NUR 209/NUR209 Exam 1 V3 | 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. Crackles in the lungs
B. Peripheral edema
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: A
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot pump blood efficiently into the systemic circulation. This causes fluid
to back up into the lungs, leading to symptoms like crackles, dyspnea, and orthopnea.
Right-sided failure typically presents with systemic signs like peripheral edema and jugular
vein distention.
2. A client is prescribed digoxin for heart failure. Which of the following laboratory values
should the nurse monitor most closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
,C. Serum Calcium
D. Serum Magnesium
Correct Answer: B
Expert Explanation: Hypokalemia increases the risk of digoxin toxicity because potassium
and digoxin compete for binding sites on the sodium-potassium ATPase pump. When
potassium levels are low, more digoxin binds to these sites, enhancing its effect and
potential for toxicity. The nurse must ensure the client’s potassium levels remain within
the normal range of 3.5 to 5.0 mEq/L.
3. Which cardiac rhythm is characterized by the absence of P waves and an irregularly
irregular QRS complex?
A. Atrial Fibrillation
B. Ventricular Tachycardia
C. First-Degree AV Block
D. Sinus Bradycardia
Correct Answer: A
Expert Explanation: Atrial fibrillation occurs when the atria quiver instead of contracting
effectively, resulting in a lack of discernible P waves. The rhythm is irregularly irregular
because the AV node allows impulses to pass to the ventricles at inconsistent intervals. This
condition puts the client at a high risk for thromboembolism and stroke.
, 4. A patient with a history of COPD presents with an arterial blood gas (ABG) result of pH
7.32, PaCO2 55, and HCO3 28. How should the nurse interpret these results?
A. Metabolic Alkalosis, partially compensated
B. Respiratory Alkalosis, uncompensated
C. Metabolic Acidosis, fully compensated
D. Respiratory Acidosis, partially compensated
Correct Answer: D
Expert Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause), and
the HCO3 is elevated (indicating the kidneys are trying to compensate). Because the pH is
not yet within the normal range, it is considered partially compensated. This is a common
finding in patients with chronic obstructive pulmonary disease who retain carbon dioxide.
5. Which intervention is a priority for a client diagnosed with a Pulmonary Embolism (PE)?
A. Administering oral aspirin
B. Initiating intravenous Heparin therapy
C. Encouraging high-intensity exercise
D. Placing the client in a prone position
Correct Answer: B
Expert Explanation: Intravenous Heparin is the standard initial treatment for a
pulmonary embolism to prevent the clot from enlarging and to stop new clots from
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. Crackles in the lungs
B. Peripheral edema
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: A
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot pump blood efficiently into the systemic circulation. This causes fluid
to back up into the lungs, leading to symptoms like crackles, dyspnea, and orthopnea.
Right-sided failure typically presents with systemic signs like peripheral edema and jugular
vein distention.
2. A client is prescribed digoxin for heart failure. Which of the following laboratory values
should the nurse monitor most closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
,C. Serum Calcium
D. Serum Magnesium
Correct Answer: B
Expert Explanation: Hypokalemia increases the risk of digoxin toxicity because potassium
and digoxin compete for binding sites on the sodium-potassium ATPase pump. When
potassium levels are low, more digoxin binds to these sites, enhancing its effect and
potential for toxicity. The nurse must ensure the client’s potassium levels remain within
the normal range of 3.5 to 5.0 mEq/L.
3. Which cardiac rhythm is characterized by the absence of P waves and an irregularly
irregular QRS complex?
A. Atrial Fibrillation
B. Ventricular Tachycardia
C. First-Degree AV Block
D. Sinus Bradycardia
Correct Answer: A
Expert Explanation: Atrial fibrillation occurs when the atria quiver instead of contracting
effectively, resulting in a lack of discernible P waves. The rhythm is irregularly irregular
because the AV node allows impulses to pass to the ventricles at inconsistent intervals. This
condition puts the client at a high risk for thromboembolism and stroke.
, 4. A patient with a history of COPD presents with an arterial blood gas (ABG) result of pH
7.32, PaCO2 55, and HCO3 28. How should the nurse interpret these results?
A. Metabolic Alkalosis, partially compensated
B. Respiratory Alkalosis, uncompensated
C. Metabolic Acidosis, fully compensated
D. Respiratory Acidosis, partially compensated
Correct Answer: D
Expert Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause), and
the HCO3 is elevated (indicating the kidneys are trying to compensate). Because the pH is
not yet within the normal range, it is considered partially compensated. This is a common
finding in patients with chronic obstructive pulmonary disease who retain carbon dioxide.
5. Which intervention is a priority for a client diagnosed with a Pulmonary Embolism (PE)?
A. Administering oral aspirin
B. Initiating intravenous Heparin therapy
C. Encouraging high-intensity exercise
D. Placing the client in a prone position
Correct Answer: B
Expert Explanation: Intravenous Heparin is the standard initial treatment for a
pulmonary embolism to prevent the clot from enlarging and to stop new clots from
