NUR 209/NUR209 Exam 1 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with left-sided heart failure. Which clinical manifestation
should the nurse expect to find during the assessment?
A. Peripheral edema and jugular venous distention
B. Ascites and hepatomegaly
C. Splenomegaly and weight gain
D. Crackles and dyspnea on exertion
Correct Answer: D
Expert Explanation: Left-sided heart failure typically involves backflow into the
pulmonary system, leading to respiratory symptoms. Crackles are heard when fluid builds
up in the alveoli, and dyspnea occurs due to impaired gas exchange. This differs from right-
sided failure, which manifests as systemic venous congestion like edema and ascites.
2. The nurse is interpreting a client’s arterial blood gas (ABG) results: pH 7.31, PaCO2 50
mmHg, and HCO3 24 mEq/L. Which acid-base imbalance is present?
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Respiratory Acidosis
,D. Metabolic Alkalosis
Correct Answer: C
Expert Explanation: The pH is below 7.35, which signifies acidosis. The PaCO2 is elevated
above 45 mmHg, indicating that the respiratory system is the cause of the acidity. Since the
bicarbonate level is normal, this is an uncompensated respiratory acidosis commonly seen
in conditions like COPD or respiratory depression.
3. A client is prescribed Digoxin for heart failure. Which of the following findings should the
nurse identify as an early sign of Digoxin toxicity?
A. Yellow-green halos around lights
B. Tachycardia and hypertension
C. Loss of appetite and nausea
D. Increased urinary output
Correct Answer: C
Expert Explanation: Gastrointestinal symptoms such as anorexia, nausea, and vomiting
are often the earliest signs of digoxin toxicity. While visual changes like yellow-green halos
are classic, they usually appear later in the progression of toxicity. Monitoring serum
potassium is crucial because hypokalemia increases the risk of digoxin-related
dysrhythmias.
, 4. A nurse is providing discharge instructions to a client with COPD. What should the nurse
emphasize regarding oxygen therapy?
A. Maintain oxygen flow at 6-10 L/min via simple mask
B. Oxygen is only needed when the client feels short of breath
C. Do not exceed 2 L/min unless otherwise directed
D. Smoking is allowed if oxygen is turned off for 15 minutes
Correct Answer: C
Expert Explanation: In clients with COPD, high concentrations of oxygen can suppress the
hypoxic drive to breathe, leading to carbon dioxide retention. It is generally recommended
to maintain low-flow oxygen, typically 1 to 2 L/min, to keep saturations between 88% and
92%. The nurse must teach the client that oxygen is a medication and should not be
adjusted without medical consultation.
5. A client returns to the unit after a cardiac catheterization via the femoral artery. Which
nursing intervention is the highest priority?
A. Encouraging the client to walk to prevent DVT
B. Assessing the pedal pulses and the insertion site
C. Providing a high-protein meal for wound healing
D. Teaching the client about low-sodium diets
Correct Answer: B
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with left-sided heart failure. Which clinical manifestation
should the nurse expect to find during the assessment?
A. Peripheral edema and jugular venous distention
B. Ascites and hepatomegaly
C. Splenomegaly and weight gain
D. Crackles and dyspnea on exertion
Correct Answer: D
Expert Explanation: Left-sided heart failure typically involves backflow into the
pulmonary system, leading to respiratory symptoms. Crackles are heard when fluid builds
up in the alveoli, and dyspnea occurs due to impaired gas exchange. This differs from right-
sided failure, which manifests as systemic venous congestion like edema and ascites.
2. The nurse is interpreting a client’s arterial blood gas (ABG) results: pH 7.31, PaCO2 50
mmHg, and HCO3 24 mEq/L. Which acid-base imbalance is present?
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Respiratory Acidosis
,D. Metabolic Alkalosis
Correct Answer: C
Expert Explanation: The pH is below 7.35, which signifies acidosis. The PaCO2 is elevated
above 45 mmHg, indicating that the respiratory system is the cause of the acidity. Since the
bicarbonate level is normal, this is an uncompensated respiratory acidosis commonly seen
in conditions like COPD or respiratory depression.
3. A client is prescribed Digoxin for heart failure. Which of the following findings should the
nurse identify as an early sign of Digoxin toxicity?
A. Yellow-green halos around lights
B. Tachycardia and hypertension
C. Loss of appetite and nausea
D. Increased urinary output
Correct Answer: C
Expert Explanation: Gastrointestinal symptoms such as anorexia, nausea, and vomiting
are often the earliest signs of digoxin toxicity. While visual changes like yellow-green halos
are classic, they usually appear later in the progression of toxicity. Monitoring serum
potassium is crucial because hypokalemia increases the risk of digoxin-related
dysrhythmias.
, 4. A nurse is providing discharge instructions to a client with COPD. What should the nurse
emphasize regarding oxygen therapy?
A. Maintain oxygen flow at 6-10 L/min via simple mask
B. Oxygen is only needed when the client feels short of breath
C. Do not exceed 2 L/min unless otherwise directed
D. Smoking is allowed if oxygen is turned off for 15 minutes
Correct Answer: C
Expert Explanation: In clients with COPD, high concentrations of oxygen can suppress the
hypoxic drive to breathe, leading to carbon dioxide retention. It is generally recommended
to maintain low-flow oxygen, typically 1 to 2 L/min, to keep saturations between 88% and
92%. The nurse must teach the client that oxygen is a medication and should not be
adjusted without medical consultation.
5. A client returns to the unit after a cardiac catheterization via the femoral artery. Which
nursing intervention is the highest priority?
A. Encouraging the client to walk to prevent DVT
B. Assessing the pedal pulses and the insertion site
C. Providing a high-protein meal for wound healing
D. Teaching the client about low-sodium diets
Correct Answer: B
