Med-Surg II Exam 4 – Fortis Medical-Surgical Nursing
Review Complete Solution Guide
SECTION 1: CRITICAL CARE & PRIORITIZATION
1. Which patient in the progressive care unit should the nurse be most
concerned about?
• A) A patient with a urinary tract infection receiving IV antibiotics
• B) A patient prescribed tPA or IV heparin who has the opportunity to
bleed
• C) A patient with a fractured tibia awaiting surgery
• D) A patient with diabetes mellitus requiring insulin
Correct Answer: B
Rationale: A patient receiving tPA (tissue plasminogen activator) or IV heparin is at
high risk for hemorrhage, which is a life-threatening complication requiring
immediate monitoring and intervention. This is a critical safety priority in the
progressive care unit .
2. Which patient on ventilator weaning should the nurse be most concerned
about?
• A) A patient who is anxious and requesting sedation
• B) A patient who has recently been extubated with decreased urinary
output
• C) A patient with a respiratory rate of 22 breaths per minute
• D) A patient with an SpO2 of 92% on room air
,Correct Answer: B
Rationale: Decreased urinary output in a recently extubated patient indicates
potential renal compromise, hypovolemia, or inadequate perfusion. This is a
critical finding that requires immediate assessment and intervention. Normal urine
output should be at least 30 mL/hour .
3. What is the priority intervention for a patient with a subarachnoid
hemorrhage and elevated intracranial pressure (ICP)?
• A) Administer aspirin immediately
• B) Check for jugular venous distension (JVD) to assess for fluid overload
• C) Place the patient in Trendelenburg position
• D) Encourage the patient to cough and deep breathe
Correct Answer: B
Rationale: In a patient with subarachnoid hemorrhage and elevated ICP, the nurse
should assess for JVD to evaluate fluid overload, which can increase ICP. If JVD is
present, the provider should be notified immediately. Fluid management is critical
in these patients .
4. How should the nurse manage a patient who is "fighting" or breathing over
the ventilator?
• A) Sedate the patient immediately with a bolus of midazolam
• B) Verbally coach the patient to coordinate breathing efforts with the
ventilator settings
• C) Increase the ventilator rate without notifying the provider
• D) Disconnect the patient from the ventilator
Correct Answer: B
Rationale: Verbal coaching helps the patient synchronize their breathing with the
,ventilator. This non-invasive approach should be attempted before considering
sedation. Fighting the vent can cause increased ICP, barotrauma, and
hemodynamic instability .
5. What should the nurse do when caring for an elderly ICU patient with new-
onset confusion who is starting to go into ICU delirium during transfer?
• A) Cancel the transfer until the patient is stable
• B) Report findings to the receiving nurse and continue the transfer
• C) Administer a sedative to calm the patient
• D) Restrain the patient to prevent injury
Correct Answer: B
Rationale: ICU delirium is a common complication in elderly patients. The priority
is to ensure a safe handoff by reporting findings to the receiving nurse while
continuing the transfer. Delaying care may compromise the patient's needs .
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 hydrates the patient and thins respiratory
secretions, making them easier to expectorate. This is a basic but effective
intervention .
, 7. A patient with sepsis and petechiae is going into multiorgan failure. What
complication is she at 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, a
condition characterized by widespread clotting and subsequent bleeding.
Petechiae may indicate this complication. DIC results from the activation of the
coagulation cascade, leading to consumption of clotting factors .
8. What are the major concerns for a patient receiving vasopressor therapy
(vasopressin)?
• A) Fluid overload and pulmonary edema
• B) Chest pain due to decreased coronary artery perfusion
• C) Severe bradycardia
• D) Hyperglycemia
Correct Answer: B
Rationale: Vasopressin is a potent vasoconstrictor that can decrease coronary
artery perfusion. If the patient complains of chest pain, this is an immediate
concern and should be reported to the provider. Vasopressors can cause
myocardial ischemia .
9. How can the nurse recognize that a patient is going into hypovolemic shock,
and what is the first action to take?
