NUR 201 Final Exam Fortis |
Medical-Surgical Nursing I Final Exam |
Questions & Correct Answers | Already
Graded A+
1. A 68-year-old patient with congestive heart failure reports sudden weight gain of 4 lb in 2
days and increased shortness of breath. What is the nurse’s best first action?
A. Restrict oral fluids. B. Notify the provider. C. Assess lung sounds and oxygen
saturation. D. Give a diuretic.
Answer: C
Rationale: Assessments come first to determine severity (lung sounds/O₂ sat) before
interventions or notification.
2. Which finding best indicates effective pain control after morphine administration?
A. Patient sleeping. B. Respiratory rate 10 breaths/min. C. Patient reports pain 2/10 and
is engaged in conversation. D. Pupils constricted.
Answer: C
Rationale: Pain score and functioning demonstrate analgesic effectiveness; RR of 10
suggests possible respiratory depression.
3. A patient on heparin has aPTT above therapeutic range. The nurse should:
A. Increase heparin rate. B. Hold heparin and notify provider. C. Give protamine sulfate
immediately. D. Continue and recheck aPTT tomorrow.
Answer: B
Rationale: Elevated aPTT risks bleeding; hold and notify provider for orders; reversal
given per orders if bleeding.
4. Which sign is earliest indicator of hypoxia?
A. Cyanosis. B. Restlessness and confusion. C. Bradycardia. D. Hypotension.
Answer: B
, Rationale: Neuro changes (restlessness/confusion) occur early; cyanosis is a late sign.
5. The normal range for serum potassium is:
A. 2.5–3.5 mEq/L. B. 3.5–5.0 mEq/L. C. 5.0–6.5 mEq/L. D. 1.5–2.5 mEq/L.
Answer: B
Rationale: Standard reference range is 3.5–5.0 mEq/L.
6. A patient with diabetic ketoacidosis has K+ 3.4 mEq/L. The nurse expects:
A. Give IV insulin bolus immediately. B. Hold potassium and start insulin. C. Administer
potassium replacement before insulin. D. No change in plan.
Answer: C
Rationale: Insulin drives K+ into cells and can worsen hypokalemia—replace potassium
before giving insulin if low.
7. What PPE is required when caring for a patient with C. difficile?
A. Standard precautions only. B. Gloves and gown. C. N95 respirator. D. Face shield
only.
Answer: B
Rationale: Contact precautions (gloves and gown) prevent transmission; hand hygiene
with soap and water is required.
8. A postoperative patient’s wound edge pulls apart with viscera visible. The nurse should:
A. Attempt to return organs to the abdomen. B. Cover with sterile saline-moistened
dressing and notify surgeon. C. Apply sterile dry dressing and call family. D. Place
patient in Trendelenburg position.
Answer: B
Rationale: Evisceration requires sterile, moist dressing to protect tissues and urgent
surgical evaluation.
9. Best intervention to prevent atelectasis in a postoperative patient:
A. Encourage deep breathing and use of incentive spirometer. B. Keep patient supine.
C. Limit analgesics. D. Encourage only coughing.
Answer: A
Rationale: Deep breathing and incentive spirometry promote lung expansion and
alveolar recruitment.
10.The nurse suspects hypovolemia. Which assessment finding supports this?
A. Bounding pulse and elevated JVD. B. Orthostatic hypotension and flat neck veins. C.
Slow capillary refill and dependent edema. D. Increased urine output.
Answer: B
Rationale: Hypovolemia causes orthostatic hypotension and decreased venous filling
(flat neck veins).
,11.A patient receiving blood transfusion develops itching and hives. Nurse action:
A. Stop the transfusion and notify provider. B. Slow the transfusion and monitor. C.
Continue transfusion and give antihistamine later. D. Increase rate to finish quickly.
Answer: A
Rationale: Allergic reaction: stop transfusion, maintain IV with saline, notify provider.
12.The most appropriate site for IM injection in an adult is:
A. Deltoid for large volumes (5 mL). B. Ventrogluteal for deep IM of up to 3 mL. C.
Dorsogluteal for infants. D. Vastus lateralis for adults only.
