
A. Diabetic Ketoacidosis (DKA)
B. Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
C. Hypoglycemia
D. Metabolic Alkalosis
Answer: A
Rationale: DKA is characterized by hyperglycemia, ketosis, and metabolic acidosis.
Kussmaul respirations are the body’s attempt to compensate for acidosis by blowing off
carbon dioxide. This condition is a medical emergency requiring insulin therapy and fluid
resuscitation.
4. When caring for a patient with Grave’s disease, which clinical manifestation should the
nurse expect?
A. Weight gain
, B. Cold intolerance
C. Bradycardia
D. Exophthalmos
Answer: D
Rationale: Exophthalmos is the protrusion of the eyeballs frequently seen in
hyperthyroidism or Grave’s disease. This occurs due to edema and fat deposits in the retro-
orbital tissues. The nurse should advise the patient to use artificial tears and wear
sunglasses for protection.
5. Which assessment finding is most indicative of a tension pneumothorax?
A. Bilateral breath sounds
B. Tracheal deviation to the unaffected side
C. Flattened neck veins
D. Resonance on percussion
Answer: B
Rationale: Tracheal deviation is a late and life-threatening sign of a tension pneumothorax.
It occurs as pressure builds in the pleural space, shifting the mediastinum toward the
healthy lung. Immediate needle decompression or chest tube insertion is required to save
the patient’s life.
