PNR 206/PNR206 Exam 2 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with heart failure who is prescribed furosemide. Which
laboratory value should the nurse monitor most closely for potential complications?
A. Serum sodium
B. Blood urea nitrogen
C. Serum potassium
D. Serum calcium
Correct Answer: C
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of potassium
along with water and sodium. Monitoring serum potassium levels is critical to prevent life-
threatening cardiac arrhythmias. The nurse must also educate the patient on signs of
hypokalemia such as muscle weakness and leg cramps.
2. Which clinical manifestation should a nurse expect to find in a client experiencing an acute
asthma exacerbation?
A. Inspiratory stridor
B. Audible expiratory wheezing
C. Productive cough with rust-colored sputum
,D. Decreased tactile fremitus
Correct Answer: B
Expert Explanation: Asthma is characterized by airway inflammation and
bronchoconstriction, which typically results in expiratory wheezing. This occurs as air is
forced through narrowed bronchioles during exhalation. Early recognition of these breath
sounds allows for timely administration of bronchodilators to improve ventilation.
3. A client is diagnosed with Type 1 Diabetes Mellitus. What is the primary physiological
cause of this condition that the nurse should include in the teaching plan?
A. Insulin resistance at the cellular level
B. Autoimmune destruction of pancreatic beta cells
C. Excessive production of glucagon by the liver
D. Impaired absorption of glucose in the small intestine
Correct Answer: B
Expert Explanation: Type 1 Diabetes Mellitus is an autoimmune disorder where the
immune system destroys the beta cells in the Islets of Langerhans. This leads to an absolute
deficiency of insulin, making the patient dependent on exogenous insulin for life.
Understanding this pathophysiology helps the client realize why oral hypoglycemics are
not effective for their condition.
, 4. When assessing a client with chronic obstructive pulmonary disease (COPD), which finding
is indicative of the ‘pink puffer’ clinical phenotype?
A. Peripheral edema and cyanosis
B. Hypoventilation and obesity
C. Copious amounts of purulent sputum
D. Barrel chest and pursed-lip breathing
Correct Answer: D
Expert Explanation: The ‘pink puffer’ phenotype is associated with emphysema, where
patients use accessory muscles and pursed-lip breathing to maintain oxygenation. The
barrel chest develops over time due to air trapping and hyperinflation of the lungs. These
compensatory mechanisms help keep the airways open during expiration but increase the
work of breathing.
5. A nurse is preparing to administer digoxin to a client with atrial fibrillation. Which action is
the priority before giving the medication?
A. Checking the client’s blood pressure
B. Measuring the apical pulse for 60 seconds
C. Assessing for peripheral edema
D. Monitoring the client’s respiratory rate
Correct Answer: B
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with heart failure who is prescribed furosemide. Which
laboratory value should the nurse monitor most closely for potential complications?
A. Serum sodium
B. Blood urea nitrogen
C. Serum potassium
D. Serum calcium
Correct Answer: C
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of potassium
along with water and sodium. Monitoring serum potassium levels is critical to prevent life-
threatening cardiac arrhythmias. The nurse must also educate the patient on signs of
hypokalemia such as muscle weakness and leg cramps.
2. Which clinical manifestation should a nurse expect to find in a client experiencing an acute
asthma exacerbation?
A. Inspiratory stridor
B. Audible expiratory wheezing
C. Productive cough with rust-colored sputum
,D. Decreased tactile fremitus
Correct Answer: B
Expert Explanation: Asthma is characterized by airway inflammation and
bronchoconstriction, which typically results in expiratory wheezing. This occurs as air is
forced through narrowed bronchioles during exhalation. Early recognition of these breath
sounds allows for timely administration of bronchodilators to improve ventilation.
3. A client is diagnosed with Type 1 Diabetes Mellitus. What is the primary physiological
cause of this condition that the nurse should include in the teaching plan?
A. Insulin resistance at the cellular level
B. Autoimmune destruction of pancreatic beta cells
C. Excessive production of glucagon by the liver
D. Impaired absorption of glucose in the small intestine
Correct Answer: B
Expert Explanation: Type 1 Diabetes Mellitus is an autoimmune disorder where the
immune system destroys the beta cells in the Islets of Langerhans. This leads to an absolute
deficiency of insulin, making the patient dependent on exogenous insulin for life.
Understanding this pathophysiology helps the client realize why oral hypoglycemics are
not effective for their condition.
, 4. When assessing a client with chronic obstructive pulmonary disease (COPD), which finding
is indicative of the ‘pink puffer’ clinical phenotype?
A. Peripheral edema and cyanosis
B. Hypoventilation and obesity
C. Copious amounts of purulent sputum
D. Barrel chest and pursed-lip breathing
Correct Answer: D
Expert Explanation: The ‘pink puffer’ phenotype is associated with emphysema, where
patients use accessory muscles and pursed-lip breathing to maintain oxygenation. The
barrel chest develops over time due to air trapping and hyperinflation of the lungs. These
compensatory mechanisms help keep the airways open during expiration but increase the
work of breathing.
5. A nurse is preparing to administer digoxin to a client with atrial fibrillation. Which action is
the priority before giving the medication?
A. Checking the client’s blood pressure
B. Measuring the apical pulse for 60 seconds
C. Assessing for peripheral edema
D. Monitoring the client’s respiratory rate
Correct Answer: B
