NURS 120 | NURS120 Exam 2: Med Surg 1 - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a patient with suspected right-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Crackles in the lungs
B. Frothy pink sputum
C. Orthopnea
D. Jugular venous distention
Correct Answer: D
Rationale: Right-sided heart failure leads to systemic venous congestion because the right
ventricle cannot pump efficiently. This results in observable jugular venous distention and
peripheral edema in the lower extremities. Options A, C, and D are characteristic of left-
sided heart failure where blood backs up into the pulmonary system. Nurses must
accurately differentiate these signs to provide appropriate systemic or pulmonary
interventions. Monitoring for these symptoms helps in assessing the severity of the
patient’s fluid volume overload.
2. A patient with asthma is prescribed albuterol via a metered-dose inhaler. Which
instruction should the nurse emphasize during teaching?
A. Rinse the mouth immediately after use to prevent thrush.
B. Wait at least one minute between puffs of the medication.
C. Use this medication only when you feel short of breath.
D. Take this medication daily at the same time every morning.
Correct Answer: B
Rationale: Albuterol is a short-acting beta-agonist used as a rescue medication to provide
rapid bronchodilation. Waiting one minute between puffs allows the first dose to open the
airways for better penetration of the second dose. Rinsing the mouth is specifically
required for inhaled corticosteroids, not for albuterol. It is not a maintenance drug and
should be used according to the prescribed rescue protocol. Proper technique ensures that
the maximum amount of medication reaches the smaller airways in the lungs.
3. Which laboratory value is most critical for the nurse to monitor in a patient receiving
Furosemide for hypertension?
A. Serum sodium level
B. Serum calcium level
,C. Serum potassium level
D. Serum magnesium level
Correct Answer: C
Rationale: Furosemide is a loop diuretic that promotes the excretion of water, sodium, and
potassium. Hypokalemia is a common and potentially dangerous side effect that can lead to
cardiac dysrhythmias. The nurse must monitor potassium levels closely to prevent
complications associated with electrolyte imbalance. Patients are often encouraged to eat
potassium-rich foods or take supplements while on this medication. Regular blood tests are
necessary to ensure the patient remains within the therapeutic range of 3.5 to 5.0 mEq/L.
4. A nurse is teaching a patient about the DASH diet to manage hypertension. Which food
choice indicates the patient understands the teaching?
A. Canned vegetable soup for lunch
B. Fresh steamed broccoli and brown rice
C. A deli turkey sandwich with pickles
D. Red meat three times per week
Correct Answer: B
Rationale: The DASH diet focuses on high fiber, low sodium, and increased intake of fruits
and vegetables. Fresh vegetables and whole grains like brown rice are core components of
this heart-healthy eating plan. Canned soups and deli meats are typically very high in
sodium and should be avoided. The diet also recommends limiting red meats and sweets to
reduce saturated fat intake. Educating patients on reading food labels is essential for
maintaining a low-sodium lifestyle.
5. A patient is admitted with an exacerbation of COPD. The nurse notes the patient is using
pursed-lip breathing. What is the primary purpose of this technique?
A. To increase the rate of respirations
B. To decrease the amount of oxygen needed
C. To strengthen the diaphragm muscle
D. To promote carbon dioxide elimination
Correct Answer: D
Rationale: Pursed-lip breathing creates positive pressure in the airways during exhalation
to prevent airway collapse. This allows the patient to exhale more completely and reduces
the amount of trapped air in the lungs. By extending the expiratory phase, it facilitates the
removal of carbon dioxide from the alveoli. It also helps to slow down the breathing rate
and reduce the work of breathing. Patients with COPD find this technique helpful during
periods of dyspnea or physical activity.
, 6. A nurse is caring for a patient with Peripheral Artery Disease (PAD). Which assessment
finding is consistent with this diagnosis?
A. Intermittent claudication during walking
B. Warm, red, and swollen lower extremities
C. Painless ulcers on the medial malleolus
D. Bounding pedal pulses
Correct Answer: A
Rationale: Intermittent claudication is the classic symptom of PAD caused by muscle
ischemia during exercise. The pain occurs because the narrowed arteries cannot supply
enough oxygenated blood to the working muscles. Ulcers in PAD are typically painful and
located on the toes or heels rather than the medial malleolus. Pedal pulses are usually
diminished or absent rather than bounding in patients with arterial disease. Nursing care
focuses on improving circulation and preventing injury to the ischemic tissues.
7. A patient is receiving Digoxin for heart failure. Which of the following signs should the
nurse identify as an early indicator of Digoxin toxicity?
A. Visual disturbances like yellow halos
B. Increased appetite
C. Sudden onset of hypertension
D. Anorexia and nausea
Correct Answer: D
Rationale: Gastrointestinal symptoms such as anorexia, nausea, and vomiting are often the
earliest signs of Digoxin toxicity. While visual disturbances are a classic sign, they usually
occur after the onset of gastrointestinal distress. It is critical for the nurse to assess the
apical pulse for one full minute before administration. Digoxin levels must be monitored to
ensure they stay within the narrow therapeutic range of 0.5 to 2.0 ng/mL. Toxicity is more
likely to occur if the patient is hypokalemic.
8. A nurse is preparing to administer Nitroglycerin sublingually to a patient with chest pain.
What is the priority action?
