NUR 209/NUR209 Exam 2 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is 2 hours postoperative following a cardiac
catheterization. Which of the following is the priority nursing assessment?
A. Monitoring the client’s urinary output
B. Checking the peripheral pulses in the affected extremity
C. Assessing the client’s level of pain
D. Measuring the client’s temperature
Correct Answer: B
Expert Explanation: After a cardiac catheterization, the most critical assessment is to
ensure the integrity of the vascular system distal to the puncture site. Checking peripheral
pulses allows the nurse to identify arterial occlusion or hematoma formation early. This
intervention is essential for preventing limb ischemia and identifying internal bleeding.
2. A client presents with a heart rate of 42 beats per minute, reports dizziness, and has a
blood pressure of 88/50 mmHg. The nurse should anticipate administering which medication?
A. Atropine
B. Amiodarone
C. Lisinopril
,D. Metoprolol
Correct Answer: A
Expert Explanation: Atropine is the primary medication used to treat symptomatic
bradycardia because it blocks the parasympathetic nervous system’s effect on the heart. By
increasing the heart rate, it improves cardiac output and subsequently raises blood
pressure. The nurse must monitor for side effects such as dry mouth or urinary retention
after administration.
3. Which of the following laboratory values should a nurse prioritize for a client receiving a
heparin infusion for a deep vein thrombosis?
A. Activated Partial Thromboplastin Time (aPTT)
B. International Normalized Ratio (INR)
C. Prothrombin Time (PT)
D. Glycosylated hemoglobin (HbA1c)
Correct Answer: A
Expert Explanation: The aPTT is the standard laboratory test used to monitor the
therapeutic effectiveness of unfractionated heparin. Maintaining the aPTT within a specific
range (usually 1.5 to 2.5 times the control) ensures the blood is sufficiently anticoagulated
without causing hemorrhage. Monitoring PT/INR is reserved for patients taking oral
warfarin, not intravenous heparin.
, 4. A nurse is teaching a client about the manifestations of left-sided heart failure. Which of
the following should be included in the teaching?
A. Dyspnea and crackles
B. Jugular venous distention
C. Peripheral edema
D. Hepatomegaly
Correct Answer: A
Expert Explanation: Left-sided heart failure primarily affects the pulmonary system
because blood backs up into the lungs when the left ventricle cannot pump efficiently. This
leads to pulmonary congestion, which manifests as dyspnea, crackles on auscultation, and
orthopnea. Right-sided heart failure, conversely, causes systemic symptoms like peripheral
edema and jugular venous distention.
5. A client is diagnosed with pernicious anemia. The nurse should explain that the client lacks
which of the following substances?
A. Intrinsic factor
B. Iron
C. Erythropoietin
D. Folic acid
Correct Answer: A
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is 2 hours postoperative following a cardiac
catheterization. Which of the following is the priority nursing assessment?
A. Monitoring the client’s urinary output
B. Checking the peripheral pulses in the affected extremity
C. Assessing the client’s level of pain
D. Measuring the client’s temperature
Correct Answer: B
Expert Explanation: After a cardiac catheterization, the most critical assessment is to
ensure the integrity of the vascular system distal to the puncture site. Checking peripheral
pulses allows the nurse to identify arterial occlusion or hematoma formation early. This
intervention is essential for preventing limb ischemia and identifying internal bleeding.
2. A client presents with a heart rate of 42 beats per minute, reports dizziness, and has a
blood pressure of 88/50 mmHg. The nurse should anticipate administering which medication?
A. Atropine
B. Amiodarone
C. Lisinopril
,D. Metoprolol
Correct Answer: A
Expert Explanation: Atropine is the primary medication used to treat symptomatic
bradycardia because it blocks the parasympathetic nervous system’s effect on the heart. By
increasing the heart rate, it improves cardiac output and subsequently raises blood
pressure. The nurse must monitor for side effects such as dry mouth or urinary retention
after administration.
3. Which of the following laboratory values should a nurse prioritize for a client receiving a
heparin infusion for a deep vein thrombosis?
A. Activated Partial Thromboplastin Time (aPTT)
B. International Normalized Ratio (INR)
C. Prothrombin Time (PT)
D. Glycosylated hemoglobin (HbA1c)
Correct Answer: A
Expert Explanation: The aPTT is the standard laboratory test used to monitor the
therapeutic effectiveness of unfractionated heparin. Maintaining the aPTT within a specific
range (usually 1.5 to 2.5 times the control) ensures the blood is sufficiently anticoagulated
without causing hemorrhage. Monitoring PT/INR is reserved for patients taking oral
warfarin, not intravenous heparin.
, 4. A nurse is teaching a client about the manifestations of left-sided heart failure. Which of
the following should be included in the teaching?
A. Dyspnea and crackles
B. Jugular venous distention
C. Peripheral edema
D. Hepatomegaly
Correct Answer: A
Expert Explanation: Left-sided heart failure primarily affects the pulmonary system
because blood backs up into the lungs when the left ventricle cannot pump efficiently. This
leads to pulmonary congestion, which manifests as dyspnea, crackles on auscultation, and
orthopnea. Right-sided heart failure, conversely, causes systemic symptoms like peripheral
edema and jugular venous distention.
5. A client is diagnosed with pernicious anemia. The nurse should explain that the client lacks
which of the following substances?
A. Intrinsic factor
B. Iron
C. Erythropoietin
D. Folic acid
Correct Answer: A
