Med Surg II Exam 4, Fortis Med/surg 2 Exam 4 with
Complete Solution 2026
SECTION 1: CRITICAL CARE & PRIORITIZATION
1. A nurse is caring for a patient prescribed tPA (tissue plasminogen activator)
for an acute ischemic stroke. Which finding requires immediate intervention?
• A) Blood pressure 145/90 mmHg
• B) Change in level of consciousness
• C) Heart rate 88 beats/min
• D) Respiratory rate 16 breaths/min
Correct Answer: B
Rationale: tPA carries a high risk of intracranial hemorrhage. A change in level of
consciousness (LOC) is a critical indicator of possible bleeding and requires
immediate intervention. This is a life-threatening complication that must be
reported to the provider immediately .
2. A patient who was extubated 2 hours ago has a urinary output of 20 mL over
the past hour. Which action should the nurse take FIRST?
• A) Notify the healthcare provider
• B) Increase the IV fluid rate
• C) Insert a Foley catheter
• D) Assess for bladder distension
Correct Answer: B
Rationale: Urine output <30 mL/hr indicates oliguria and potential hypovolemia.
,The nurse should first increase IV fluids to improve renal perfusion. If output does
not improve, further assessment and provider notification are needed .
3. A patient with increased intracranial pressure (ICP) has jugular venous
distension (JVD). Which action should the nurse take?
• A) Notify the healthcare provider immediately
• B) Elevate the head of the bed to 90 degrees
• C) Apply cold compresses to the neck
• D) Administer a diuretic
Correct Answer: A
Rationale: JVD in a patient with increased ICP indicates fluid overload, which can
worsen ICP. The provider should be notified immediately for potential fluid
restriction or diuretic therapy .
4. A patient is "fighting" the ventilator. What is the nurse's priority action?
• A) Administer a sedative immediately
• B) Verbally coach the patient to coordinate breathing with the ventilator
• C) Increase the ventilator rate
• D) Disconnect the patient from the ventilator
Correct Answer: B
Rationale: Verbal coaching helps the patient synchronize breathing with the
ventilator. This non-invasive intervention should be attempted before sedation to
prevent complications like increased ICP, barotrauma, and hemodynamic
instability .
,5. An elderly ICU patient develops new-onset confusion during transfer. What
should the nurse do?
• A) Cancel the transfer until the patient is stable
• B) Report findings to the receiving nurse and continue the transfer
• C) Administer a sedative
• D) Restrain the patient
Correct Answer: B
Rationale: ICU delirium is common in elderly patients. The priority is a safe
handoff—reporting findings to the receiving nurse while continuing the transfer to
avoid delaying necessary care .
6. What is the BEST intervention for a patient with thick respiratory secretions?
• A) Suction the patient every hour
• B) Increase fluid intake
• C) Administer a mucolytic
• D) Perform chest physiotherapy
Correct Answer: B
Rationale: Increasing fluid intake is the most effective way to thin respiratory
secretions, facilitating expectoration and improving airway clearance .
7. A patient with sepsis and petechiae is developing multiorgan failure. Which
complication is the patient at highest risk for?
• A) Acute respiratory distress syndrome (ARDS)
• B) Disseminated Intravascular Coagulation (DIC)
• C) Pulmonary embolism
, • D) Myocardial infarction
Correct Answer: B
Rationale: Sepsis with multiorgan failure places the patient at high risk for DIC,
characterized by widespread clotting and subsequent bleeding. Petechiae may
indicate this complication .
8. A patient receiving vasopressin (vasopressor) therapy reports chest pain.
What is the priority action?
• A) Administer nitroglycerin
• B) Notify the healthcare provider immediately
• C) Decrease the vasopressin infusion rate
• D) Administer morphine for pain
Correct Answer: B
Rationale: Vasopressin is a potent vasoconstrictor that can decrease coronary
artery perfusion. Chest pain indicates possible myocardial ischemia and requires
immediate provider notification .
9. A patient in hypovolemic shock has cool, clammy skin. What is the nurse's
priority action?
