NUR 304 | NUR304 Exam 2: Med Surg - MCPHS
Updated and Latest Questions and Correct
Answers with Rationale
1. A patient with heart failure is prescribed Furosemide. Which assessment finding indicates
the medication is having the desired effect?
A. Increased weight gain of 2 lbs in 24 hours
B. Presence of 2+ pitting edema in lower extremities
C. Decreased serum potassium levels
D. Clearer breath sounds upon auscultation
Correct Answer: D
Rationale: Furosemide is a loop diuretic used to reduce fluid volume overload in patients
with heart failure. Improved respiratory status, such as clearer breath sounds, indicates a
reduction in pulmonary congestion. Weight gain and persistent edema would indicate the
drug is not yet effective or the condition is worsening. Hypokalemia is a side effect, not the
primary therapeutic goal of the medication. The nurse must monitor for fluid balance and
improved perfusion to validate efficacy.
2. A patient presents to the emergency department with sharp chest pain that worsens on
inspiration and is relieved by leaning forward. What is the priority nursing diagnosis?
A. Impaired Gas Exchange
B. Acute Pain related to myocardial ischemia
C. Acute Pain related to pericardial inflammation
D. Decreased Cardiac Output
Correct Answer: C
Rationale: The clinical presentation of chest pain relieved by sitting forward is classic for
acute pericarditis. This condition involves inflammation of the pericardial sac, which
causes friction and pain during respiratory cycles. While ischemia causes pain, it is typically
not relieved by position changes. Impaired gas exchange is a secondary concern unless a
large effusion develops. The nurse should prioritize pain management and monitoring for
cardiac tamponade signs.
3. Which lab value is the most specific indicator of myocardial infarction (MI)?
A. Troponin I
B. Creatine Kinase (CK-MB)
C. Myoglobin
,D. B-type Natriuretic Peptide (BNP)
Correct Answer: A
Rationale: Troponin I is a highly sensitive and cardiac-specific protein released during
myocardial cell death. It remains elevated for several days, making it the gold standard for
diagnosing an MI. CK-MB is also used but is less specific as it can be found in skeletal
muscle. Myoglobin rises early but lacks specificity to cardiac tissue. BNP is used to assess
for heart failure and fluid overload rather than acute infarction.
4. A patient with COPD is receiving oxygen via nasal cannula at 2L/min. The patient’s SpO2 is
89% and they appear comfortable. What is the nurse’s best action?
A. Increase oxygen flow to 6L/min immediately
B. Maintain current settings and continue to monitor
C. Switch the patient to a non-rebreather mask
D. Notify the physician to request an intubation
Correct Answer: B
Rationale: In patients with chronic COPD, the target SpO2 range is typically between 88%
and 92%. Giving too much oxygen can suppress the hypoxic drive, leading to CO2 retention
and respiratory depression. Since the patient is stable and comfortable at 89%, the current
intervention is appropriate. Aggressive oxygenation could be harmful due to the patient’s
altered drive to breathe. The nurse must prioritize safety by avoiding oxygen toxicity in this
specific population.
5. Which medication is typically the first-line treatment for an acute asthma exacerbation?
A. Salmeterol (Serevent)
B. Albuterol (Proventil)
C. Fluticasone (Flovent)
D. Theophylline
Correct Answer: B
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) that provides rapid
bronchodilation during an acute attack. Salmeterol is a long-acting agonist and is never
used for rescue therapy. Fluticasone is an inhaled corticosteroid used for long-term
maintenance and does not work fast enough for emergencies. Theophylline has a narrow
therapeutic range and is rarely used as first-line therapy. Prompt administration of
Albuterol is critical for airway patency during an exacerbation.
6. The nurse is monitoring a patient with a chest tube. Which observation in the water seal
chamber requires immediate intervention?
A. Water level at the 2cm mark
, B. Intermittent bubbling during coughing
C. Fluctuation of water level with inspiration (tidaling)
D. Continuous bubbling in the water seal chamber
Correct Answer: D
Rationale: Continuous bubbling in the water seal chamber usually indicates a leak in the
system or at the insertion site. Intermittent bubbling while coughing or exhaling is normal
if the patient has a pneumothorax. Tidaling is a normal finding and shows the system is
patent and responsive to intrapleural pressure. Maintaining 2cm of water is standard for
the water seal function. Any air leak must be identified and corrected immediately to
ensure lung re-expansion.
7. A patient with Atrial Fibrillation is at high risk for which complication?
A. Ventricular Tachycardia
B. Ischemic Stroke
C. Hypovolemic Shock
D. Pneumothorax
Correct Answer: B
Rationale: Atrial fibrillation involves quivering of the atria, which leads to blood stasis and
the formation of mural thrombi. These clots can break loose and travel to the brain, causing
an embolic or ischemic stroke. Anticoagulation therapy is a standard intervention for these
patients to prevent such events. V-Tach is a separate ventricular rhythm issue and not a
direct consequence of A-Fib. Monitoring neurological status is a priority nursing action for
these patients.
8. A patient is admitted with Pulmonary Embolism. Which assessment finding is most
characteristic of this condition?
A. Bradypnea and bradycardia
B. Flattened neck veins and hypotension
C. Productive cough with thick yellow sputum
D. Sudden onset of dyspnea and tachycardia
Correct Answer: D
Rationale: A pulmonary embolism typically presents abruptly with shortness of breath
and an increased heart rate as the body compensates for hypoxia. Chest pain is also
common, often worsening with inspiration. Productive cough and fever are more indicative
of pneumonia or infection. Neck veins would more likely be distended due to right-sided
Updated and Latest Questions and Correct
Answers with Rationale
1. A patient with heart failure is prescribed Furosemide. Which assessment finding indicates
the medication is having the desired effect?
