PNR 201/PNR201 Final Exam V3 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient who is 48 hours postoperative following abdominal surgery.
Which finding would most likely indicate the development of a wound infection?
A. A temperature of 99.2°F (37.3°C)
B. Purulent drainage from the incision site
C. Serosanguinous drainage on the dressing
D. Pain reported as a 4 on a 10-point scale
Correct Answer: B
Explanation: Purulent drainage is a classic sign of infection because it contains white
blood cells, dead tissue, and bacteria. While a low-grade fever or mild pain can occur
postoperatively, they are less definitive for infection than pus. Serosanguinous drainage is
actually expected in the early stages of wound healing for surgical incisions.
2. The nurse is collecting data from a patient diagnosed with right-sided heart failure. Which
clinical manifestation should the nurse expect to find?
A. Pulmonary crackles
B. Dyspnea on exertion
C. Orthopnea
D. Peripheral edema
,Correct Answer: D
Explanation: Right-sided heart failure leads to systemic venous congestion because the
right ventricle is unable to pump blood effectively to the lungs. This backup results in fluid
accumulation in the periphery, leading to dependent edema and jugular venous distention.
In contrast, crackles, dyspnea, and orthopnea are hallmark signs of left-sided heart failure.
3. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen. Why is it
crucial for the nurse to keep the oxygen flow rate at a low level (usually 1-2 L/min)?
A. High flow rates increase the risk of oxygen toxicity.
B. Low flow oxygen prevents the drying of the nasal mucosa.
C. Higher levels of oxygen can eliminate the patient’s stimulus to breathe.
D. The patient’s lungs cannot process higher concentrations of oxygen.
Correct Answer: C
Explanation: In many patients with COPD, the primary stimulus for breathing is low
arterial oxygen levels rather than high carbon dioxide levels. Providing high concentrations
of oxygen can negate this ‘hypoxic drive,’ potentially leading to respiratory hypoventilation
or arrest. The nurse must balance oxygenation with the need to maintain the natural drive
to breathe.
4. When assessing a patient with a suspected deep vein thrombosis (DVT) in the right leg,
which finding requires immediate notification of the healthcare provider?
A. Calf tenderness
,B. Slight swelling of the right ankle
C. Warmth over the affected area
D. Sudden onset of shortness of breath
Correct Answer: D
Explanation: The sudden onset of shortness of breath suggests that a piece of the
thrombus has broken off and traveled to the lungs, causing a pulmonary embolism. This is a
life-threatening emergency that requires immediate medical intervention to prevent
respiratory or cardiac collapse. While calf tenderness and warmth are common signs of
DVT, they are not as immediately critical as respiratory distress.
5. A nurse is educating a patient newly diagnosed with Type 1 Diabetes Mellitus about
hypoglycemia. Which symptom should the nurse instruct the patient to report as a common
sign of low blood sugar?
A. Extreme thirst
B. Frequent urination
C. Nervousness and tremors
D. Fruity-smelling breath
Correct Answer: C
Explanation: Hypoglycemia triggers the sympathetic nervous system, leading to symptoms
like tremors, nervousness, diaphoresis, and tachycardia. Conversely, thirst, frequent
, urination, and fruity breath are classic signs of hyperglycemia or ketoacidosis. Educating
the patient on recognizing these early warning signs is vital for preventing severe
hypoglycemic episodes.
6. A patient is admitted with a diagnosis of acute pancreatitis. Which laboratory result would
the nurse expect to see elevated?
A. Serum potassium
B. Serum amylase
C. Hemoglobin
D. Serum calcium
Correct Answer: B
Explanation: Serum amylase and lipase levels typically rise significantly within 24 hours of
the onset of acute pancreatitis. These enzymes are released into the bloodstream as a result
of inflammation and damage to the pancreatic acinar cells. Monitoring these levels helps
clinicians confirm the diagnosis and track the progression of the disease.
7. The nurse is providing discharge instructions to a patient who had a total hip arthroplasty.
Which position should the nurse instruct the patient to avoid?
