PNR 206/PNR206 Exam 2 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client prescribed Lisinopril for hypertension. Which assessment
finding should the nurse prioritize as a common adverse effect of this medication?
A. Peripheral edema
B. Hypokalemia
C. Tachycardia
D. Persistent dry cough
Correct Answer: D
Expert Explanation: ACE inhibitors such as Lisinopril are well known for causing a
persistent, dry, nonproductive cough in many patients. This occurs because the medication
leads to an accumulation of bradykinin and substance P in the lungs. If this side effect
becomes bothersome, the provider may consider switching the client to an Angiotensin II
Receptor Blocker (ARB).
2. Which clinical manifestation should the nurse expect to find in a client diagnosed with
right-sided heart failure?
A. Crackles in the lungs
B. Pink frothy sputum
,C. Jugular venous distension
D. Orthopnea
Correct Answer: C
Expert Explanation: Right-sided heart failure leads to systemic venous congestion
because the right ventricle cannot pump blood forward into the lungs efficiently. This
results in observable signs like jugular venous distension, peripheral edema, and
hepatomegaly. Left-sided heart failure, by contrast, causes pulmonary congestion and
symptoms like crackles and pink frothy sputum.
3. A nurse is preparing to administer Digoxin to a client. Which laboratory value should the
nurse check first to prevent potential toxicity?
A. Serum Sodium
B. Serum Calcium
C. Serum Potassium
D. Serum Magnesium
Correct Answer: C
Expert Explanation: Hypokalemia increases the risk of Digoxin toxicity because low
potassium levels allow more digoxin to bind to the ATPase pump. The nurse must verify
that the potassium level is within the normal range of 3.5 to 5.0 mEq/L before
administration. If the potassium is low, the nurse should hold the medication and notify the
healthcare provider immediately.
, 4. The nurse provides education to a client starting Warfarin therapy. Which statement by the
client indicates a need for further teaching?
A. I will use a soft-bristled toothbrush to brush my teeth.
B. I need to have my PT and INR levels checked regularly.
C. I will increase my intake of spinach and kale to stay healthy.
D. I will report any unusual bruising or bleeding to my doctor.
Correct Answer: C
Expert Explanation: Warfarin acts as a Vitamin K antagonist, and sudden changes in
Vitamin K intake can interfere with the medication’s effectiveness. Green leafy vegetables
like spinach and kale are high in Vitamin K and should be consumed in consistent amounts
rather than increased or decreased drastically. The other options reflect correct safety
measures for patients on anticoagulation therapy.
5. A client with COPD is receiving oxygen therapy. Why is it crucial for the nurse to maintain
the oxygen flow at a low rate, typically 1 to 2 liters per minute?
A. To prevent oxygen-induced carbon dioxide narcosis.
B. To avoid drying out the nasal mucosa.
C. To reduce the risk of spontaneous pneumothorax.
D. To decrease the work of breathing for the client.
Correct Answer: A
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client prescribed Lisinopril for hypertension. Which assessment
finding should the nurse prioritize as a common adverse effect of this medication?
A. Peripheral edema
B. Hypokalemia
C. Tachycardia
D. Persistent dry cough
Correct Answer: D
Expert Explanation: ACE inhibitors such as Lisinopril are well known for causing a
persistent, dry, nonproductive cough in many patients. This occurs because the medication
leads to an accumulation of bradykinin and substance P in the lungs. If this side effect
becomes bothersome, the provider may consider switching the client to an Angiotensin II
Receptor Blocker (ARB).
2. Which clinical manifestation should the nurse expect to find in a client diagnosed with
right-sided heart failure?
A. Crackles in the lungs
B. Pink frothy sputum
,C. Jugular venous distension
D. Orthopnea
Correct Answer: C
Expert Explanation: Right-sided heart failure leads to systemic venous congestion
because the right ventricle cannot pump blood forward into the lungs efficiently. This
results in observable signs like jugular venous distension, peripheral edema, and
hepatomegaly. Left-sided heart failure, by contrast, causes pulmonary congestion and
symptoms like crackles and pink frothy sputum.
3. A nurse is preparing to administer Digoxin to a client. Which laboratory value should the
nurse check first to prevent potential toxicity?
A. Serum Sodium
B. Serum Calcium
C. Serum Potassium
D. Serum Magnesium
Correct Answer: C
Expert Explanation: Hypokalemia increases the risk of Digoxin toxicity because low
potassium levels allow more digoxin to bind to the ATPase pump. The nurse must verify
that the potassium level is within the normal range of 3.5 to 5.0 mEq/L before
administration. If the potassium is low, the nurse should hold the medication and notify the
healthcare provider immediately.
, 4. The nurse provides education to a client starting Warfarin therapy. Which statement by the
client indicates a need for further teaching?
A. I will use a soft-bristled toothbrush to brush my teeth.
B. I need to have my PT and INR levels checked regularly.
C. I will increase my intake of spinach and kale to stay healthy.
D. I will report any unusual bruising or bleeding to my doctor.
Correct Answer: C
Expert Explanation: Warfarin acts as a Vitamin K antagonist, and sudden changes in
Vitamin K intake can interfere with the medication’s effectiveness. Green leafy vegetables
like spinach and kale are high in Vitamin K and should be consumed in consistent amounts
rather than increased or decreased drastically. The other options reflect correct safety
measures for patients on anticoagulation therapy.
5. A client with COPD is receiving oxygen therapy. Why is it crucial for the nurse to maintain
the oxygen flow at a low rate, typically 1 to 2 liters per minute?
A. To prevent oxygen-induced carbon dioxide narcosis.
B. To avoid drying out the nasal mucosa.
C. To reduce the risk of spontaneous pneumothorax.
D. To decrease the work of breathing for the client.
Correct Answer: A
