NURS 211L | NURS211L Exam 2: Med Surg 2 - WCU
Updated and Latest Questions and Correct
Answers with Rationale
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. Dependent edema
C. Hepatosplenomegaly
D. Pulmonary crackles
Correct Answer: D
Rationale: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot effectively pump blood into systemic circulation. This leads to an
accumulation of fluid in the lungs, manifested as crackles or wheezes. In contrast, jugular
venous distention and dependent edema are hallmark signs of right-sided heart failure.
Hepatosplenomegaly is also associated with systemic venous congestion from right-sided
failure. Monitoring breath sounds is a priority intervention for patients with left-sided
cardiac dysfunction.
2. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. Which physiological factor serves as the primary respiratory drive for this
patient?
A. High serum carbon dioxide levels
B. Low serum bicarbonate
C. High serum pH
D. Low serum oxygen levels
Correct Answer: D
Rationale: In healthy individuals, the primary stimulus for breathing is an increase in
carbon dioxide levels. However, patients with chronic COPD often retain CO2, leading the
body to adapt and rely on low oxygen levels as the trigger to breathe. Providing high
concentrations of oxygen can inadvertently suppress this hypoxic drive and cause
respiratory depression. Nurses must carefully titrate oxygen therapy to maintain a
saturation of 88% to 92%. Understanding this mechanism is vital to preventing
complications in respiratory management.
,3. Which of the following medications is considered the ‘gold standard’ for the immediate
relief of an acute asthma attack?
A. Salmeterol
B. Fluticasone
C. Albuterol
D. Prednisone
Correct Answer: C
Rationale: Albuterol is a short-acting beta2-agonist (SABA) that provides rapid
bronchodilation by relaxing smooth muscle. It is the medication of choice for treating acute
exacerbations of asthma and exercise-induced bronchospasm. Salmeterol is a long-acting
agent and is not appropriate for emergency use. Fluticasone and prednisone are
corticosteroids used for long-term inflammation control rather than acute relief. Nurses
must educate patients on the difference between rescue and maintenance inhalers to
ensure safety.
4. A nurse is caring for a client who is taking lisinopril for hypertension. Which of the
following side effects should the nurse instruct the client to report immediately?
A. Occasional headache
B. Slight metallic taste
C. Increased appetite
D. Persistent dry cough
Correct Answer: D
Rationale: Lisinopril is an ACE inhibitor that can cause a buildup of bradykinin in the
lungs, leading to a persistent dry cough. This side effect is a common reason for patients to
discontinue the medication and often requires a switch to an ARB. While headaches can
occur, they are generally not as significant as the cough or more severe reactions like
angioedema. The nurse should also monitor for signs of hyperkalemia, which is another
risk with this drug class. Patient adherence depends heavily on managing these adverse
effects through education. Timely reporting of the cough allows the provider to adjust the
treatment plan safely.
5. A nurse is reviewing the laboratory results of a patient suspected of having a myocardial
infarction. Which cardiac enzyme is the most sensitive and specific for cardiac muscle injury?
A. Creatine kinase (CK-MB)
B. Myoglobin
C. Lactate dehydrogenase (LDH)
D. Troponin I
, Correct Answer: D
Rationale: Troponin I is highly specific to cardiac tissue and remains elevated for several
days after an injury occurs. While CK-MB was previously the standard, it is less specific
than troponin because it can rise with skeletal muscle damage. Myoglobin rises quickly but
lacks specificity for the heart muscle specifically. LDH is no longer commonly used for
diagnosing acute MI due to its late rise and lack of specificity. Prompt recognition of
elevated troponin levels allows for rapid intervention in the cardiac catheterization lab.
6. A client is prescribed digoxin for heart failure. Which of the following electrolyte
imbalances increases the risk of digoxin toxicity?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hyponatremia
Correct Answer: B
Rationale: Low serum potassium levels enhance the effects of digoxin at the myocardial
cell level, increasing the risk of toxicity. Digoxin toxicity can manifest as bradycardia, visual
disturbances like yellow halos, and gastrointestinal distress. Nurses must monitor
potassium levels closely, especially if the patient is also taking potassium-wasting diuretics
like furosemide. Normal potassium levels range from 3.5 to 5.0 mEq/L. Ensuring the
patient maintains stable electrolyte levels is critical for safe digoxin administration.
7. A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the
water-seal chamber. What does this finding indicate?
A. The system is functioning normally.
B. The suction pressure is too high.
C. The lung has fully re-expanded.
D. There is a leak in the drainage system.
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber usually signifies an air leak in
the system or at the insertion site. Intermittent bubbling is expected during expiration or
coughing in a patient with a pneumothorax. If the bubbling becomes constant, the nurse
should check the connections and the dressing. Constant bubbling in the suction control
chamber, however, is a normal finding if suction is applied. Maintaining the integrity of the
chest tube system is essential for proper lung re-expansion.
8. An arterial blood gas (ABG) result shows pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L.
How should the nurse interpret these results?