Review Complete Solution Guide
SECTION 1: CRITICAL CARE & PRIORITIZATION
1. Which patient in the progressive care unit should the nurse be most
concerned about?
• A) A patient with a urinary tract infection receiving IV antibiotics
• B) A patient prescribed tPA or IV heparin who has the opportunity to
bleed
• C) A patient with a fractured tibia awaiting surgery
• D) A patient with diabetes mellitus requiring insulin
Correct Answer: B
Rationale: A patient receiving tPA (tissue plasminogen activator) or IV heparin is at
high risk for hemorrhage, which is a life-threatening complication requiring
immediate monitoring and intervention. This is a critical safety priority in the
progressive care unit .
2. Which patient on ventilator weaning should the nurse be most concerned
about?
• A) A patient who is anxious and requesting sedation
• B) A patient who has recently been extubated with decreased urinary
output
• C) A patient with a respiratory rate of 22 breaths per minute
• D) A patient with an SpO2 of 92% on room air
,Correct Answer: B
Rationale: Decreased urinary output in a recently extubated patient indicates
potential renal compromise, hypovolemia, or inadequate perfusion. This is a
critical finding that requires immediate assessment and intervention. Normal urine
output should be at least 30 mL/hour .
3. What is the priority intervention for a patient with a subarachnoid
hemorrhage and elevated intracranial pressure (ICP)?
• A) Administer aspirin immediately
• B) Check for jugular venous distension (JVD) to assess for fluid overload
• C) Place the patient in Trendelenburg position
• D) Encourage the patient to cough and deep breathe
Correct Answer: B
Rationale: In a patient with subarachnoid hemorrhage and elevated ICP, the nurse
should assess for JVD to evaluate fluid overload, which can increase ICP. If JVD is
present, the provider should be notified immediately. Fluid management is critical
in these patients .
4. How should the nurse manage a patient who is "fighting" or breathing over
the ventilator?
• A) Sedate the patient immediately with a bolus of midazolam
• B) Verbally coach the patient to coordinate breathing efforts with the
ventilator settings
• C) Increase the ventilator rate without notifying the provider
• D) Disconnect the patient from the ventilator
Correct Answer: B
Rationale: Verbal coaching helps the patient synchronize their breathing with the
,ventilator. This non-invasive approach should be attempted before considering
sedation. Fighting the vent can cause increased ICP, barotrauma, and
hemodynamic instability .
5. What should the nurse do when caring for an elderly ICU patient with new-
onset confusion who is starting to go into ICU delirium during transfer?
• A) Cancel the transfer until the patient is stable
• B) Report findings to the receiving nurse and continue the transfer
• C) Administer a sedative to calm the patient
• D) Restrain the patient to prevent injury
Correct Answer: B
Rationale: ICU delirium is a common complication in elderly patients. The priority
is to ensure a safe handoff by reporting findings to the receiving nurse while
continuing the transfer. Delaying care may compromise the patient's needs .
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 hydrates the patient and thins respiratory
secretions, making them easier to expectorate. This is a basic but effective
intervention .
, 7. A patient with sepsis and petechiae is going into multiorgan failure. What
complication is she at 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, a
condition characterized by widespread clotting and subsequent bleeding.
Petechiae may indicate this complication. DIC results from the activation of the
coagulation cascade, leading to consumption of clotting factors .
8. What are the major concerns for a patient receiving vasopressor therapy
(vasopressin)?
• A) Fluid overload and pulmonary edema
• B) Chest pain due to decreased coronary artery perfusion
• C) Severe bradycardia
• D) Hyperglycemia
Correct Answer: B
Rationale: Vasopressin is a potent vasoconstrictor that can decrease coronary
artery perfusion. If the patient complains of chest pain, this is an immediate
concern and should be reported to the provider. Vasopressors can cause
myocardial ischemia .
9. How can the nurse recognize that a patient is going into hypovolemic shock,
and what is the first action to take?