A. Assess the patient’s lung sounds.
B. Check the patient’s blood pressure.
C. Wait for a 12-lead EKG to be completed.
D. Administer a glass of water with the pill.
Correct Answer: B
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a patient with suspected right-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Crackles in the lungs
B. Frothy pink sputum
C. Orthopnea
D. Jugular venous distention
Correct Answer: D
Rationale: Right-sided heart failure leads to systemic venous congestion because the right
ventricle cannot pump efficiently. This results in observable jugular venous distention and
peripheral edema in the lower extremities. Options A, C, and D are characteristic of left-
sided heart failure where blood backs up into the pulmonary system. Nurses must
accurately differentiate these signs to provide appropriate systemic or pulmonary
interventions. Monitoring for these symptoms helps in assessing the severity of the
patient’s fluid volume overload.
2. A patient with asthma is prescribed albuterol via a metered-dose inhaler. Which
instruction should the nurse emphasize during teaching?
A. Rinse the mouth immediately after use to prevent thrush.
B. Wait at least one minute between puffs of the medication.
C. Use this medication only when you feel short of breath.
D. Take this medication daily at the same time every morning.
Correct Answer: B
Rationale: Albuterol is a short-acting beta-agonist used as a rescue medication to provide
rapid bronchodilation. Waiting one minute between puffs allows the first dose to open the
airways for better penetration of the second dose. Rinsing the mouth is specifically
required for inhaled corticosteroids, not for albuterol. It is not a maintenance drug and
should be used according to the prescribed rescue protocol. Proper technique ensures that
the maximum amount of medication reaches the smaller airways in the lungs.
3. Which laboratory value is most critical for the nurse to monitor in a patient receiving
Furosemide for hypertension?
A. Serum sodium level
B. Serum calcium level
,C. Serum potassium level
D. Serum magnesium level
Correct Answer: C
Rationale: Furosemide is a loop diuretic that promotes the excretion of water, sodium, and
potassium. Hypokalemia is a common and potentially dangerous side effect that can lead to
cardiac dysrhythmias. The nurse must monitor potassium levels closely to prevent
complications associated with electrolyte imbalance. Patients are often encouraged to eat
potassium-rich foods or take supplements while on this medication. Regular blood tests are
necessary to ensure the patient remains within the therapeutic range of 3.5 to 5.0 mEq/L.
4. A nurse is teaching a patient about the DASH diet to manage hypertension. Which food
choice indicates the patient understands the teaching?
A. Canned vegetable soup for lunch
B. Fresh steamed broccoli and brown rice
C. A deli turkey sandwich with pickles
D. Red meat three times per week
Correct Answer: B
Rationale: The DASH diet focuses on high fiber, low sodium, and increased intake of fruits
and vegetables. Fresh vegetables and whole grains like brown rice are core components of
this heart-healthy eating plan. Canned soups and deli meats are typically very high in
sodium and should be avoided. The diet also recommends limiting red meats and sweets to
reduce saturated fat intake. Educating patients on reading food labels is essential for
maintaining a low-sodium lifestyle.
5. A patient is admitted with an exacerbation of COPD. The nurse notes the patient is using
pursed-lip breathing. What is the primary purpose of this technique?
A. To increase the rate of respirations
B. To decrease the amount of oxygen needed
C. To strengthen the diaphragm muscle
D. To promote carbon dioxide elimination
Correct Answer: D
Rationale: Pursed-lip breathing creates positive pressure in the airways during exhalation
to prevent airway collapse. This allows the patient to exhale more completely and reduces
the amount of trapped air in the lungs. By extending the expiratory phase, it facilitates the
removal of carbon dioxide from the alveoli. It also helps to slow down the breathing rate
and reduce the work of breathing. Patients with COPD find this technique helpful during
periods of dyspnea or physical activity.
, 6. A nurse is caring for a patient with Peripheral Artery Disease (PAD). Which assessment
finding is consistent with this diagnosis?
A. Intermittent claudication during walking
B. Warm, red, and swollen lower extremities
C. Painless ulcers on the medial malleolus
D. Bounding pedal pulses
Correct Answer: A
Rationale: Intermittent claudication is the classic symptom of PAD caused by muscle
ischemia during exercise. The pain occurs because the narrowed arteries cannot supply
enough oxygenated blood to the working muscles. Ulcers in PAD are typically painful and
located on the toes or heels rather than the medial malleolus. Pedal pulses are usually
diminished or absent rather than bounding in patients with arterial disease. Nursing care
focuses on improving circulation and preventing injury to the ischemic tissues.
7. A patient is receiving Digoxin for heart failure. Which of the following signs should the
nurse identify as an early indicator of Digoxin toxicity?
A. Visual disturbances like yellow halos
B. Increased appetite
C. Sudden onset of hypertension
D. Anorexia and nausea
Correct Answer: D
Rationale: Gastrointestinal symptoms such as anorexia, nausea, and vomiting are often the
earliest signs of Digoxin toxicity. While visual disturbances are a classic sign, they usually
occur after the onset of gastrointestinal distress. It is critical for the nurse to assess the
apical pulse for one full minute before administration. Digoxin levels must be monitored to
ensure they stay within the narrow therapeutic range of 0.5 to 2.0 ng/mL. Toxicity is more
likely to occur if the patient is hypokalemic.
8. A nurse is preparing to administer Nitroglycerin sublingually to a patient with chest pain.
What is the priority action?
A. Assess the patient’s lung sounds.
B. Check the patient’s blood pressure.
C. Wait for a 12-lead EKG to be completed.
D. Administer a glass of water with the pill.
Correct Answer: B
