NUR185/NUR 185 Exam 3 V2 | Concepts of
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A patient with left-sided heart failure is being assessed. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Peripheral edema in the lower extremities
C. Crackles auscultated in the lungs
D. Hepatomegaly and abdominal tenderness
Correct Answer: C
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
leading to pulmonary congestion. This results in respiratory symptoms such as dyspnea,
orthopnea, and audible crackles during lung auscultation. In contrast, right-sided heart
failure typically manifests as systemic venous congestion, including jugular venous
distention and peripheral edema.
2. Which lab value is most specific for diagnosing a myocardial infarction (MI)?
A. Troponin I
B. Creatine Kinase (CK-MB)
,C. Myoglobin
D. Brain Natriuretic Peptide (BNP)
Correct Answer: A
Rationale: Troponin I is highly specific to cardiac muscle and is the gold standard for
identifying myocardial injury. Levels begin to rise within a few hours of an MI and can
remain elevated for up to two weeks. While CK-MB and myoglobin are also used, they are
less cardiac-specific than troponin markers.
3. A nurse is preparing to administer Digoxin to a patient with heart failure. Which action is
the priority before administration?
A. Check the patient’s blood pressure
B. Auscultate the apical pulse for 60 seconds
C. Review the most recent serum sodium level
D. Encourage the patient to increase fiber intake
Correct Answer: B
Rationale: The nurse must assess the apical pulse for one full minute before giving Digoxin
to ensure the heart rate is above 60 beats per minute. Digoxin is a negative chronotrope
that slows the heart rate, and giving it during bradycardia could be dangerous. If the heart
rate is below the specified threshold, the medication must be held and the provider
notified.
, 4. A patient with Peripheral Arterial Disease (PAD) complains of pain while walking that
resolves with rest. What is the correct term for this symptom?
A. Rest pain
B. Intermittent claudication
C. Neuropathic discomfort
D. Venous stasis pain
Correct Answer: B
Rationale: Intermittent claudication is the classic symptom of PAD, caused by inadequate
oxygen delivery to working muscles during exercise. The pain is usually described as
cramping or aching in the calves and disappears when the patient stops walking. This
indicates that the arterial blood flow is sufficient at rest but insufficient during increased
metabolic demand.
5. Which position is most appropriate for a patient suffering from Chronic Venous
Insufficiency?
A. Dangling the legs over the side of the bed
B. Keeping the legs in a dependent position
C. Elevating the legs above the level of the heart
D. Crossing the legs at the knees while sitting
Correct Answer: C
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A patient with left-sided heart failure is being assessed. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Peripheral edema in the lower extremities
C. Crackles auscultated in the lungs
D. Hepatomegaly and abdominal tenderness
Correct Answer: C
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
leading to pulmonary congestion. This results in respiratory symptoms such as dyspnea,
orthopnea, and audible crackles during lung auscultation. In contrast, right-sided heart
failure typically manifests as systemic venous congestion, including jugular venous
distention and peripheral edema.
2. Which lab value is most specific for diagnosing a myocardial infarction (MI)?
A. Troponin I
B. Creatine Kinase (CK-MB)
,C. Myoglobin
D. Brain Natriuretic Peptide (BNP)
Correct Answer: A
Rationale: Troponin I is highly specific to cardiac muscle and is the gold standard for
identifying myocardial injury. Levels begin to rise within a few hours of an MI and can
remain elevated for up to two weeks. While CK-MB and myoglobin are also used, they are
less cardiac-specific than troponin markers.
3. A nurse is preparing to administer Digoxin to a patient with heart failure. Which action is
the priority before administration?
A. Check the patient’s blood pressure
B. Auscultate the apical pulse for 60 seconds
C. Review the most recent serum sodium level
D. Encourage the patient to increase fiber intake
Correct Answer: B
Rationale: The nurse must assess the apical pulse for one full minute before giving Digoxin
to ensure the heart rate is above 60 beats per minute. Digoxin is a negative chronotrope
that slows the heart rate, and giving it during bradycardia could be dangerous. If the heart
rate is below the specified threshold, the medication must be held and the provider
notified.
, 4. A patient with Peripheral Arterial Disease (PAD) complains of pain while walking that
resolves with rest. What is the correct term for this symptom?
A. Rest pain
B. Intermittent claudication
C. Neuropathic discomfort
D. Venous stasis pain
Correct Answer: B
Rationale: Intermittent claudication is the classic symptom of PAD, caused by inadequate
oxygen delivery to working muscles during exercise. The pain is usually described as
cramping or aching in the calves and disappears when the patient stops walking. This
indicates that the arterial blood flow is sufficient at rest but insufficient during increased
metabolic demand.
5. Which position is most appropriate for a patient suffering from Chronic Venous
Insufficiency?
A. Dangling the legs over the side of the bed
B. Keeping the legs in a dependent position
C. Elevating the legs above the level of the heart
D. Crossing the legs at the knees while sitting
Correct Answer: C
