PNR 206/PNR206 Exam 2 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient with suspected left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Peripheral edema and weight gain
B. Jugular venous distention (JVD)
C. Hepatomegaly and abdominal distension
D. Dyspnea and crackles upon auscultation
Correct Answer: D
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot effectively pump blood into systemic circulation. This leads to
symptoms such as dyspnea, orthopnea, and crackles in the lungs. Options A, B, and D are
characteristic of right-sided heart failure, which involves systemic venous congestion.
2. A patient is prescribed Digoxin 0.125 mg daily. Which assessment finding requires the
nurse to hold the medication and notify the healthcare provider?
A. Serum potassium level of 4.2 mEq/L
B. Blood pressure of 110/70 mmHg
C. Respiratory rate of 18 breaths per minute
,D. Apical heart rate of 52 beats per minute
Correct Answer: D
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
contractility. The nurse must assess the apical pulse for one full minute before
administration and hold the dose if the heart rate is below 60 bpm. Bradycardia is a
primary indicator of potential digoxin toxicity.
3. Which arterial blood gas (ABG) result indicates respiratory acidosis?
A. pH 7.30, PaCO2 50, HCO3 26
B. pH 7.48, PaCO2 32, HCO3 24
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: A
Expert Explanation: Respiratory acidosis is characterized by a pH lower than 7.35 and a
PaCO2 higher than 45 mmHg. This condition often occurs due to hypoventilation or COPD
where CO2 is retained. The other options represent respiratory alkalosis, metabolic
acidosis, and metabolic alkalosis, respectively.
4. A nurse is caring for a patient with a history of Chronic Obstructive Pulmonary Disease
(COPD). Which oxygen delivery rate is most appropriate to avoid suppressing the hypoxic
drive?
A. 6-8 L/min via simple face mask
, B. 10-15 L/min via non-rebreather mask
C. 4 L/min via nasal cannula
D. 1-2 L/min via nasal cannula
Correct Answer: D
Expert Explanation: Patients with chronic CO2 retention rely on low oxygen levels
(hypoxic drive) to stimulate breathing. Administering high levels of oxygen can cause their
respiratory rate to decrease or stop entirely. Typically, 1 to 2 L/min is used to maintain an
SpO2 between 88% and 92%.
5. A patient with suspected Pulmonary Embolism (PE) is admitted. What is the priority
nursing intervention?
A. Apply high-flow oxygen and elevate the head of the bed
B. Administer oral anticoagulants immediately
C. Ambulate the patient to improve circulation
D. Perform a deep palpation of the lower extremities
Correct Answer: A
Expert Explanation: A pulmonary embolism causes a ventilation-perfusion mismatch
leading to acute hypoxia. The immediate priority is maintaining oxygenation and reducing
respiratory distress by positioning the patient upright. Diagnostic tests and anticoagulant
therapy follow stabilization.
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient with suspected left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Peripheral edema and weight gain
B. Jugular venous distention (JVD)
C. Hepatomegaly and abdominal distension
D. Dyspnea and crackles upon auscultation
Correct Answer: D
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot effectively pump blood into systemic circulation. This leads to
symptoms such as dyspnea, orthopnea, and crackles in the lungs. Options A, B, and D are
characteristic of right-sided heart failure, which involves systemic venous congestion.
2. A patient is prescribed Digoxin 0.125 mg daily. Which assessment finding requires the
nurse to hold the medication and notify the healthcare provider?
A. Serum potassium level of 4.2 mEq/L
B. Blood pressure of 110/70 mmHg
C. Respiratory rate of 18 breaths per minute
,D. Apical heart rate of 52 beats per minute
Correct Answer: D
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
contractility. The nurse must assess the apical pulse for one full minute before
administration and hold the dose if the heart rate is below 60 bpm. Bradycardia is a
primary indicator of potential digoxin toxicity.
3. Which arterial blood gas (ABG) result indicates respiratory acidosis?
A. pH 7.30, PaCO2 50, HCO3 26
B. pH 7.48, PaCO2 32, HCO3 24
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: A
Expert Explanation: Respiratory acidosis is characterized by a pH lower than 7.35 and a
PaCO2 higher than 45 mmHg. This condition often occurs due to hypoventilation or COPD
where CO2 is retained. The other options represent respiratory alkalosis, metabolic
acidosis, and metabolic alkalosis, respectively.
4. A nurse is caring for a patient with a history of Chronic Obstructive Pulmonary Disease
(COPD). Which oxygen delivery rate is most appropriate to avoid suppressing the hypoxic
drive?
A. 6-8 L/min via simple face mask
, B. 10-15 L/min via non-rebreather mask
C. 4 L/min via nasal cannula
D. 1-2 L/min via nasal cannula
Correct Answer: D
Expert Explanation: Patients with chronic CO2 retention rely on low oxygen levels
(hypoxic drive) to stimulate breathing. Administering high levels of oxygen can cause their
respiratory rate to decrease or stop entirely. Typically, 1 to 2 L/min is used to maintain an
SpO2 between 88% and 92%.
5. A patient with suspected Pulmonary Embolism (PE) is admitted. What is the priority
nursing intervention?
A. Apply high-flow oxygen and elevate the head of the bed
B. Administer oral anticoagulants immediately
C. Ambulate the patient to improve circulation
D. Perform a deep palpation of the lower extremities
Correct Answer: A
Expert Explanation: A pulmonary embolism causes a ventilation-perfusion mismatch
leading to acute hypoxia. The immediate priority is maintaining oxygenation and reducing
respiratory distress by positioning the patient upright. Diagnostic tests and anticoagulant
therapy follow stabilization.