Answer: B
Rationale: Ventrogluteal is preferred for deep IM injections due to fewer nerves and
muscles; deltoid for small volumes.
13.A patient with chronic obstructive pulmonary disease (COPD) uses home O₂. Which
intervention is important?
A. Set O₂ at 6 L/min. B. Encourage smoking to prevent withdrawal. C. Use
humidification and avoid open flames. D. Restrict activity to conserve O₂.
Answer: C
Rationale: Humidification prevents mucosal dryness; oxygen is a fire risk—avoid open
flames and smoking.
14.The nurse auscultates crackles in the bases after IV fluid bolus. The priority is to:
A. Increase fluid infusion. B. Slow/stop IV and reassess lung sounds and vital signs. C.
Encourage coughing only. D. Notify physical therapy.
Answer: B
Rationale: Crackles may indicate fluid overload—stop or slow infusion and reassess.
15.A patient with Parkinson’s disease has difficulty swallowing. Best nursing action to
reduce aspiration:
A. Offer thin liquids only. B. Tilt head back during swallowing. C. Provide small bites,
tuck chin, and supervise meals. D. Feed quickly to reduce overall time.
Answer: C
Rationale: Small bites and chin-tuck technique improve swallowing safety and reduce
aspiration risk.
16.Which lab verifies kidney function and is most useful for drug dosing?
A. ALT. B. BUN. C. Creatinine clearance or serum creatinine and GFR. D. Troponin.
Answer: C
Rationale: Creatinine clearance/serum creatinine and GFR reflect renal function for
dosing adjustments.
17.Best action for a confused patient trying to remove IV:
A. Restrain the patient immediately. B. Reorient, explain purpose, and distract or use
sitter; if necessary apply soft restraints per policy. C. Ignore the behavior. D. Pull IV and
, allow the patient to walk.
Answer: B
Rationale: Use least restrictive measures first (reorientation, supervision); restraints
only if necessary and per protocol.
18.A patient with hyperkalemia (K+ 6.8 mEq/L) is symptomatic. Immediate treatment:
A. Administer furosemide only. B. Give IV calcium gluconate, then insulin with dextrose.
C. Give oral potassium binder only. D. Start potassium infusion.
Answer: B
Rationale: Calcium stabilizes cardiac membranes; insulin shifts K+
intracellularly—urgent stabilization is needed.
19.Which electrolyte imbalance is associated with prolonged vomiting?
A. Metabolic acidosis and hyperkalemia. B. Metabolic alkalosis and hypokalemia. C.
Respiratory acidosis and hypernatremia. D. Metabolic alkalosis and hyperkalemia.
Answer: B
Rationale: Loss of gastric acid causes metabolic alkalosis; volume loss and renal
adjustments often cause hypokalemia.
20.A patient has an order for PRN morphine for pain. The nurse should assess:
A. Pain rating, respiratory rate, sedation level, allergies. B. Blood glucose only. C. BP
only. D. Temperature and bowel sounds only.
Answer: A
Rationale: Assess pain, RR, sedation, and allergies/safety before administering
opioids.
21.Which action prevents catheter-associated urinary tract infection (CAUTI)?
A. Routine daily catheter irrigation. B. Aseptic insertion and remove catheter as soon as
possible. C. Change catheter weekly. D. Disconnect catheter tubing to empty bag
bed-side.
Answer: B
Rationale: Aseptic insertion and early removal reduce CAUTI risk; routine irrigation and
disconnections increase risk.
22.A patient with heart failure has BNP significantly elevated. BNP indicates:
A. Liver failure. B. Cardiac muscle stretch and severity of heart failure. C. Renal
function. D. Infection.
Answer: B
Rationale: BNP is released in response to ventricular stretch—used to assess heart
failure severity.
23.Which is the priority for a patient with suspected stroke?
A. Administer analgesic. B. Determine time of onset and activate stroke protocol. C.
Start physical therapy. D. Give clopidogrel immediately.
