PNR 201/PNR201 Exam 2 V1 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
experiencing dyspnea. Which breathing technique should the nurse teach the client to
promote carbon dioxide elimination?
A. Deep abdominal breathing
B. Pursed-lip breathing
C. Rapid shallow breathing
D. Huff coughing
Correct Answer: B
Expert Explanation: Pursed-lip breathing prolongs exhalation and prevents airway
collapse by maintaining positive pressure in the bronchial tree. This technique effectively
helps the client to release trapped air and reduce the level of carbon dioxide in the lungs. It
is a primary intervention taught to clients with obstructive lung diseases to improve gas
exchange and reduce the work of breathing.
2. A client is admitted with a diagnosis of Left-Sided Heart Failure. Which clinical
manifestation should the nurse expect to find during the physical assessment?
A. Jugular venous distention
,B. Crackles heard upon lung auscultation
C. Peripheral edema in the lower extremities
D. Hepatomegaly and abdominal tenderness
Correct Answer: B
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot effectively pump blood into the systemic circulation. This causes fluid
to back up into the lungs, leading to symptoms such as crackles, dyspnea, and orthopnea. In
contrast, peripheral edema and jugular venous distention are characteristic signs of right-
sided heart failure.
3. The nurse is monitoring a client receiving Digoxin for heart failure. Which of the following
symptoms should the nurse report immediately as a potential sign of toxicity?
A. Increased appetite
B. Increased urinary output
C. Occasional dry cough
D. Visual disturbances such as yellow-green halos
Correct Answer: D
Expert Explanation: Visual disturbances, including seeing yellow or green halos around
lights, are a classic sign of digoxin toxicity. The nurse must also monitor for gastrointestinal
symptoms like nausea and bradycardia, which are common early indicators of toxic levels.
,Prompt reporting is essential because digoxin has a narrow therapeutic index and can lead
to life-threatening arrhythmias.
4. A nurse is preparing to administer Lisinopril to a client with hypertension. Which adverse
effect should the nurse instruct the client to report if it occurs?
A. Persistent dry cough
B. Yellowing of the sclera
C. Increased frequency of urination
D. Metallic taste in the mouth
Correct Answer: A
Expert Explanation: Lisinopril is an ACE inhibitor that frequently causes a persistent, non-
productive dry cough as a side effect due to the accumulation of bradykinin. While this side
effect is not life-threatening, it is often bothersome enough that the healthcare provider
may need to switch the client to an Angiotensin II Receptor Blocker (ARB). The nurse
should educate the client that this cough will usually resolve once the medication is
discontinued.
5. A client with suspected Tuberculosis (TB) is admitted to the hospital. Which type of
isolation precautions must the nurse implement?
A. Droplet precautions
B. Airborne precautions
C. Contact precautions
, D. Standard precautions only
Correct Answer: B
Expert Explanation: Mycobacterium tuberculosis is transmitted through small droplets
that remain suspended in the air, requiring airborne precautions. This includes placing the
client in a private, negative-pressure room and ensuring all staff wear a fitted N95
respirator. Standard and contact precautions are insufficient to prevent the spread of this
specific infectious agent.
6. A nurse is assessing a client with Peripheral Arterial Disease (PAD). Which finding is
consistent with this diagnosis?
A. Warm skin and brownish discoloration of the ankles
B. Painless ulcers on the medial malleolus
C. Dependent rubor and pain that increases with elevation
D. Bounding pedal pulses
Correct Answer: C
Expert Explanation: Peripheral Arterial Disease involves impaired blood flow to the
extremities, leading to dependent rubor (redness when the legs are down) and pallor when
elevated. Clients often experience intermittent claudication or resting pain that worsens
when the limb is raised because gravity no longer assists arterial flow. In contrast,
brownish discoloration and medial ulcers are typically associated with venous
insufficiency.
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
experiencing dyspnea. Which breathing technique should the nurse teach the client to
promote carbon dioxide elimination?
A. Deep abdominal breathing
B. Pursed-lip breathing
C. Rapid shallow breathing
D. Huff coughing
Correct Answer: B
Expert Explanation: Pursed-lip breathing prolongs exhalation and prevents airway
collapse by maintaining positive pressure in the bronchial tree. This technique effectively
helps the client to release trapped air and reduce the level of carbon dioxide in the lungs. It
is a primary intervention taught to clients with obstructive lung diseases to improve gas
exchange and reduce the work of breathing.
2. A client is admitted with a diagnosis of Left-Sided Heart Failure. Which clinical
manifestation should the nurse expect to find during the physical assessment?
A. Jugular venous distention
,B. Crackles heard upon lung auscultation
C. Peripheral edema in the lower extremities
D. Hepatomegaly and abdominal tenderness
Correct Answer: B
Expert Explanation: Left-sided heart failure results in pulmonary congestion because the
left ventricle cannot effectively pump blood into the systemic circulation. This causes fluid
to back up into the lungs, leading to symptoms such as crackles, dyspnea, and orthopnea. In
contrast, peripheral edema and jugular venous distention are characteristic signs of right-
sided heart failure.
3. The nurse is monitoring a client receiving Digoxin for heart failure. Which of the following
symptoms should the nurse report immediately as a potential sign of toxicity?
A. Increased appetite
B. Increased urinary output
C. Occasional dry cough
D. Visual disturbances such as yellow-green halos
Correct Answer: D
Expert Explanation: Visual disturbances, including seeing yellow or green halos around
lights, are a classic sign of digoxin toxicity. The nurse must also monitor for gastrointestinal
symptoms like nausea and bradycardia, which are common early indicators of toxic levels.
,Prompt reporting is essential because digoxin has a narrow therapeutic index and can lead
to life-threatening arrhythmias.
4. A nurse is preparing to administer Lisinopril to a client with hypertension. Which adverse
effect should the nurse instruct the client to report if it occurs?
A. Persistent dry cough
B. Yellowing of the sclera
C. Increased frequency of urination
D. Metallic taste in the mouth
Correct Answer: A
Expert Explanation: Lisinopril is an ACE inhibitor that frequently causes a persistent, non-
productive dry cough as a side effect due to the accumulation of bradykinin. While this side
effect is not life-threatening, it is often bothersome enough that the healthcare provider
may need to switch the client to an Angiotensin II Receptor Blocker (ARB). The nurse
should educate the client that this cough will usually resolve once the medication is
discontinued.
5. A client with suspected Tuberculosis (TB) is admitted to the hospital. Which type of
isolation precautions must the nurse implement?
A. Droplet precautions
B. Airborne precautions
C. Contact precautions
, D. Standard precautions only
Correct Answer: B
Expert Explanation: Mycobacterium tuberculosis is transmitted through small droplets
that remain suspended in the air, requiring airborne precautions. This includes placing the
client in a private, negative-pressure room and ensuring all staff wear a fitted N95
respirator. Standard and contact precautions are insufficient to prevent the spread of this
specific infectious agent.
6. A nurse is assessing a client with Peripheral Arterial Disease (PAD). Which finding is
consistent with this diagnosis?
A. Warm skin and brownish discoloration of the ankles
B. Painless ulcers on the medial malleolus
C. Dependent rubor and pain that increases with elevation
D. Bounding pedal pulses
Correct Answer: C
Expert Explanation: Peripheral Arterial Disease involves impaired blood flow to the
extremities, leading to dependent rubor (redness when the legs are down) and pallor when
elevated. Clients often experience intermittent claudication or resting pain that worsens
when the limb is raised because gravity no longer assists arterial flow. In contrast,
brownish discoloration and medial ulcers are typically associated with venous
insufficiency.