• A) Administer IV fluids
• B) Initiate oxygen therapy via non-rebreather mask
• C) Apply warm blankets
• D) Obtain a blood pressure reading
Correct Answer: B
Rationale: In hypovolemic shock, the priority is to improve tissue perfusion and
Complete Solution 2026
SECTION 1: CRITICAL CARE & PRIORITIZATION
1. A nurse is caring for a patient prescribed tPA (tissue plasminogen activator)
for an acute ischemic stroke. Which finding requires immediate intervention?
• A) Blood pressure 145/90 mmHg
• B) Change in level of consciousness
• C) Heart rate 88 beats/min
• D) Respiratory rate 16 breaths/min
Correct Answer: B
Rationale: tPA carries a high risk of intracranial hemorrhage. A change in level of
consciousness (LOC) is a critical indicator of possible bleeding and requires
immediate intervention. This is a life-threatening complication that must be
reported to the provider immediately .
2. A patient who was extubated 2 hours ago has a urinary output of 20 mL over
the past hour. Which action should the nurse take FIRST?
• A) Notify the healthcare provider
• B) Increase the IV fluid rate
• C) Insert a Foley catheter
• D) Assess for bladder distension
Correct Answer: B
Rationale: Urine output <30 mL/hr indicates oliguria and potential hypovolemia.
,The nurse should first increase IV fluids to improve renal perfusion. If output does
not improve, further assessment and provider notification are needed .
3. A patient with increased intracranial pressure (ICP) has jugular venous
distension (JVD). Which action should the nurse take?
• A) Notify the healthcare provider immediately
• B) Elevate the head of the bed to 90 degrees
• C) Apply cold compresses to the neck
• D) Administer a diuretic
Correct Answer: A
Rationale: JVD in a patient with increased ICP indicates fluid overload, which can
worsen ICP. The provider should be notified immediately for potential fluid
restriction or diuretic therapy .
4. A patient is "fighting" the ventilator. What is the nurse's priority action?
• A) Administer a sedative immediately
• B) Verbally coach the patient to coordinate breathing with the ventilator
• C) Increase the ventilator rate
• D) Disconnect the patient from the ventilator
Correct Answer: B
Rationale: Verbal coaching helps the patient synchronize breathing with the
ventilator. This non-invasive intervention should be attempted before sedation to
prevent complications like increased ICP, barotrauma, and hemodynamic
instability .
,5. An elderly ICU patient develops new-onset confusion during transfer. What
should the nurse do?
• A) Cancel the transfer until the patient is stable
• B) Report findings to the receiving nurse and continue the transfer
• C) Administer a sedative
• D) Restrain the patient
Correct Answer: B
Rationale: ICU delirium is common in elderly patients. The priority is a safe
handoff—reporting findings to the receiving nurse while continuing the transfer to
avoid delaying necessary care .
6. What is the BEST intervention for a patient with thick respiratory secretions?
• A) Suction the patient every hour
• B) Increase fluid intake
• C) Administer a mucolytic
• D) Perform chest physiotherapy
Correct Answer: B
Rationale: Increasing fluid intake is the most effective way to thin respiratory
secretions, facilitating expectoration and improving airway clearance .
7. A patient with sepsis and petechiae is developing multiorgan failure. Which
complication is the patient at highest risk for?
• A) Acute respiratory distress syndrome (ARDS)
• B) Disseminated Intravascular Coagulation (DIC)
• C) Pulmonary embolism
, • D) Myocardial infarction
Correct Answer: B
Rationale: Sepsis with multiorgan failure places the patient at high risk for DIC,
characterized by widespread clotting and subsequent bleeding. Petechiae may
indicate this complication .
8. A patient receiving vasopressin (vasopressor) therapy reports chest pain.
What is the priority action?
• A) Administer nitroglycerin
• B) Notify the healthcare provider immediately
• C) Decrease the vasopressin infusion rate
• D) Administer morphine for pain
Correct Answer: B
Rationale: Vasopressin is a potent vasoconstrictor that can decrease coronary
artery perfusion. Chest pain indicates possible myocardial ischemia and requires
immediate provider notification .
9. A patient in hypovolemic shock has cool, clammy skin. What is the nurse's
priority action?
• A) Administer IV fluids
• B) Initiate oxygen therapy via non-rebreather mask
• C) Apply warm blankets
• D) Obtain a blood pressure reading
Correct Answer: B
Rationale: In hypovolemic shock, the priority is to improve tissue perfusion and
