NUR 201/NUR201 Exam 3 V3 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient with right-sided heart failure. Which of the following clinical
manifestations should the nurse expect to find?
A. Crackles and wheezes in the lungs
B. Frothy, pink-tinged sputum
C. Orthopnea and paroxysmal nocturnal dyspnea
D. Jugular venous distention and peripheral edema
Correct Answer: D
Expert Explanation: Right-sided heart failure results in the backward flow of blood into
the systemic venous circulation. This leads to symptoms such as jugular venous distention,
hepatomegaly, and peripheral dependent edema. Other options like crackles and frothy
sputum are indicative of left-sided heart failure and pulmonary congestion.
2. The nurse is preparing to administer Digoxin to a patient with heart failure. Which action is
the priority before administration?
A. Measure the patient’s blood pressure
B. Assess the apical pulse for one full minute
C. Check the patient’s serum glucose level
,D. Evaluate the patient’s respiratory rate
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
myocardial contractility. It is essential to assess the apical pulse for a full minute to ensure
it is above 60 beats per minute before administration. If the pulse is below the threshold,
the dose must be held and the provider notified to prevent further bradycardia.
3. A patient with COPD is being discharged. Which statement by the patient indicates a
correct understanding of pursed-lip breathing?
A. I should exhale through my lips as if I am whistling.
B. I will hold my breath for five seconds after inhaling.
C. I will exhale twice as long as I inhale through my nose.
D. I should inhale quickly through my mouth.
Correct Answer: A
Expert Explanation: Pursed-lip breathing helps to maintain positive pressure in the
airways and prevents alveolar collapse. The technique involves inhaling through the nose
and exhaling slowly through pursed lips, mimicking a whistling or blowing motion. This
process increases the duration of exhalation and promotes better gas exchange in patients
with obstructive lung disease.
, 4. A patient is admitted with a suspected pulmonary embolism. Which diagnostic test is
considered the gold standard for confirming this diagnosis?
A. Chest X-ray
B. Computed Tomography Angiography (CTA)
C. Electrocardiogram (ECG)
D. Arterial Blood Gas (ABG)
Correct Answer: B
Expert Explanation: Computed Tomography Angiography (CTA) is currently the most
commonly used and definitive diagnostic tool for identifying a pulmonary embolism. While
ABGs and ECGs may show abnormalities, they are non-specific and do not confirm the
presence of a clot. A chest X-ray is typically used to rule out other conditions like
pneumonia rather than confirm an embolism.
5. The nurse is monitoring a patient receiving a blood transfusion. Within the first 15 minutes,
the patient reports low back pain and chills. What is the priority action?
A. Stop the infusion and disconnect the tubing
B. Slow the infusion rate and notify the provider
C. Administer diphenhydramine as ordered
D. Re-check the patient’s ID band and blood bag
Correct Answer: A
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient with right-sided heart failure. Which of the following clinical
manifestations should the nurse expect to find?
A. Crackles and wheezes in the lungs
B. Frothy, pink-tinged sputum
C. Orthopnea and paroxysmal nocturnal dyspnea
D. Jugular venous distention and peripheral edema
Correct Answer: D
Expert Explanation: Right-sided heart failure results in the backward flow of blood into
the systemic venous circulation. This leads to symptoms such as jugular venous distention,
hepatomegaly, and peripheral dependent edema. Other options like crackles and frothy
sputum are indicative of left-sided heart failure and pulmonary congestion.
2. The nurse is preparing to administer Digoxin to a patient with heart failure. Which action is
the priority before administration?
A. Measure the patient’s blood pressure
B. Assess the apical pulse for one full minute
C. Check the patient’s serum glucose level
,D. Evaluate the patient’s respiratory rate
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
myocardial contractility. It is essential to assess the apical pulse for a full minute to ensure
it is above 60 beats per minute before administration. If the pulse is below the threshold,
the dose must be held and the provider notified to prevent further bradycardia.
3. A patient with COPD is being discharged. Which statement by the patient indicates a
correct understanding of pursed-lip breathing?
A. I should exhale through my lips as if I am whistling.
B. I will hold my breath for five seconds after inhaling.
C. I will exhale twice as long as I inhale through my nose.
D. I should inhale quickly through my mouth.
Correct Answer: A
Expert Explanation: Pursed-lip breathing helps to maintain positive pressure in the
airways and prevents alveolar collapse. The technique involves inhaling through the nose
and exhaling slowly through pursed lips, mimicking a whistling or blowing motion. This
process increases the duration of exhalation and promotes better gas exchange in patients
with obstructive lung disease.
, 4. A patient is admitted with a suspected pulmonary embolism. Which diagnostic test is
considered the gold standard for confirming this diagnosis?
A. Chest X-ray
B. Computed Tomography Angiography (CTA)
C. Electrocardiogram (ECG)
D. Arterial Blood Gas (ABG)
Correct Answer: B
Expert Explanation: Computed Tomography Angiography (CTA) is currently the most
commonly used and definitive diagnostic tool for identifying a pulmonary embolism. While
ABGs and ECGs may show abnormalities, they are non-specific and do not confirm the
presence of a clot. A chest X-ray is typically used to rule out other conditions like
pneumonia rather than confirm an embolism.
5. The nurse is monitoring a patient receiving a blood transfusion. Within the first 15 minutes,
the patient reports low back pain and chills. What is the priority action?
A. Stop the infusion and disconnect the tubing
B. Slow the infusion rate and notify the provider
C. Administer diphenhydramine as ordered
D. Re-check the patient’s ID band and blood bag
Correct Answer: A