A. Crossing the legs at the knees
B. Sitting in a high-seated chair
C. Keeping the legs abducted
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient who is 48 hours postoperative following abdominal surgery.
Which finding would most likely indicate the development of a wound infection?
A. A temperature of 99.2°F (37.3°C)
B. Purulent drainage from the incision site
C. Serosanguinous drainage on the dressing
D. Pain reported as a 4 on a 10-point scale
Correct Answer: B
Explanation: Purulent drainage is a classic sign of infection because it contains white
blood cells, dead tissue, and bacteria. While a low-grade fever or mild pain can occur
postoperatively, they are less definitive for infection than pus. Serosanguinous drainage is
actually expected in the early stages of wound healing for surgical incisions.
2. The nurse is collecting data from a patient diagnosed with right-sided heart failure. Which
clinical manifestation should the nurse expect to find?
A. Pulmonary crackles
B. Dyspnea on exertion
C. Orthopnea
D. Peripheral edema
,Correct Answer: D
Explanation: Right-sided heart failure leads to systemic venous congestion because the
right ventricle is unable to pump blood effectively to the lungs. This backup results in fluid
accumulation in the periphery, leading to dependent edema and jugular venous distention.
In contrast, crackles, dyspnea, and orthopnea are hallmark signs of left-sided heart failure.
3. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen. Why is it
crucial for the nurse to keep the oxygen flow rate at a low level (usually 1-2 L/min)?
A. High flow rates increase the risk of oxygen toxicity.
B. Low flow oxygen prevents the drying of the nasal mucosa.
C. Higher levels of oxygen can eliminate the patient’s stimulus to breathe.
D. The patient’s lungs cannot process higher concentrations of oxygen.
Correct Answer: C
Explanation: In many patients with COPD, the primary stimulus for breathing is low
arterial oxygen levels rather than high carbon dioxide levels. Providing high concentrations
of oxygen can negate this ‘hypoxic drive,’ potentially leading to respiratory hypoventilation
or arrest. The nurse must balance oxygenation with the need to maintain the natural drive
to breathe.
4. When assessing a patient with a suspected deep vein thrombosis (DVT) in the right leg,
which finding requires immediate notification of the healthcare provider?
A. Calf tenderness
,B. Slight swelling of the right ankle
C. Warmth over the affected area
D. Sudden onset of shortness of breath
Correct Answer: D
Explanation: The sudden onset of shortness of breath suggests that a piece of the
thrombus has broken off and traveled to the lungs, causing a pulmonary embolism. This is a
life-threatening emergency that requires immediate medical intervention to prevent
respiratory or cardiac collapse. While calf tenderness and warmth are common signs of
DVT, they are not as immediately critical as respiratory distress.
5. A nurse is educating a patient newly diagnosed with Type 1 Diabetes Mellitus about
hypoglycemia. Which symptom should the nurse instruct the patient to report as a common
sign of low blood sugar?
A. Extreme thirst
B. Frequent urination
C. Nervousness and tremors
D. Fruity-smelling breath
Correct Answer: C
Explanation: Hypoglycemia triggers the sympathetic nervous system, leading to symptoms
like tremors, nervousness, diaphoresis, and tachycardia. Conversely, thirst, frequent
, urination, and fruity breath are classic signs of hyperglycemia or ketoacidosis. Educating
the patient on recognizing these early warning signs is vital for preventing severe
hypoglycemic episodes.
6. A patient is admitted with a diagnosis of acute pancreatitis. Which laboratory result would
the nurse expect to see elevated?
A. Serum potassium
B. Serum amylase
C. Hemoglobin
D. Serum calcium
Correct Answer: B
Explanation: Serum amylase and lipase levels typically rise significantly within 24 hours of
the onset of acute pancreatitis. These enzymes are released into the bloodstream as a result
of inflammation and damage to the pancreatic acinar cells. Monitoring these levels helps
clinicians confirm the diagnosis and track the progression of the disease.
7. The nurse is providing discharge instructions to a patient who had a total hip arthroplasty.
Which position should the nurse instruct the patient to avoid?
A. Crossing the legs at the knees
B. Sitting in a high-seated chair
C. Keeping the legs abducted
