NUR209 Exam 1 Medical-Surgical Nursing II Exam 1 Questions and
Answers and Explanations | Latest - Fortis
1. A nurse is assessing a client with left-sided heart failure. Which of the
following findings should the nurse expect?
• A. Jugular venous distension
• B. Crackles in the lungs
• C. Dependent edema
• D. Ascites
Answer: B
Explanation: Left-sided heart failure results in pulmonary congestion, leading to
symptoms like crackles, dyspnea, and orthopnea. Jugular venous distension, edema, and
ascites are signs of right-sided heart failure.
2. A patient’s ABG results are pH 7.30, PaCO2 55 mmHg, and HCO3 24 mEq/L.
How should the nurse interpret these results?
• A. Respiratory acidosis
• B. Metabolic acidosis
• C. Metabolic alkalosis
• D. Respiratory alkalosis
Answer: A
,Explanation: The pH is low (acidosis) and the PaCO2 is high (respiratory cause), indicating
respiratory acidosis.
3. Which medication is considered the gold standard for the initial treatment of
an acute asthma attack?
• A. Albuterol
• B. Salmeterol
• C. Fluticasone
• D. Montelukast
Answer: A
Explanation: Albuterol is a short-acting beta-2 agonist (SABA) used as a rescue medication
for rapid bronchodilation.
4. A nurse is monitoring a client receiving a blood transfusion. Which action
should the nurse take first if a hemolytic reaction is suspected?
• A. Slow the infusion rate
• B. Notify the provider
• C. Stop the infusion
• D. Administer diphenhydramine
Answer: C
Explanation: The priority action is to stop the infusion immediately to prevent further
exposure to the incompatible blood.
,5. Which of the following ECG changes is most characteristic of hypokalemia?
• A. Tall, peaked T waves
• B. Presence of U waves
• C. Widened QRS complex
• D. Shortened QT interval
Answer: B
Explanation: Hypokalemia typically causes flattened T waves and the appearance of U
waves on an ECG.
6. A client with Type 1 Diabetes is found unconscious and clammy. The nurse
suspects hypoglycemia. What is the priority action?
• A. Administer 15g of oral glucose
• B. Check a hemoglobin A1c level
• C. Administer Glucagon IM or SQ
• D. Call the family
Answer: C
Explanation: For an unconscious patient with suspected hypoglycemia, parenteral
glucagon or IV dextrose is required since they cannot safely swallow.
7. What is the primary goal of oxygen therapy for a client with COPD?
• A. Maintain SpO2 at 100%
• B. Increase PaCO2 levels
, • C. Maintain SpO2 between 88% and 92%
• D. Eliminate the hypoxic drive
Answer: C
Explanation: In COPD, excessive oxygen can suppress the hypoxic drive; therefore, a lower
target range of 88-92% is often appropriate.
8. A client is prescribed Warfarin. Which lab value must the nurse monitor to
evaluate the effectiveness of this therapy?
• A. aPTT
• B. Platelet count
• C. Hemoglobin
• D. INR
Answer: D
Explanation: The International Normalized Ratio (INR) is the standard lab used to monitor
the therapeutic effect of Warfarin.
9. A nurse is caring for a patient post-thyroidectomy. Which assessment finding
is most concerning?
• A. Sore throat
• B. Laryngeal stridor
• C. Hoarseness
• D. Incisional pain
Answers and Explanations | Latest - Fortis
1. A nurse is assessing a client with left-sided heart failure. Which of the
following findings should the nurse expect?
• A. Jugular venous distension
• B. Crackles in the lungs
• C. Dependent edema
• D. Ascites
Answer: B
Explanation: Left-sided heart failure results in pulmonary congestion, leading to
symptoms like crackles, dyspnea, and orthopnea. Jugular venous distension, edema, and
ascites are signs of right-sided heart failure.
2. A patient’s ABG results are pH 7.30, PaCO2 55 mmHg, and HCO3 24 mEq/L.
How should the nurse interpret these results?
• A. Respiratory acidosis
• B. Metabolic acidosis
• C. Metabolic alkalosis
• D. Respiratory alkalosis
Answer: A
,Explanation: The pH is low (acidosis) and the PaCO2 is high (respiratory cause), indicating
respiratory acidosis.
3. Which medication is considered the gold standard for the initial treatment of
an acute asthma attack?
• A. Albuterol
• B. Salmeterol
• C. Fluticasone
• D. Montelukast
Answer: A
Explanation: Albuterol is a short-acting beta-2 agonist (SABA) used as a rescue medication
for rapid bronchodilation.
4. A nurse is monitoring a client receiving a blood transfusion. Which action
should the nurse take first if a hemolytic reaction is suspected?
• A. Slow the infusion rate
• B. Notify the provider
• C. Stop the infusion
• D. Administer diphenhydramine
Answer: C
Explanation: The priority action is to stop the infusion immediately to prevent further
exposure to the incompatible blood.
,5. Which of the following ECG changes is most characteristic of hypokalemia?
• A. Tall, peaked T waves
• B. Presence of U waves
• C. Widened QRS complex
• D. Shortened QT interval
Answer: B
Explanation: Hypokalemia typically causes flattened T waves and the appearance of U
waves on an ECG.
6. A client with Type 1 Diabetes is found unconscious and clammy. The nurse
suspects hypoglycemia. What is the priority action?
• A. Administer 15g of oral glucose
• B. Check a hemoglobin A1c level
• C. Administer Glucagon IM or SQ
• D. Call the family
Answer: C
Explanation: For an unconscious patient with suspected hypoglycemia, parenteral
glucagon or IV dextrose is required since they cannot safely swallow.
7. What is the primary goal of oxygen therapy for a client with COPD?
• A. Maintain SpO2 at 100%
• B. Increase PaCO2 levels
, • C. Maintain SpO2 between 88% and 92%
• D. Eliminate the hypoxic drive
Answer: C
Explanation: In COPD, excessive oxygen can suppress the hypoxic drive; therefore, a lower
target range of 88-92% is often appropriate.
8. A client is prescribed Warfarin. Which lab value must the nurse monitor to
evaluate the effectiveness of this therapy?
• A. aPTT
• B. Platelet count
• C. Hemoglobin
• D. INR
Answer: D
Explanation: The International Normalized Ratio (INR) is the standard lab used to monitor
the therapeutic effect of Warfarin.
9. A nurse is caring for a patient post-thyroidectomy. Which assessment finding
is most concerning?
• A. Sore throat
• B. Laryngeal stridor
• C. Hoarseness
• D. Incisional pain
