PNR 201/PNR201 Exam 3 V1 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient diagnosed with right-sided heart failure. Which of the
following findings should the nurse expect to document?
A. Crackles in the lungs
B. Dyspnea on exertion
C. Frothy, pink-tinged sputum
D. Dependent edema
Correct Answer: D
Expert Explanation: Right-sided heart failure leads to systemic venous congestion
because the right ventricle fails to pump blood effectively into the pulmonary circulation.
This results in fluid backing up into the systemic tissues, manifesting as dependent edema,
jugular venous distention, and hepatomegaly. Left-sided heart failure symptoms are
primarily pulmonary, such as crackles and frothy sputum.
2. Which laboratory value is the most specific indicator of myocardial damage in a patient
suspected of having a myocardial infarction?
A. Creatine kinase (CK-MB)
B. Myoglobin
,C. Troponin I
D. Lactate dehydrogenase (LDH)
Correct Answer: C
Expert Explanation: Troponin I is a highly specific cardiac marker that rises within 3 to 6
hours after myocardial injury. It remains elevated for several days, providing a wider
diagnostic window than other markers. While CK-MB is also used, it is less specific than
Troponin I in identifying cardiac-specific damage.
3. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. Which physiological stimulus drives this patient’s respiratory rate?
A. Low oxygen levels
B. Low carbon dioxide levels
C. High carbon dioxide levels
D. High pH levels
Correct Answer: A
Expert Explanation: In patients with chronic hypercapnia, such as those with COPD, the
central chemoreceptors become insensitive to high CO2 levels. Their primary drive to
breathe shifts to the peripheral chemoreceptors, which respond to low arterial oxygen
levels (hypoxic drive). Administering excessive oxygen can suppress this drive, leading to
respiratory depression or arrest.
, 4. A nurse is caring for a patient experiencing a sickle cell crisis. What is the priority nursing
intervention for this patient?
A. Administering prophylactic antibiotics
B. Encouraging physical activity
C. Applying cold compresses to joints
D. Providing intravenous hydration
Correct Answer: D
Expert Explanation: Intravenous hydration is a critical priority during a sickle cell crisis to
reduce blood viscosity and prevent further sickling. Adequate fluid intake helps the
misshapen red blood cells flow more easily through the vasculature, reducing pain and
tissue ischemia. Pain management and oxygenation are also vital, but cold compresses
should be avoided as they cause vasoconstriction.
5. A patient is scheduled for a thoracentesis. In which position should the nurse place the
patient for this procedure?
A. Supine with the head of the bed flat
B. Left side-lying with the right arm elevated
C. Prone with a pillow under the abdomen
D. Sitting on the edge of the bed leaning over a bedside table
Correct Answer: D
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient diagnosed with right-sided heart failure. Which of the
following findings should the nurse expect to document?
A. Crackles in the lungs
B. Dyspnea on exertion
C. Frothy, pink-tinged sputum
D. Dependent edema
Correct Answer: D
Expert Explanation: Right-sided heart failure leads to systemic venous congestion
because the right ventricle fails to pump blood effectively into the pulmonary circulation.
This results in fluid backing up into the systemic tissues, manifesting as dependent edema,
jugular venous distention, and hepatomegaly. Left-sided heart failure symptoms are
primarily pulmonary, such as crackles and frothy sputum.
2. Which laboratory value is the most specific indicator of myocardial damage in a patient
suspected of having a myocardial infarction?
A. Creatine kinase (CK-MB)
B. Myoglobin
,C. Troponin I
D. Lactate dehydrogenase (LDH)
Correct Answer: C
Expert Explanation: Troponin I is a highly specific cardiac marker that rises within 3 to 6
hours after myocardial injury. It remains elevated for several days, providing a wider
diagnostic window than other markers. While CK-MB is also used, it is less specific than
Troponin I in identifying cardiac-specific damage.
3. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. Which physiological stimulus drives this patient’s respiratory rate?
A. Low oxygen levels
B. Low carbon dioxide levels
C. High carbon dioxide levels
D. High pH levels
Correct Answer: A
Expert Explanation: In patients with chronic hypercapnia, such as those with COPD, the
central chemoreceptors become insensitive to high CO2 levels. Their primary drive to
breathe shifts to the peripheral chemoreceptors, which respond to low arterial oxygen
levels (hypoxic drive). Administering excessive oxygen can suppress this drive, leading to
respiratory depression or arrest.
, 4. A nurse is caring for a patient experiencing a sickle cell crisis. What is the priority nursing
intervention for this patient?
A. Administering prophylactic antibiotics
B. Encouraging physical activity
C. Applying cold compresses to joints
D. Providing intravenous hydration
Correct Answer: D
Expert Explanation: Intravenous hydration is a critical priority during a sickle cell crisis to
reduce blood viscosity and prevent further sickling. Adequate fluid intake helps the
misshapen red blood cells flow more easily through the vasculature, reducing pain and
tissue ischemia. Pain management and oxygenation are also vital, but cold compresses
should be avoided as they cause vasoconstriction.
5. A patient is scheduled for a thoracentesis. In which position should the nurse place the
patient for this procedure?
A. Supine with the head of the bed flat
B. Left side-lying with the right arm elevated
C. Prone with a pillow under the abdomen
D. Sitting on the edge of the bed leaning over a bedside table
Correct Answer: D
