PNR 206/PNR206 Exam 1 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient with left-sided heart failure is experiencing increasing dyspnea and crackles in
the lungs. Which physiological process is primarily responsible for these symptoms?
A. Fluid backing up into the systemic venous circulation.
B. Excessive sodium retention in the lower extremities.
C. Inability of the right ventricle to pump to the pulmonary artery.
D. Blood backing up from the left ventricle into the lungs.
Correct Answer: D
Expert Explanation: In left-sided heart failure, the left ventricle fails to pump efficiently,
causing blood to back up into the left atrium and then the pulmonary veins. This increased
pressure forces fluid into the alveoli, resulting in pulmonary congestion and symptoms like
crackles and dyspnea. Right-sided failure typically results in systemic edema and jugular
venous distention.
2. A nurse is preparing to administer digoxin to a client with heart failure. Which action is
most critical before administering the medication?
A. Assess the radial pulse for 30 seconds.
B. Monitor the patient’s blood pressure.
,C. Auscultate the apical pulse for one full minute.
D. Check the patient’s serum glucose level.
Correct Answer: C
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
the force of contraction. The nurse must assess the apical pulse for a full 60 seconds to
ensure the heart rate is at least 60 beats per minute. If the heart rate is below the threshold,
the medication must be withheld and the provider notified.
3. Which teaching point is most important for a patient newly diagnosed with Peripheral
Artery Disease (PAD)?
A. Keep the legs elevated above the heart level while sleeping.
B. Apply heating pads directly to the feet to improve circulation.
C. Limit physical activity to prevent intermittent claudication.
D. Avoid crossing the legs and wear sturdy, well-fitting shoes.
Correct Answer: D
Expert Explanation: PAD involves decreased arterial blood flow to the extremities, so
preventing constriction and injury is vital. Crossing legs can further impair circulation, and
protective footwear prevents ulcers that heal poorly due to low blood flow. Elevation is
usually avoided in PAD as it hinders gravity-assisted blood flow to the feet.
, 4. A patient is admitted with a suspected Myocardial Infarction (MI). Which laboratory test is
most specific for diagnosing cardiac muscle damage?
A. Creatinine Phosphokinase (CPK)
B. Troponin I or T
C. Myoglobin
D. Serum Potassium
Correct Answer: B
Expert Explanation: Troponin is a protein released into the bloodstream specifically when
cardiac muscle is damaged. It is considered the gold standard for diagnosing an MI because
it remains elevated for several days. Other markers like myoglobin are less specific as they
can be elevated in skeletal muscle injury.
5. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically appropriate for this patient?
A. O2 is contraindicated in COPD patients
B. 6 to 8 Liters per minute
C. 10 to 12 Liters per minute
D. 1 to 2 Liters per minute
Correct Answer: D
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient with left-sided heart failure is experiencing increasing dyspnea and crackles in
the lungs. Which physiological process is primarily responsible for these symptoms?
A. Fluid backing up into the systemic venous circulation.
B. Excessive sodium retention in the lower extremities.
C. Inability of the right ventricle to pump to the pulmonary artery.
D. Blood backing up from the left ventricle into the lungs.
Correct Answer: D
Expert Explanation: In left-sided heart failure, the left ventricle fails to pump efficiently,
causing blood to back up into the left atrium and then the pulmonary veins. This increased
pressure forces fluid into the alveoli, resulting in pulmonary congestion and symptoms like
crackles and dyspnea. Right-sided failure typically results in systemic edema and jugular
venous distention.
2. A nurse is preparing to administer digoxin to a client with heart failure. Which action is
most critical before administering the medication?
A. Assess the radial pulse for 30 seconds.
B. Monitor the patient’s blood pressure.
,C. Auscultate the apical pulse for one full minute.
D. Check the patient’s serum glucose level.
Correct Answer: C
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
the force of contraction. The nurse must assess the apical pulse for a full 60 seconds to
ensure the heart rate is at least 60 beats per minute. If the heart rate is below the threshold,
the medication must be withheld and the provider notified.
3. Which teaching point is most important for a patient newly diagnosed with Peripheral
Artery Disease (PAD)?
A. Keep the legs elevated above the heart level while sleeping.
B. Apply heating pads directly to the feet to improve circulation.
C. Limit physical activity to prevent intermittent claudication.
D. Avoid crossing the legs and wear sturdy, well-fitting shoes.
Correct Answer: D
Expert Explanation: PAD involves decreased arterial blood flow to the extremities, so
preventing constriction and injury is vital. Crossing legs can further impair circulation, and
protective footwear prevents ulcers that heal poorly due to low blood flow. Elevation is
usually avoided in PAD as it hinders gravity-assisted blood flow to the feet.
, 4. A patient is admitted with a suspected Myocardial Infarction (MI). Which laboratory test is
most specific for diagnosing cardiac muscle damage?
A. Creatinine Phosphokinase (CPK)
B. Troponin I or T
C. Myoglobin
D. Serum Potassium
Correct Answer: B
Expert Explanation: Troponin is a protein released into the bloodstream specifically when
cardiac muscle is damaged. It is considered the gold standard for diagnosing an MI because
it remains elevated for several days. Other markers like myoglobin are less specific as they
can be elevated in skeletal muscle injury.
5. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically appropriate for this patient?
A. O2 is contraindicated in COPD patients
B. 6 to 8 Liters per minute
C. 10 to 12 Liters per minute
D. 1 to 2 Liters per minute
Correct Answer: D
