NUR 170 Exam 2: Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation should the nurse
expect to find?
A. Jugular venous distention
B. Hepatomegaly
C. Peripheral edema
D. Crackles in the lungs
Correct Answer: D
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation, leading to
respiratory symptoms. Crackles are a hallmark sign of pulmonary congestion resulting from fluid in the
alveoli. Options A, C, and D are characteristic signs of right-sided heart failure due to systemic venous
congestion. Assessing lung sounds is a priority nursing action for these patients to monitor for worsening
pulmonary edema. Understanding this distinction helps the nurse focus on respiratory management for
left-sided failure.
2. A client is prescribed Digoxin for heart failure. Which of the following findings should the nurse identify as
an early sign of Digoxin toxicity?
A. Anorexia and nausea
B. Hypertension
C. Tachycardia
D. Constipation
,Correct Answer: A
Rationale: Gastrointestinal symptoms such as anorexia, nausea, and vomiting are often the earliest
indicators of digoxin toxicity. Digoxin has a narrow therapeutic range, making monitoring for toxicity
essential for patient safety. Visual disturbances like yellow-green halos are also classic signs but usually
occur later. The nurse must check the apical pulse for one full minute before administration and hold the
drug if the heart rate is too low. Early identification of these symptoms can prevent life-threatening
dysrhythmias.
3. The nurse is teaching a client with COPD about pursed-lip breathing. What is the primary purpose of this
technique?
A. To strengthen the diaphragm muscle
B. To increase the inhalation of oxygen
C. To decrease the rate of breathing
D. To prevent airway collapse during expiration
Correct Answer: D
Rationale: Pursed-lip breathing creates positive pressure within the airways to keep them open longer
during exhalation. This technique allows for more effective removal of trapped air and carbon dioxide
from the lungs. It helps reduce dyspnea and allows the client to control their breathing pattern more
effectively. Clients should be taught to breathe in through the nose and out slowly through pursed lips as
if blowing out a candle. This intervention is a non-pharmacological way to manage the chronic air
trapping associated with emphysema.
4. A nurse reviews the ABG results for a client: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the
nurse interpret these results?
A. Metabolic Acidosis
, B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Rationale: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg indicates a respiratory
cause. Since the bicarbonate (HCO3) level is within the normal range, the condition is uncompensated
respiratory acidosis. This state often occurs in clients with COPD or hypoventilation where carbon
dioxide is retained. The nurse should focus on improving ventilation to blow off the excess CO2.
Monitoring the client’s respiratory rate and depth is crucial for evaluating the effectiveness of
interventions.
5. Which nursing intervention is a priority for a client immediately following a cardiac catheterization via the
femoral artery?
A. Assessing distal pulses and the insertion site
B. Encouraging early ambulation
C. Providing a high-fiber diet
D. Monitoring for signs of infection
Correct Answer: A
Rationale: The primary concern post-cardiac catheterization is hemorrhage or hematoma formation at
the puncture site. Assessing pedal pulses ensures that peripheral circulation remains intact and that no
arterial occlusion has occurred. The client must remain on bed rest with the affected extremity straight
for several hours to promote clotting. While infection is a concern later, immediate vascular
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation should the nurse
expect to find?
A. Jugular venous distention
B. Hepatomegaly
C. Peripheral edema
D. Crackles in the lungs
Correct Answer: D
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation, leading to
respiratory symptoms. Crackles are a hallmark sign of pulmonary congestion resulting from fluid in the
alveoli. Options A, C, and D are characteristic signs of right-sided heart failure due to systemic venous
congestion. Assessing lung sounds is a priority nursing action for these patients to monitor for worsening
pulmonary edema. Understanding this distinction helps the nurse focus on respiratory management for
left-sided failure.
2. A client is prescribed Digoxin for heart failure. Which of the following findings should the nurse identify as
an early sign of Digoxin toxicity?
A. Anorexia and nausea
B. Hypertension
C. Tachycardia
D. Constipation
,Correct Answer: A
Rationale: Gastrointestinal symptoms such as anorexia, nausea, and vomiting are often the earliest
indicators of digoxin toxicity. Digoxin has a narrow therapeutic range, making monitoring for toxicity
essential for patient safety. Visual disturbances like yellow-green halos are also classic signs but usually
occur later. The nurse must check the apical pulse for one full minute before administration and hold the
drug if the heart rate is too low. Early identification of these symptoms can prevent life-threatening
dysrhythmias.
3. The nurse is teaching a client with COPD about pursed-lip breathing. What is the primary purpose of this
technique?
A. To strengthen the diaphragm muscle
B. To increase the inhalation of oxygen
C. To decrease the rate of breathing
D. To prevent airway collapse during expiration
Correct Answer: D
Rationale: Pursed-lip breathing creates positive pressure within the airways to keep them open longer
during exhalation. This technique allows for more effective removal of trapped air and carbon dioxide
from the lungs. It helps reduce dyspnea and allows the client to control their breathing pattern more
effectively. Clients should be taught to breathe in through the nose and out slowly through pursed lips as
if blowing out a candle. This intervention is a non-pharmacological way to manage the chronic air
trapping associated with emphysema.
4. A nurse reviews the ABG results for a client: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the
nurse interpret these results?
A. Metabolic Acidosis
, B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Rationale: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg indicates a respiratory
cause. Since the bicarbonate (HCO3) level is within the normal range, the condition is uncompensated
respiratory acidosis. This state often occurs in clients with COPD or hypoventilation where carbon
dioxide is retained. The nurse should focus on improving ventilation to blow off the excess CO2.
Monitoring the client’s respiratory rate and depth is crucial for evaluating the effectiveness of
interventions.
5. Which nursing intervention is a priority for a client immediately following a cardiac catheterization via the
femoral artery?
A. Assessing distal pulses and the insertion site
B. Encouraging early ambulation
C. Providing a high-fiber diet
D. Monitoring for signs of infection
Correct Answer: A
Rationale: The primary concern post-cardiac catheterization is hemorrhage or hematoma formation at
the puncture site. Assessing pedal pulses ensures that peripheral circulation remains intact and that no
arterial occlusion has occurred. The client must remain on bed rest with the affected extremity straight
for several hours to promote clotting. While infection is a concern later, immediate vascular
