PNR 201/PNR201 Exam 2 V3 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a history of heart failure who is taking digoxin. The client
reports blurred vision and seeing yellow-green halos. What is the nurse’s priority action?
A. Check the client’s blood pressure and pulse.
B. Assess the client’s potassium level and notify the provider.
C. Administer the next scheduled dose of digoxin.
D. Document the findings as a common side effect.
Correct Answer: B
Expert Explanation: Visual disturbances such as yellow-green halos are classic signs of
digoxin toxicity. Hypokalemia often predisposes a client to digoxin toxicity, making
potassium assessment critical. The nurse must hold the medication and report these
findings to the healthcare provider immediately for further intervention.
2. Which of the following clinical manifestations is most indicative of right-sided heart
failure?
A. Pulmonary crackles and wheezing
B. Orthopnea and paroxysmal nocturnal dyspnea
C. Peripheral edema and jugular venous distention
,D. Pink, frothy sputum
Correct Answer: C
Expert Explanation: Right-sided heart failure results in systemic congestion because the
right ventricle fails to pump blood effectively into the lungs. This leads to blood backing up
into the venous system, causing edema in the extremities and distended neck veins. In
contrast, pulmonary symptoms like crackles and frothy sputum are characteristic of left-
sided heart failure.
3. A nurse is teaching a client with newly diagnosed hypertension about the DASH diet. Which
food choice by the client indicates an understanding of the teaching?
A. Fresh fruits, vegetables, and low-fat dairy
B. Canned soup and crackers
C. Processed deli meats and white bread
D. Pickled vegetables and salted nuts
Correct Answer: A
Expert Explanation: The Dietary Approaches to Stop Hypertension (DASH) diet
emphasizes the consumption of whole grains, fruits, vegetables, and low-fat dairy products.
It specifically targets reducing sodium intake to lower blood pressure and improve
cardiovascular health. Canned foods and processed meats are high in sodium and should be
avoided by patients with hypertension.
, 4. A client is diagnosed with Peripheral Arterial Disease (PAD). What is the classic symptom of
this condition that the nurse should expect the client to report?
A. Painless, shallow ulcers on the ankles
B. Warm, red, and swollen lower extremities
C. Intermittent claudication
D. Bounding pedal pulses
Correct Answer: C
Expert Explanation: Intermittent claudication is ischemic muscle pain that occurs during
exercise and is relieved by rest. It is caused by an inadequate blood supply to the lower
extremities due to arterial narrowing. Clients with PAD typically have cool, pale skin and
diminished or absent pulses rather than warm or red extremities.
5. When administering nitroglycerin sublingually for angina, the nurse should instruct the
client to:
A. Swallow the tablet with a full glass of water.
B. Chew the tablet thoroughly to increase absorption.
C. Take one tablet every 5 minutes, up to three doses, if pain persists.
D. Exercise immediately after taking the medication to improve circulation.
Correct Answer: C
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a history of heart failure who is taking digoxin. The client
reports blurred vision and seeing yellow-green halos. What is the nurse’s priority action?
A. Check the client’s blood pressure and pulse.
B. Assess the client’s potassium level and notify the provider.
C. Administer the next scheduled dose of digoxin.
D. Document the findings as a common side effect.
Correct Answer: B
Expert Explanation: Visual disturbances such as yellow-green halos are classic signs of
digoxin toxicity. Hypokalemia often predisposes a client to digoxin toxicity, making
potassium assessment critical. The nurse must hold the medication and report these
findings to the healthcare provider immediately for further intervention.
2. Which of the following clinical manifestations is most indicative of right-sided heart
failure?
A. Pulmonary crackles and wheezing
B. Orthopnea and paroxysmal nocturnal dyspnea
C. Peripheral edema and jugular venous distention
,D. Pink, frothy sputum
Correct Answer: C
Expert Explanation: Right-sided heart failure results in systemic congestion because the
right ventricle fails to pump blood effectively into the lungs. This leads to blood backing up
into the venous system, causing edema in the extremities and distended neck veins. In
contrast, pulmonary symptoms like crackles and frothy sputum are characteristic of left-
sided heart failure.
3. A nurse is teaching a client with newly diagnosed hypertension about the DASH diet. Which
food choice by the client indicates an understanding of the teaching?
A. Fresh fruits, vegetables, and low-fat dairy
B. Canned soup and crackers
C. Processed deli meats and white bread
D. Pickled vegetables and salted nuts
Correct Answer: A
Expert Explanation: The Dietary Approaches to Stop Hypertension (DASH) diet
emphasizes the consumption of whole grains, fruits, vegetables, and low-fat dairy products.
It specifically targets reducing sodium intake to lower blood pressure and improve
cardiovascular health. Canned foods and processed meats are high in sodium and should be
avoided by patients with hypertension.
, 4. A client is diagnosed with Peripheral Arterial Disease (PAD). What is the classic symptom of
this condition that the nurse should expect the client to report?
A. Painless, shallow ulcers on the ankles
B. Warm, red, and swollen lower extremities
C. Intermittent claudication
D. Bounding pedal pulses
Correct Answer: C
Expert Explanation: Intermittent claudication is ischemic muscle pain that occurs during
exercise and is relieved by rest. It is caused by an inadequate blood supply to the lower
extremities due to arterial narrowing. Clients with PAD typically have cool, pale skin and
diminished or absent pulses rather than warm or red extremities.
5. When administering nitroglycerin sublingually for angina, the nurse should instruct the
client to:
A. Swallow the tablet with a full glass of water.
B. Chew the tablet thoroughly to increase absorption.
C. Take one tablet every 5 minutes, up to three doses, if pain persists.
D. Exercise immediately after taking the medication to improve circulation.
Correct Answer: C