Medical-Surgical Nursing I Final Exam |
Questions & Correct Answers | Already
Graded A+
1. A 68-year-old patient with congestive heart failure reports sudden weight gain of 4 lb in 2
days and increased shortness of breath. What is the nurse’s best first action?
A. Restrict oral fluids. B. Notify the provider. C. Assess lung sounds and oxygen
saturation. D. Give a diuretic.
Answer: C
Rationale: Assessments come first to determine severity (lung sounds/O₂ sat) before
interventions or notification.
2. Which finding best indicates effective pain control after morphine administration?
A. Patient sleeping. B. Respiratory rate 10 breaths/min. C. Patient reports pain 2/10 and
is engaged in conversation. D. Pupils constricted.
Answer: C
Rationale: Pain score and functioning demonstrate analgesic effectiveness; RR of 10
suggests possible respiratory depression.
3. A patient on heparin has aPTT above therapeutic range. The nurse should:
A. Increase heparin rate. B. Hold heparin and notify provider. C. Give protamine sulfate
immediately. D. Continue and recheck aPTT tomorrow.
Answer: B
Rationale: Elevated aPTT risks bleeding; hold and notify provider for orders; reversal
given per orders if bleeding.
4. Which sign is earliest indicator of hypoxia?
A. Cyanosis. B. Restlessness and confusion. C. Bradycardia. D. Hypotension.
Answer: B
, Rationale: Neuro changes (restlessness/confusion) occur early; cyanosis is a late sign.
5. The normal range for serum potassium is:
A. 2.5–3.5 mEq/L. B. 3.5–5.0 mEq/L. C. 5.0–6.5 mEq/L. D. 1.5–2.5 mEq/L.
Answer: B
Rationale: Standard reference range is 3.5–5.0 mEq/L.
6. A patient with diabetic ketoacidosis has K+ 3.4 mEq/L. The nurse expects:
A. Give IV insulin bolus immediately. B. Hold potassium and start insulin. C. Administer
potassium replacement before insulin. D. No change in plan.
Answer: C
Rationale: Insulin drives K+ into cells and can worsen hypokalemia—replace potassium
before giving insulin if low.
7. What PPE is required when caring for a patient with C. difficile?
A. Standard precautions only. B. Gloves and gown. C. N95 respirator. D. Face shield
only.
Answer: B
Rationale: Contact precautions (gloves and gown) prevent transmission; hand hygiene
with soap and water is required.
8. A postoperative patient’s wound edge pulls apart with viscera visible. The nurse should:
A. Attempt to return organs to the abdomen. B. Cover with sterile saline-moistened
dressing and notify surgeon. C. Apply sterile dry dressing and call family. D. Place
patient in Trendelenburg position.
Answer: B
Rationale: Evisceration requires sterile, moist dressing to protect tissues and urgent
surgical evaluation.
9. Best intervention to prevent atelectasis in a postoperative patient:
A. Encourage deep breathing and use of incentive spirometer. B. Keep patient supine.
C. Limit analgesics. D. Encourage only coughing.
Answer: A
Rationale: Deep breathing and incentive spirometry promote lung expansion and
alveolar recruitment.
10.The nurse suspects hypovolemia. Which assessment finding supports this?
A. Bounding pulse and elevated JVD. B. Orthostatic hypotension and flat neck veins. C.
Slow capillary refill and dependent edema. D. Increased urine output.
Answer: B
Rationale: Hypovolemia causes orthostatic hypotension and decreased venous filling
(flat neck veins).
,11.A patient receiving blood transfusion develops itching and hives. Nurse action:
A. Stop the transfusion and notify provider. B. Slow the transfusion and monitor. C.
Continue transfusion and give antihistamine later. D. Increase rate to finish quickly.
Answer: A
Rationale: Allergic reaction: stop transfusion, maintain IV with saline, notify provider.
12.The most appropriate site for IM injection in an adult is:
A. Deltoid for large volumes (5 mL). B. Ventrogluteal for deep IM of up to 3 mL. C.
Dorsogluteal for infants. D. Vastus lateralis for adults only.
