PNR 206/PNR206 Exam 1 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which
finding should the nurse prioritize for immediate intervention?
A. Oxygen saturation of 85% on room air
B. Barrel-shaped chest
C. Occasional dry cough
D. Clubbing of the fingers
Correct Answer: A
Expert Explanation: An oxygen saturation of 85% indicates significant hypoxemia and
requires immediate oxygen therapy or adjustment. Barrel chest and finger clubbing are
chronic adaptations to long-term hypoxia and are expected findings in COPD patients. The
nurse must prioritize airway and oxygenation according to the ABC framework.
2. A client is admitted with a diagnosis of left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Crackles upon lung auscultation
C. Dependent edema in the lower extremities
,D. Hepatosplenomegaly
Correct Answer: B
Expert Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to pulmonary congestion and crackles. The other options, such as JVD
and peripheral edema, are classic signs of right-sided heart failure. Distinguishing between
left and right heart failure is critical for implementing correct nursing interventions.
3. The nurse is preparing to administer Lisinopril to a client with hypertension. Which adverse
effect is a common reason for discontinuing this medication?
A. Increased appetite
B. Persistent dry cough
C. Tachycardia
D. Hypokalemia
Correct Answer: B
Expert Explanation: A persistent dry cough is a well-known side effect of ACE inhibitors
like Lisinopril due to the accumulation of bradykinin. Unlike some other side effects, this
cough does not usually resolve over time and often requires a switch to an Angiotensin II
Receptor Blocker (ARB). Nurses must educate patients to report this symptom
immediately.
, 4. A client returns to the unit after a bronchoscopy. What is the nurse’s priority assessment
before allowing the client to consume fluids?
A. Ability to ambulate independently
B. Urine output volume
C. Presence of a gag reflex
D. Level of pain on a scale of 0-10
Correct Answer: C
Expert Explanation: Post-bronchoscopy, the client’s throat is typically numbed with a
local anesthetic, which suppresses the gag reflex. Providing fluids before the gag reflex
returns places the patient at a high risk for aspiration and airway obstruction. The nurse
must verify the return of the reflex by using a tongue depressor or stimulating the back of
the throat.
5. A client with a chest tube has continuous bubbling in the water seal chamber. What does
this finding suggest to the nurse?
A. The lung has fully re-expanded
B. The suction pressure is too high
C. This is a normal finding during expiration
D. There is an air leak in the system
Correct Answer: D
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which
finding should the nurse prioritize for immediate intervention?
A. Oxygen saturation of 85% on room air
B. Barrel-shaped chest
C. Occasional dry cough
D. Clubbing of the fingers
Correct Answer: A
Expert Explanation: An oxygen saturation of 85% indicates significant hypoxemia and
requires immediate oxygen therapy or adjustment. Barrel chest and finger clubbing are
chronic adaptations to long-term hypoxia and are expected findings in COPD patients. The
nurse must prioritize airway and oxygenation according to the ABC framework.
2. A client is admitted with a diagnosis of left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Crackles upon lung auscultation
C. Dependent edema in the lower extremities
,D. Hepatosplenomegaly
Correct Answer: B
Expert Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to pulmonary congestion and crackles. The other options, such as JVD
and peripheral edema, are classic signs of right-sided heart failure. Distinguishing between
left and right heart failure is critical for implementing correct nursing interventions.
3. The nurse is preparing to administer Lisinopril to a client with hypertension. Which adverse
effect is a common reason for discontinuing this medication?
A. Increased appetite
B. Persistent dry cough
C. Tachycardia
D. Hypokalemia
Correct Answer: B
Expert Explanation: A persistent dry cough is a well-known side effect of ACE inhibitors
like Lisinopril due to the accumulation of bradykinin. Unlike some other side effects, this
cough does not usually resolve over time and often requires a switch to an Angiotensin II
Receptor Blocker (ARB). Nurses must educate patients to report this symptom
immediately.
, 4. A client returns to the unit after a bronchoscopy. What is the nurse’s priority assessment
before allowing the client to consume fluids?
A. Ability to ambulate independently
B. Urine output volume
C. Presence of a gag reflex
D. Level of pain on a scale of 0-10
Correct Answer: C
Expert Explanation: Post-bronchoscopy, the client’s throat is typically numbed with a
local anesthetic, which suppresses the gag reflex. Providing fluids before the gag reflex
returns places the patient at a high risk for aspiration and airway obstruction. The nurse
must verify the return of the reflex by using a tongue depressor or stimulating the back of
the throat.
5. A client with a chest tube has continuous bubbling in the water seal chamber. What does
this finding suggest to the nurse?
A. The lung has fully re-expanded
B. The suction pressure is too high
C. This is a normal finding during expiration
D. There is an air leak in the system
Correct Answer: D