A. Respiratory Alkalosis
Updated and Latest Questions and Correct
Answers with Rationale
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. Dependent edema
C. Hepatosplenomegaly
D. Pulmonary crackles
Correct Answer: D
Rationale: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot effectively pump blood into systemic circulation. This leads to an
accumulation of fluid in the lungs, manifested as crackles or wheezes. In contrast, jugular
venous distention and dependent edema are hallmark signs of right-sided heart failure.
Hepatosplenomegaly is also associated with systemic venous congestion from right-sided
failure. Monitoring breath sounds is a priority intervention for patients with left-sided
cardiac dysfunction.
2. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. Which physiological factor serves as the primary respiratory drive for this
patient?
A. High serum carbon dioxide levels
B. Low serum bicarbonate
C. High serum pH
D. Low serum oxygen levels
Correct Answer: D
Rationale: In healthy individuals, the primary stimulus for breathing is an increase in
carbon dioxide levels. However, patients with chronic COPD often retain CO2, leading the
body to adapt and rely on low oxygen levels as the trigger to breathe. Providing high
concentrations of oxygen can inadvertently suppress this hypoxic drive and cause
respiratory depression. Nurses must carefully titrate oxygen therapy to maintain a
saturation of 88% to 92%. Understanding this mechanism is vital to preventing
complications in respiratory management.
,3. Which of the following medications is considered the ‘gold standard’ for the immediate
relief of an acute asthma attack?
A. Salmeterol
B. Fluticasone
C. Albuterol
D. Prednisone
Correct Answer: C
Rationale: Albuterol is a short-acting beta2-agonist (SABA) that provides rapid
bronchodilation by relaxing smooth muscle. It is the medication of choice for treating acute
exacerbations of asthma and exercise-induced bronchospasm. Salmeterol is a long-acting
agent and is not appropriate for emergency use. Fluticasone and prednisone are
corticosteroids used for long-term inflammation control rather than acute relief. Nurses
must educate patients on the difference between rescue and maintenance inhalers to
ensure safety.
4. A nurse is caring for a client who is taking lisinopril for hypertension. Which of the
following side effects should the nurse instruct the client to report immediately?
A. Occasional headache
B. Slight metallic taste
C. Increased appetite
D. Persistent dry cough
Correct Answer: D
Rationale: Lisinopril is an ACE inhibitor that can cause a buildup of bradykinin in the
lungs, leading to a persistent dry cough. This side effect is a common reason for patients to
discontinue the medication and often requires a switch to an ARB. While headaches can
occur, they are generally not as significant as the cough or more severe reactions like
angioedema. The nurse should also monitor for signs of hyperkalemia, which is another
risk with this drug class. Patient adherence depends heavily on managing these adverse
effects through education. Timely reporting of the cough allows the provider to adjust the
treatment plan safely.
5. A nurse is reviewing the laboratory results of a patient suspected of having a myocardial
infarction. Which cardiac enzyme is the most sensitive and specific for cardiac muscle injury?
A. Creatine kinase (CK-MB)
B. Myoglobin
C. Lactate dehydrogenase (LDH)
D. Troponin I
, Correct Answer: D
Rationale: Troponin I is highly specific to cardiac tissue and remains elevated for several
days after an injury occurs. While CK-MB was previously the standard, it is less specific
than troponin because it can rise with skeletal muscle damage. Myoglobin rises quickly but
lacks specificity for the heart muscle specifically. LDH is no longer commonly used for
diagnosing acute MI due to its late rise and lack of specificity. Prompt recognition of
elevated troponin levels allows for rapid intervention in the cardiac catheterization lab.
6. A client is prescribed digoxin for heart failure. Which of the following electrolyte
imbalances increases the risk of digoxin toxicity?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hyponatremia
Correct Answer: B
Rationale: Low serum potassium levels enhance the effects of digoxin at the myocardial
cell level, increasing the risk of toxicity. Digoxin toxicity can manifest as bradycardia, visual
disturbances like yellow halos, and gastrointestinal distress. Nurses must monitor
potassium levels closely, especially if the patient is also taking potassium-wasting diuretics
like furosemide. Normal potassium levels range from 3.5 to 5.0 mEq/L. Ensuring the
patient maintains stable electrolyte levels is critical for safe digoxin administration.
7. A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the
water-seal chamber. What does this finding indicate?
A. The system is functioning normally.
B. The suction pressure is too high.
C. The lung has fully re-expanded.
D. There is a leak in the drainage system.
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber usually signifies an air leak in
the system or at the insertion site. Intermittent bubbling is expected during expiration or
coughing in a patient with a pneumothorax. If the bubbling becomes constant, the nurse
should check the connections and the dressing. Constant bubbling in the suction control
chamber, however, is a normal finding if suction is applied. Maintaining the integrity of the
chest tube system is essential for proper lung re-expansion.
8. An arterial blood gas (ABG) result shows pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L.
How should the nurse interpret these results?
A. Respiratory Alkalosis