Answer: B
Rationale: Ventrogluteal is preferred for deep IM injections due to fewer nerves and
muscles; deltoid for small volumes.
13.A patient with chronic obstructive pulmonary disease (COPD) uses home O₂. Which
intervention is important?
A. Set O₂ at 6 L/min. B. Encourage smoking to prevent withdrawal. C. Use
humidification and avoid open flames. D. Restrict activity to conserve O₂.
Answer: C
Rationale: Humidification prevents mucosal dryness; oxygen is a fire risk—avoid open
flames and smoking.
14.The nurse auscultates crackles in the bases after IV fluid bolus. The priority is to:
A. Increase fluid infusion. B. Slow/stop IV and reassess lung sounds and vital signs. C.
Encourage coughing only. D. Notify physical therapy.
Answer: B
Rationale: Crackles may indicate fluid overload—stop or slow infusion and reassess.
15.A patient with Parkinson’s disease has difficulty swallowing. Best nursing action to
reduce aspiration:
A. Offer thin liquids only. B. Tilt head back during swallowing. C. Provide small bites,
tuck chin, and supervise meals. D. Feed quickly to reduce overall time.
Answer: C
Rationale: Small bites and chin-tuck technique improve swallowing safety and reduce
aspiration risk.
16.Which lab verifies kidney function and is most useful for drug dosing?
A. ALT. B. BUN. C. Creatinine clearance or serum creatinine and GFR. D. Troponin.
Answer: C
Rationale: Creatinine clearance/serum creatinine and GFR reflect renal function for
dosing adjustments.
17.Best action for a confused patient trying to remove IV:
A. Restrain the patient immediately. B. Reorient, explain purpose, and distract or use
sitter; if necessary apply soft restraints per policy. C. Ignore the behavior. D. Pull IV and
, allow the patient to walk.
Answer: B
Rationale: Use least restrictive measures first (reorientation, supervision); restraints
only if necessary and per protocol.
18.A patient with hyperkalemia (K+ 6.8 mEq/L) is symptomatic. Immediate treatment:
A. Administer furosemide only. B. Give IV calcium gluconate, then insulin with dextrose.
C. Give oral potassium binder only. D. Start potassium infusion.
Answer: B
Rationale: Calcium stabilizes cardiac membranes; insulin shifts K+
intracellularly—urgent stabilization is needed.
19.Which electrolyte imbalance is associated with prolonged vomiting?
A. Metabolic acidosis and hyperkalemia. B. Metabolic alkalosis and hypokalemia. C.
Respiratory acidosis and hypernatremia. D. Metabolic alkalosis and hyperkalemia.
Answer: B
Rationale: Loss of gastric acid causes metabolic alkalosis; volume loss and renal
adjustments often cause hypokalemia.
20.A patient has an order for PRN morphine for pain. The nurse should assess:
A. Pain rating, respiratory rate, sedation level, allergies. B. Blood glucose only. C. BP
only. D. Temperature and bowel sounds only.
Answer: A
Rationale: Assess pain, RR, sedation, and allergies/safety before administering
opioids.
21.Which action prevents catheter-associated urinary tract infection (CAUTI)?
A. Routine daily catheter irrigation. B. Aseptic insertion and remove catheter as soon as
possible. C. Change catheter weekly. D. Disconnect catheter tubing to empty bag
bed-side.
Answer: B
Rationale: Aseptic insertion and early removal reduce CAUTI risk; routine irrigation and
disconnections increase risk.
22.A patient with heart failure has BNP significantly elevated. BNP indicates:
A. Liver failure. B. Cardiac muscle stretch and severity of heart failure. C. Renal
function. D. Infection.
Answer: B
Rationale: BNP is released in response to ventricular stretch—used to assess heart
failure severity.
23.Which is the priority for a patient with suspected stroke?
A. Administer analgesic. B. Determine time of onset and activate stroke protocol. C.
Start physical therapy. D. Give clopidogrel immediately.