A. Increased weight gain of 2 lbs in 24 hours
B. Presence of 2+ pitting edema in lower extremities
C. Decreased serum potassium levels
D. Clearer breath sounds upon auscultation
Correct Answer: D
Rationale: Furosemide is a loop diuretic used to reduce fluid volume overload in patients
with heart failure. Improved respiratory status, such as clearer breath sounds, indicates a
reduction in pulmonary congestion. Weight gain and persistent edema would indicate the
drug is not yet effective or the condition is worsening. Hypokalemia is a side effect, not the
primary therapeutic goal of the medication. The nurse must monitor for fluid balance and
improved perfusion to validate efficacy.
2. A patient presents to the emergency department with sharp chest pain that worsens on
inspiration and is relieved by leaning forward. What is the priority nursing diagnosis?
A. Impaired Gas Exchange
B. Acute Pain related to myocardial ischemia
C. Acute Pain related to pericardial inflammation
D. Decreased Cardiac Output
Correct Answer: C
Rationale: The clinical presentation of chest pain relieved by sitting forward is classic for
acute pericarditis. This condition involves inflammation of the pericardial sac, which
causes friction and pain during respiratory cycles. While ischemia causes pain, it is typically
not relieved by position changes. Impaired gas exchange is a secondary concern unless a
large effusion develops. The nurse should prioritize pain management and monitoring for
cardiac tamponade signs.
3. Which lab value is the most specific indicator of myocardial infarction (MI)?
A. Troponin I
B. Creatine Kinase (CK-MB)
C. Myoglobin
,D. B-type Natriuretic Peptide (BNP)
Correct Answer: A
Rationale: Troponin I is a highly sensitive and cardiac-specific protein released during
myocardial cell death. It remains elevated for several days, making it the gold standard for
diagnosing an MI. CK-MB is also used but is less specific as it can be found in skeletal
muscle. Myoglobin rises early but lacks specificity to cardiac tissue. BNP is used to assess
for heart failure and fluid overload rather than acute infarction.
4. A patient with COPD is receiving oxygen via nasal cannula at 2L/min. The patient’s SpO2 is
89% and they appear comfortable. What is the nurse’s best action?
A. Increase oxygen flow to 6L/min immediately
B. Maintain current settings and continue to monitor
C. Switch the patient to a non-rebreather mask
D. Notify the physician to request an intubation
Correct Answer: B
Rationale: In patients with chronic COPD, the target SpO2 range is typically between 88%
and 92%. Giving too much oxygen can suppress the hypoxic drive, leading to CO2 retention
and respiratory depression. Since the patient is stable and comfortable at 89%, the current
intervention is appropriate. Aggressive oxygenation could be harmful due to the patient’s
altered drive to breathe. The nurse must prioritize safety by avoiding oxygen toxicity in this
specific population.
5. Which medication is typically the first-line treatment for an acute asthma exacerbation?
A. Salmeterol (Serevent)
B. Albuterol (Proventil)
C. Fluticasone (Flovent)
D. Theophylline
Correct Answer: B
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) that provides rapid
bronchodilation during an acute attack. Salmeterol is a long-acting agonist and is never
used for rescue therapy. Fluticasone is an inhaled corticosteroid used for long-term
maintenance and does not work fast enough for emergencies. Theophylline has a narrow
therapeutic range and is rarely used as first-line therapy. Prompt administration of
Albuterol is critical for airway patency during an exacerbation.
6. The nurse is monitoring a patient with a chest tube. Which observation in the water seal
chamber requires immediate intervention?
A. Water level at the 2cm mark
, B. Intermittent bubbling during coughing
C. Fluctuation of water level with inspiration (tidaling)
D. Continuous bubbling in the water seal chamber
Correct Answer: D
Rationale: Continuous bubbling in the water seal chamber usually indicates a leak in the
system or at the insertion site. Intermittent bubbling while coughing or exhaling is normal
if the patient has a pneumothorax. Tidaling is a normal finding and shows the system is
patent and responsive to intrapleural pressure. Maintaining 2cm of water is standard for
the water seal function. Any air leak must be identified and corrected immediately to
ensure lung re-expansion.
7. A patient with Atrial Fibrillation is at high risk for which complication?
A. Ventricular Tachycardia
B. Ischemic Stroke
C. Hypovolemic Shock
D. Pneumothorax
Correct Answer: B
Rationale: Atrial fibrillation involves quivering of the atria, which leads to blood stasis and
the formation of mural thrombi. These clots can break loose and travel to the brain, causing
an embolic or ischemic stroke. Anticoagulation therapy is a standard intervention for these
patients to prevent such events. V-Tach is a separate ventricular rhythm issue and not a
direct consequence of A-Fib. Monitoring neurological status is a priority nursing action for
these patients.
8. A patient is admitted with Pulmonary Embolism. Which assessment finding is most
characteristic of this condition?
A. Bradypnea and bradycardia
B. Flattened neck veins and hypotension
C. Productive cough with thick yellow sputum
D. Sudden onset of dyspnea and tachycardia
Correct Answer: D
Rationale: A pulmonary embolism typically presents abruptly with shortness of breath
and an increased heart rate as the body compensates for hypoxia. Chest pain is also
common, often worsening with inspiration. Productive cough and fever are more indicative
of pneumonia or infection. Neck veins would more likely be distended due to right-sided
