PNR 201/PNR201 Final Exam V3 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with left-sided heart failure. Which of the following findings
should the nurse expect?
A. Jugular venous distention
B. Hepatomagaly
C. Dependent edema
D. Crackles in the lungs
Correct Answer: D
Expert Explanation: Left-sided heart failure results in pulmonary congestion as the left
ventricle fails to pump blood into the systemic circulation. This leads to an accumulation of
fluid in the alveoli, resulting in crackles or wheezes. Options A, C, and D are characteristic
signs of right-sided heart failure.
2. A client is prescribed Digoxin 0.125 mg daily. Which assessment finding requires the nurse
to withhold the medication?
A. Blood pressure of 110/70 mmHg
B. Apical pulse of 52 beats per minute
C. Respiratory rate of 18 breaths per minute
,D. Potassium level of 4.2 mEq/L
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate to improve
filling time and contractility. The nurse must check the apical pulse for one full minute and
withhold the dose if the heart rate is less than 60 bpm in adults. Bradycardia is a primary
sign of Digoxin toxicity that necessitates immediate intervention.
3. A nurse is teaching a client with Type 1 Diabetes about hypoglycemia. Which symptom
should the nurse include in the teaching?
A. Extreme thirst
B. Fruity breath odor
C. Shakiness and diaphoresis
D. Abdominal pain
Correct Answer: C
Expert Explanation: Hypoglycemia triggers the sympathetic nervous system, leading to
symptoms like tremors, sweating, and palpitations. Extreme thirst and fruity breath are
associated with hyperglycemia and ketoacidosis. Educating the client on recognizing these
early warning signs is crucial for prompt self-treatment.
4. A client is 24 hours post-operative following an abdominal surgery. Which intervention is
most effective in preventing deep vein thrombosis (DVT)?
A. Encouraging early and frequent ambulation
, B. Massaging the legs daily
C. Applying heating pads to the calves
D. Restricting oral fluid intake
Correct Answer: A
Expert Explanation: Early ambulation promotes venous return and prevents stasis of
blood in the lower extremities. Massaging the legs is contraindicated as it could dislodge a
thrombus if one has already formed. Sequential compression devices and adequate
hydration are also key components of DVT prophylaxis in surgical patients.
5. Which lab value is the most specific indicator of a Myocardial Infarction (MI)?
A. Creatine Kinase (CK)
B. C-Reactive Protein (CRP)
C. Brain Natriuretic Peptide (BNP)
D. Troponin I
Correct Answer: D
Expert Explanation: Troponin I is a protein found only in cardiac muscle and is released
when myocardial cells are damaged. It is considered the gold standard for diagnosing an MI
because it is highly specific to the heart. BNP is used to assess for heart failure rather than
acute myocardial damage.
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with left-sided heart failure. Which of the following findings
should the nurse expect?
A. Jugular venous distention
B. Hepatomagaly
C. Dependent edema
D. Crackles in the lungs
Correct Answer: D
Expert Explanation: Left-sided heart failure results in pulmonary congestion as the left
ventricle fails to pump blood into the systemic circulation. This leads to an accumulation of
fluid in the alveoli, resulting in crackles or wheezes. Options A, C, and D are characteristic
signs of right-sided heart failure.
2. A client is prescribed Digoxin 0.125 mg daily. Which assessment finding requires the nurse
to withhold the medication?
A. Blood pressure of 110/70 mmHg
B. Apical pulse of 52 beats per minute
C. Respiratory rate of 18 breaths per minute
,D. Potassium level of 4.2 mEq/L
Correct Answer: B
Expert Explanation: Digoxin is a cardiac glycoside that slows the heart rate to improve
filling time and contractility. The nurse must check the apical pulse for one full minute and
withhold the dose if the heart rate is less than 60 bpm in adults. Bradycardia is a primary
sign of Digoxin toxicity that necessitates immediate intervention.
3. A nurse is teaching a client with Type 1 Diabetes about hypoglycemia. Which symptom
should the nurse include in the teaching?
A. Extreme thirst
B. Fruity breath odor
C. Shakiness and diaphoresis
D. Abdominal pain
Correct Answer: C
Expert Explanation: Hypoglycemia triggers the sympathetic nervous system, leading to
symptoms like tremors, sweating, and palpitations. Extreme thirst and fruity breath are
associated with hyperglycemia and ketoacidosis. Educating the client on recognizing these
early warning signs is crucial for prompt self-treatment.
4. A client is 24 hours post-operative following an abdominal surgery. Which intervention is
most effective in preventing deep vein thrombosis (DVT)?
A. Encouraging early and frequent ambulation
, B. Massaging the legs daily
C. Applying heating pads to the calves
D. Restricting oral fluid intake
Correct Answer: A
Expert Explanation: Early ambulation promotes venous return and prevents stasis of
blood in the lower extremities. Massaging the legs is contraindicated as it could dislodge a
thrombus if one has already formed. Sequential compression devices and adequate
hydration are also key components of DVT prophylaxis in surgical patients.
5. Which lab value is the most specific indicator of a Myocardial Infarction (MI)?
A. Creatine Kinase (CK)
B. C-Reactive Protein (CRP)
C. Brain Natriuretic Peptide (BNP)
D. Troponin I
Correct Answer: D
Expert Explanation: Troponin I is a protein found only in cardiac muscle and is released
when myocardial cells are damaged. It is considered the gold standard for diagnosing an MI
because it is highly specific to the heart. BNP is used to assess for heart failure rather than
acute myocardial damage.
