NUR 265 Exam 2: Nur Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a patient with right-sided heart failure. Which of the following clinical manifestations
should the nurse expect to find?
A. Pulmonary crackles
B. Pink frothy sputum
C. Dependent edema
D. Orthopnea
Correct Answer: C
Rationale: Right-sided heart failure leads to systemic venous congestion. This congestion causes fluid to
back up into the peripheral tissues, resulting in dependent edema. In contrast, pulmonary symptoms like
crackles and orthopnea are characteristic of left-sided heart failure. Pink frothy sputum is a hallmark sign
of acute pulmonary edema associated with left ventricular failure. The nurse must differentiate between
systemic and pulmonary symptoms to identify the affected side of the heart.
2. A patient with a history of heart failure is prescribed digoxin. Which laboratory result should the nurse
monitor closely to prevent digoxin toxicity?
A. Serum sodium
B. Serum calcium
C. Serum potassium
D. Serum magnesium
Correct Answer: C
,Rationale: Hypokalemia significantly increases the risk of digoxin toxicity because potassium competes
with digoxin for binding sites. When potassium levels are low, more digoxin binds to the sodium-
potassium ATPase pump, enhancing its effect to toxic levels. The nurse must ensure the patient’s
potassium remains within the normal range of 3.5 to 5.0 mEq/L. Digoxin toxicity can manifest as visual
disturbances, nausea, and life-threatening dysrhythmias. Monitoring electrolytes is a critical nursing
intervention for patients on this medication.
3. A nurse is caring for a patient experiencing an acute asthma attack. Which medication should the nurse
prepare to administer first?
A. Salmeterol
B. Fluticasone
C. Montelukast
D. Albuterol
Correct Answer: D
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) used as a rescue medication for acute
bronchospasms. It works by rapidly relaxing the smooth muscles of the airway to improve ventilation.
Medications like fluticasone and salmeterol are for long-term control and do not provide immediate
relief. Montelukast is a leukotriene modifier used for maintenance therapy rather than acute attacks.
Administering a rapid-acting bronchodilator is the priority nursing action in an emergency respiratory
situation.
4. Which of the following EKG findings is most characteristic of atrial fibrillation?
A. Sawtooth P-wave patterns
B. Prolonged PR interval greater than 0.20 seconds
, C. Wide QRS complexes exceeding 0.12 seconds
D. Absence of P-waves and irregular R-R intervals
Correct Answer: D
Rationale: Atrial fibrillation is characterized by a lack of discernible P-waves due to disorganized atrial
activity. Instead of a clear P-wave, the baseline appears fibrillatory or wavy. The ventricular response is
typically irregular, leading to inconsistent R-R intervals on the strip. Sawtooth patterns are associated
with atrial flutter, not fibrillation. Understanding these specific rhythms allows the nurse to anticipate the
need for anticoagulation or rate control.
5. A patient is admitted with a suspected pulmonary embolism (PE). What is the priority nursing
intervention?
A. Administering prescribed oral anticoagulants
B. Encouraging early ambulation
C. Obtaining a sputum culture
D. Applying supplemental oxygen
Correct Answer: D
Rationale: The immediate priority for a patient with a suspected PE is to maintain adequate oxygenation
and gas exchange. Pulmonary emboli obstruct blood flow to the lungs, creating a ventilation-perfusion
mismatch. Supplemental oxygen helps compensate for decreased lung perfusion and reduces hypoxemia.
While anticoagulation is necessary for treatment, it does not address the immediate respiratory distress.
The nurse should prioritize ABCs (Airway, Breathing, Circulation) in this acute clinical scenario.
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a patient with right-sided heart failure. Which of the following clinical manifestations
should the nurse expect to find?
A. Pulmonary crackles
B. Pink frothy sputum
C. Dependent edema
D. Orthopnea
Correct Answer: C
Rationale: Right-sided heart failure leads to systemic venous congestion. This congestion causes fluid to
back up into the peripheral tissues, resulting in dependent edema. In contrast, pulmonary symptoms like
crackles and orthopnea are characteristic of left-sided heart failure. Pink frothy sputum is a hallmark sign
of acute pulmonary edema associated with left ventricular failure. The nurse must differentiate between
systemic and pulmonary symptoms to identify the affected side of the heart.
2. A patient with a history of heart failure is prescribed digoxin. Which laboratory result should the nurse
monitor closely to prevent digoxin toxicity?
A. Serum sodium
B. Serum calcium
C. Serum potassium
D. Serum magnesium
Correct Answer: C
,Rationale: Hypokalemia significantly increases the risk of digoxin toxicity because potassium competes
with digoxin for binding sites. When potassium levels are low, more digoxin binds to the sodium-
potassium ATPase pump, enhancing its effect to toxic levels. The nurse must ensure the patient’s
potassium remains within the normal range of 3.5 to 5.0 mEq/L. Digoxin toxicity can manifest as visual
disturbances, nausea, and life-threatening dysrhythmias. Monitoring electrolytes is a critical nursing
intervention for patients on this medication.
3. A nurse is caring for a patient experiencing an acute asthma attack. Which medication should the nurse
prepare to administer first?
A. Salmeterol
B. Fluticasone
C. Montelukast
D. Albuterol
Correct Answer: D
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) used as a rescue medication for acute
bronchospasms. It works by rapidly relaxing the smooth muscles of the airway to improve ventilation.
Medications like fluticasone and salmeterol are for long-term control and do not provide immediate
relief. Montelukast is a leukotriene modifier used for maintenance therapy rather than acute attacks.
Administering a rapid-acting bronchodilator is the priority nursing action in an emergency respiratory
situation.
4. Which of the following EKG findings is most characteristic of atrial fibrillation?
A. Sawtooth P-wave patterns
B. Prolonged PR interval greater than 0.20 seconds
, C. Wide QRS complexes exceeding 0.12 seconds
D. Absence of P-waves and irregular R-R intervals
Correct Answer: D
Rationale: Atrial fibrillation is characterized by a lack of discernible P-waves due to disorganized atrial
activity. Instead of a clear P-wave, the baseline appears fibrillatory or wavy. The ventricular response is
typically irregular, leading to inconsistent R-R intervals on the strip. Sawtooth patterns are associated
with atrial flutter, not fibrillation. Understanding these specific rhythms allows the nurse to anticipate the
need for anticoagulation or rate control.
5. A patient is admitted with a suspected pulmonary embolism (PE). What is the priority nursing
intervention?
A. Administering prescribed oral anticoagulants
B. Encouraging early ambulation
C. Obtaining a sputum culture
D. Applying supplemental oxygen
Correct Answer: D
Rationale: The immediate priority for a patient with a suspected PE is to maintain adequate oxygenation
and gas exchange. Pulmonary emboli obstruct blood flow to the lungs, creating a ventilation-perfusion
mismatch. Supplemental oxygen helps compensate for decreased lung perfusion and reduces hypoxemia.
While anticoagulation is necessary for treatment, it does not address the immediate respiratory distress.
The nurse should prioritize ABCs (Airway, Breathing, Circulation) in this acute clinical scenario.
