NUR201 Medical Surgical Exam 2 Version 1
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is caring for a patient with left-sided heart failure. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Crackles in the lung bases
B. Jugular venous distension
C. Peripheral edema in the lower extremities
D. Hepatomegaly and abdominal tenderness
Correct Answer: A
Expert Explanation: Left-sided heart failure leads to pulmonary congestion
because the left ventricle cannot effectively pump blood into systemic circulation.
This results in fluid backing up into the lungs, manifesting as crackles or wheezes.
Options A, C, and D are classic signs of right-sided heart failure where blood backs
up into the systemic venous system. The nurse must prioritize respiratory
assessment to ensure adequate oxygenation for these patients. Monitoring breath
sounds frequently allows for early detection of pulmonary edema.
2. A patient is prescribed Lisinopril for hypertension. Which side effect should the
nurse instruct the patient to report immediately?
A. Increased appetite
,B. Swelling of the face or lips
C. A persistent dry cough
D. Mild fatigue
Correct Answer: B
Expert Explanation: Angioedema is a rare but life-threatening adverse effect of
ACE inhibitors like Lisinopril. It involves rapid swelling of the face, lips, tongue, or
throat and requires immediate medical attention to prevent airway obstruction.
While a persistent dry cough is a common side effect, it is not as urgent as
angioedema. Fatigue and appetite changes are generally not primary concerns
associated with this medication class. Patient education must emphasize airway
safety when starting any ACE inhibitor therapy.
3. Which laboratory test is considered the most specific indicator for myocardial
infarction (MI)?
A. Creatine Kinase (CK-MB)
B. Myoglobin
C. Troponin I
D. Brain Natriuretic Peptide (BNP)
Correct Answer: C
,Expert Explanation: Troponin I is highly specific to cardiac muscle and remains
elevated for several days after an MI occurs. CK-MB is also used but is less specific as
it can be found in skeletal muscle as well. Myoglobin rises early but lacks specificity
for cardiac injury. BNP is primarily used as a diagnostic marker for heart failure
rather than acute myocardial infarction. Frequent monitoring of troponin levels
helps determine the extent of myocardial damage over time.
4. A nurse is reviewing an ECG and notes a PR interval of 0.24 seconds. How should the
nurse interpret this finding?
A. Normal sinus rhythm
B. Second-degree AV block Mobitz I
C. First-degree atrioventricular (AV) block
D. Third-degree heart block
Correct Answer: C
Expert Explanation: A normal PR interval ranges from 0.12 to 0.20 seconds in a
healthy adult. A PR interval greater than 0.20 seconds indicates a delay in
conduction through the AV node, defined as first-degree AV block. In first-degree
block, every P wave is followed by a QRS complex, unlike higher-degree blocks. This
condition is often asymptomatic but requires monitoring for progression to more
, severe blocks. Nurses should assess if the patient is taking medications like beta-
blockers that might prolong conduction.
5. A patient with stable angina is being discharged. Which instruction should the nurse
include regarding sublingual nitroglycerin use?
A. Take one tablet every 15 minutes until pain stops.
B. Swallow the tablet with a full glass of water.
C. Take one tablet at the onset of pain and call 911 if pain persists after 5 minutes.
D. Store the medication in a clear plastic container for easy access.
Correct Answer: C
Expert Explanation: Patients are taught to take one nitroglycerin dose at the first
sign of chest pain. If the pain is not relieved or worsens after five minutes, they must
call 911 immediately. Sublingual tablets must dissolve under the tongue and should
never be swallowed. The medication is light-sensitive and must be kept in its
original dark glass bottle to remain stable. This protocol ensures rapid intervention
during a potential acute coronary syndrome event.
6. Which nursing intervention is a priority for a patient immediately following a
cardiac catheterization via the femoral artery?
A. Maintaining the patient on bed rest with the affected leg straight
B. Assisting the patient to ambulate to the bathroom
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is caring for a patient with left-sided heart failure. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Crackles in the lung bases
B. Jugular venous distension
C. Peripheral edema in the lower extremities
D. Hepatomegaly and abdominal tenderness
Correct Answer: A
Expert Explanation: Left-sided heart failure leads to pulmonary congestion
because the left ventricle cannot effectively pump blood into systemic circulation.
This results in fluid backing up into the lungs, manifesting as crackles or wheezes.
Options A, C, and D are classic signs of right-sided heart failure where blood backs
up into the systemic venous system. The nurse must prioritize respiratory
assessment to ensure adequate oxygenation for these patients. Monitoring breath
sounds frequently allows for early detection of pulmonary edema.
2. A patient is prescribed Lisinopril for hypertension. Which side effect should the
nurse instruct the patient to report immediately?
A. Increased appetite
,B. Swelling of the face or lips
C. A persistent dry cough
D. Mild fatigue
Correct Answer: B
Expert Explanation: Angioedema is a rare but life-threatening adverse effect of
ACE inhibitors like Lisinopril. It involves rapid swelling of the face, lips, tongue, or
throat and requires immediate medical attention to prevent airway obstruction.
While a persistent dry cough is a common side effect, it is not as urgent as
angioedema. Fatigue and appetite changes are generally not primary concerns
associated with this medication class. Patient education must emphasize airway
safety when starting any ACE inhibitor therapy.
3. Which laboratory test is considered the most specific indicator for myocardial
infarction (MI)?
A. Creatine Kinase (CK-MB)
B. Myoglobin
C. Troponin I
D. Brain Natriuretic Peptide (BNP)
Correct Answer: C
,Expert Explanation: Troponin I is highly specific to cardiac muscle and remains
elevated for several days after an MI occurs. CK-MB is also used but is less specific as
it can be found in skeletal muscle as well. Myoglobin rises early but lacks specificity
for cardiac injury. BNP is primarily used as a diagnostic marker for heart failure
rather than acute myocardial infarction. Frequent monitoring of troponin levels
helps determine the extent of myocardial damage over time.
4. A nurse is reviewing an ECG and notes a PR interval of 0.24 seconds. How should the
nurse interpret this finding?
A. Normal sinus rhythm
B. Second-degree AV block Mobitz I
C. First-degree atrioventricular (AV) block
D. Third-degree heart block
Correct Answer: C
Expert Explanation: A normal PR interval ranges from 0.12 to 0.20 seconds in a
healthy adult. A PR interval greater than 0.20 seconds indicates a delay in
conduction through the AV node, defined as first-degree AV block. In first-degree
block, every P wave is followed by a QRS complex, unlike higher-degree blocks. This
condition is often asymptomatic but requires monitoring for progression to more
, severe blocks. Nurses should assess if the patient is taking medications like beta-
blockers that might prolong conduction.
5. A patient with stable angina is being discharged. Which instruction should the nurse
include regarding sublingual nitroglycerin use?
A. Take one tablet every 15 minutes until pain stops.
B. Swallow the tablet with a full glass of water.
C. Take one tablet at the onset of pain and call 911 if pain persists after 5 minutes.
D. Store the medication in a clear plastic container for easy access.
Correct Answer: C
Expert Explanation: Patients are taught to take one nitroglycerin dose at the first
sign of chest pain. If the pain is not relieved or worsens after five minutes, they must
call 911 immediately. Sublingual tablets must dissolve under the tongue and should
never be swallowed. The medication is light-sensitive and must be kept in its
original dark glass bottle to remain stable. This protocol ensures rapid intervention
during a potential acute coronary syndrome event.
6. Which nursing intervention is a priority for a patient immediately following a
cardiac catheterization via the femoral artery?
A. Maintaining the patient on bed rest with the affected leg straight
B. Assisting the patient to ambulate to the bathroom
