NUR 205 | NUR 205 Med Surg Exam 2 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient with heart failure is being discharged on a regimen of furosemide and
digoxin. Which statement by the patient indicates a need for further teaching?
A. I will take my heart pill even if I feel nauseated or lose my appetite.
B. I will increase my intake of dried apricots and bananas.
C. I will weigh myself every morning before breakfast.
D. I will call the doctor if I notice my shoes are getting tighter.
Correct Answer: A
Expert Explanation: Nausea and anorexia are classic early signs of digoxin toxicity
that must be reported to the healthcare provider immediately. Furosemide is a loop
diuretic that can cause hypokalemia, which significantly increases the risk of digoxin
toxicity. Patients are encouraged to consume potassium-rich foods like bananas to
maintain safe serum levels while on diuretics. Daily weights are the most reliable
indicator of fluid volume status in heart failure management. Tighter shoes indicate
peripheral edema, suggesting a worsening of right-sided heart failure that requires
medical intervention.
,2. A nurse is assessing a patient with a history of COPD who is complaining of
increased shortness of breath. Which assessment finding should the nurse prioritize?
A. A barrel-shaped chest appearance
B. Oxygen saturation of 91% on room air
C. Clubbing of the fingernails
D. The use of accessory muscles during inspiration
Correct Answer: D
Expert Explanation: The use of accessory muscles indicates a significant increase
in the work of breathing and potential respiratory failure. While a barrel chest and
clubbing are common chronic findings in COPD, they do not indicate an acute
change in status. An oxygen saturation of 91% is often considered an acceptable
baseline for patients with chronic obstructive lung disease. The nurse must
recognize signs of acute distress to intervene before the patient’s condition
deteriorates further. Prioritization in respiratory care focuses on the immediate
threat to ventilation and oxygenation.
3. A client is admitted to the emergency department with a blood pressure of 210/120
mmHg and reports a severe headache and blurred vision. Which medication should
the nurse anticipate administering first?
A. Oral Amlodipine
,B. Intravenous Nitroprusside
C. Sublingual Nitroglycerin
D. Oral Lisinopril
Correct Answer: B
Expert Explanation: The patient is experiencing a hypertensive emergency
characterized by extremely high blood pressure and signs of target organ damage
like blurred vision. Intravenous Nitroprusside is a potent vasodilator used to rapidly
but controllably lower blood pressure in these critical situations. Oral medications
are generally too slow-acting for a hypertensive crisis where immediate reduction is
necessary to prevent stroke or heart failure. The nurse must monitor the blood
pressure continuously, typically with an arterial line, during IV infusion. Lowering
the pressure too rapidly can also be dangerous, so titration is based on specific
protocol parameters.
4. When caring for a patient with Right-Sided Heart Failure, which clinical
manifestation should the nurse expect to find?
A. Crackles in the lung bases
B. Jugular venous distention
C. Orthopnea and cough
D. Dyspnea on exertion
, Correct Answer: B
Expert Explanation: Right-sided heart failure results in systemic venous
congestion because the right ventricle cannot effectively pump blood into the
pulmonary circulation. Jugular venous distention (JVD) is a classic hallmark of
systemic backup, along with peripheral edema and hepatomegaly. Crackles,
orthopnea, and dyspnea are signs of left-sided heart failure, which involves
pulmonary congestion. Understanding the difference between systemic and
pulmonary backup helps the nurse localize the primary site of cardiac dysfunction.
Comprehensive assessment involves checking for weight gain and abdominal girth
increases in these patients.
5. A nurse is teaching a patient with COPD how to perform pursed-lip breathing. What
is the primary purpose of this technique?
A. To promote carbon dioxide elimination by keeping airways open
B. To strengthen the intercostal muscles
C. To increase the rate of breathing
D. To decrease the amount of oxygen reaching the lungs
Correct Answer: A
Expert Explanation: Pursed-lip breathing creates positive pressure within the
airways, preventing them from collapsing during exhalation. This allows for a more
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient with heart failure is being discharged on a regimen of furosemide and
digoxin. Which statement by the patient indicates a need for further teaching?
A. I will take my heart pill even if I feel nauseated or lose my appetite.
B. I will increase my intake of dried apricots and bananas.
C. I will weigh myself every morning before breakfast.
D. I will call the doctor if I notice my shoes are getting tighter.
Correct Answer: A
Expert Explanation: Nausea and anorexia are classic early signs of digoxin toxicity
that must be reported to the healthcare provider immediately. Furosemide is a loop
diuretic that can cause hypokalemia, which significantly increases the risk of digoxin
toxicity. Patients are encouraged to consume potassium-rich foods like bananas to
maintain safe serum levels while on diuretics. Daily weights are the most reliable
indicator of fluid volume status in heart failure management. Tighter shoes indicate
peripheral edema, suggesting a worsening of right-sided heart failure that requires
medical intervention.
,2. A nurse is assessing a patient with a history of COPD who is complaining of
increased shortness of breath. Which assessment finding should the nurse prioritize?
A. A barrel-shaped chest appearance
B. Oxygen saturation of 91% on room air
C. Clubbing of the fingernails
D. The use of accessory muscles during inspiration
Correct Answer: D
Expert Explanation: The use of accessory muscles indicates a significant increase
in the work of breathing and potential respiratory failure. While a barrel chest and
clubbing are common chronic findings in COPD, they do not indicate an acute
change in status. An oxygen saturation of 91% is often considered an acceptable
baseline for patients with chronic obstructive lung disease. The nurse must
recognize signs of acute distress to intervene before the patient’s condition
deteriorates further. Prioritization in respiratory care focuses on the immediate
threat to ventilation and oxygenation.
3. A client is admitted to the emergency department with a blood pressure of 210/120
mmHg and reports a severe headache and blurred vision. Which medication should
the nurse anticipate administering first?
A. Oral Amlodipine
,B. Intravenous Nitroprusside
C. Sublingual Nitroglycerin
D. Oral Lisinopril
Correct Answer: B
Expert Explanation: The patient is experiencing a hypertensive emergency
characterized by extremely high blood pressure and signs of target organ damage
like blurred vision. Intravenous Nitroprusside is a potent vasodilator used to rapidly
but controllably lower blood pressure in these critical situations. Oral medications
are generally too slow-acting for a hypertensive crisis where immediate reduction is
necessary to prevent stroke or heart failure. The nurse must monitor the blood
pressure continuously, typically with an arterial line, during IV infusion. Lowering
the pressure too rapidly can also be dangerous, so titration is based on specific
protocol parameters.
4. When caring for a patient with Right-Sided Heart Failure, which clinical
manifestation should the nurse expect to find?
A. Crackles in the lung bases
B. Jugular venous distention
C. Orthopnea and cough
D. Dyspnea on exertion
, Correct Answer: B
Expert Explanation: Right-sided heart failure results in systemic venous
congestion because the right ventricle cannot effectively pump blood into the
pulmonary circulation. Jugular venous distention (JVD) is a classic hallmark of
systemic backup, along with peripheral edema and hepatomegaly. Crackles,
orthopnea, and dyspnea are signs of left-sided heart failure, which involves
pulmonary congestion. Understanding the difference between systemic and
pulmonary backup helps the nurse localize the primary site of cardiac dysfunction.
Comprehensive assessment involves checking for weight gain and abdominal girth
increases in these patients.
5. A nurse is teaching a patient with COPD how to perform pursed-lip breathing. What
is the primary purpose of this technique?
A. To promote carbon dioxide elimination by keeping airways open
B. To strengthen the intercostal muscles
C. To increase the rate of breathing
D. To decrease the amount of oxygen reaching the lungs
Correct Answer: A
Expert Explanation: Pursed-lip breathing creates positive pressure within the
airways, preventing them from collapsing during exhalation. This allows for a more
