NSG223/NSG 223 Exam 2 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is caring for a patient who has been diagnosed with left-sided heart failure. Which
of the following physical assessment findings should the nurse expect to document?
A. Hepatomegaly and abdominal girth increase
B. Jugular venous distention (JVD)
C. Dependent pitting edema
D. Crackles in the lung bases
Correct Answer: D
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle is unable to pump blood effectively to the body, causing backflow into the lungs.
This leads to pulmonary congestion, which manifests as crackles, dyspnea, and orthopnea.
The other options listed are classic signs of right-sided heart failure, where blood backs up
into the systemic venous circulation.
2. A patient with Type 1 Diabetes Mellitus presents to the emergency department with deep,
rapid respirations and a fruity breath odor. Which condition does the nurse suspect?
A. Diabetic Ketoacidosis (DKA)
B. Hyperglycemic Hyperosmolar State (HHS)
,C. Respiratory Alkalosis
D. Hypoglycemic unawareness
Correct Answer: A
Rationale: Kussmaul respirations and fruity breath are hallmark signs of Diabetic
Ketoacidosis, a life-threatening complication of Type 1 Diabetes. The body attempts to
compensate for metabolic acidosis by blowing off excess carbon dioxide through deep,
rapid breathing. HHS is more common in Type 2 Diabetes and typically lacks the significant
ketosis and acidosis seen here.
3. When administering Digoxin to a patient with heart failure, which of the following
electrolyte imbalances increases the risk of digoxin toxicity?
A. Hypercalcemia
B. Hypokalemia
C. Hyponatremia
D. Hypermagnesemia
Correct Answer: B
Rationale: Hypokalemia sensitizes the myocardium to digitalis, thereby increasing the risk
of toxicity even if the drug levels are within a therapeutic range. It is essential for the nurse
to monitor potassium levels closely, especially if the patient is also taking potassium-
wasting diuretics. Symptoms of toxicity may include visual disturbances, nausea, and
bradycardia.
,4. A patient is prescribed Spironolactone for the management of hypertension and heart
failure. What is the priority education for this patient regarding diet?
A. Increase intake of bananas and orange juice
B. Limit fluid intake to 500 mL per day
C. Maintain a high-protein diet
D. Avoid salt substitutes containing potassium
Correct Answer: D
Rationale: Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia if
potassium intake is excessive. Salt substitutes often use potassium chloride, which can
significantly raise serum potassium levels when combined with this medication. Patients
should be taught to recognize signs of hyperkalemia, such as muscle weakness and cardiac
arrhythmias.
5. A nurse is assessing a patient for a suspected Pulmonary Embolism (PE). Which of the
following is considered the gold standard diagnostic test for confirming this condition?
A. Chest X-ray
B. Computed Tomographic Angiography (CTA)
C. Electrocardiogram (ECG)
D. D-dimer assay
Correct Answer: B
, Rationale: Computed Tomographic Angiography (CTA), also known as a spiral CT, is the
preferred diagnostic test for PE because it provides high-resolution visualization of the
pulmonary vasculature. While D-dimer is helpful for screening, a positive result only
indicates that fibrinolysis is occurring and is not specific to PE. Chest X-rays and ECGs are
used to rule out other conditions but cannot definitively diagnose a PE.
6. A patient is admitted with Chronic Obstructive Pulmonary Disease (COPD) exacerbation.
The nurse notes the patient has a barrel chest. This physical finding is a result of:
A. Alveolar destruction and air trapping
B. Chronic inflammation of the bronchial tubes
C. Fluid accumulation in the pleural space
D. Hypertrophy of the diaphragm
Correct Answer: A
Rationale: The barrel chest appearance in COPD patients is caused by chronic
hyperinflation of the lungs due to air trapping in the alveoli. As the alveoli lose their elastic
recoil, they remain partially inflated even during expiration, leading to an increased
anteroposterior diameter of the chest. This structural change reflects the long-term
progression of emphysematous changes in the lung tissue.
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is caring for a patient who has been diagnosed with left-sided heart failure. Which
of the following physical assessment findings should the nurse expect to document?
A. Hepatomegaly and abdominal girth increase
B. Jugular venous distention (JVD)
C. Dependent pitting edema
D. Crackles in the lung bases
Correct Answer: D
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle is unable to pump blood effectively to the body, causing backflow into the lungs.
This leads to pulmonary congestion, which manifests as crackles, dyspnea, and orthopnea.
The other options listed are classic signs of right-sided heart failure, where blood backs up
into the systemic venous circulation.
2. A patient with Type 1 Diabetes Mellitus presents to the emergency department with deep,
rapid respirations and a fruity breath odor. Which condition does the nurse suspect?
A. Diabetic Ketoacidosis (DKA)
B. Hyperglycemic Hyperosmolar State (HHS)
,C. Respiratory Alkalosis
D. Hypoglycemic unawareness
Correct Answer: A
Rationale: Kussmaul respirations and fruity breath are hallmark signs of Diabetic
Ketoacidosis, a life-threatening complication of Type 1 Diabetes. The body attempts to
compensate for metabolic acidosis by blowing off excess carbon dioxide through deep,
rapid breathing. HHS is more common in Type 2 Diabetes and typically lacks the significant
ketosis and acidosis seen here.
3. When administering Digoxin to a patient with heart failure, which of the following
electrolyte imbalances increases the risk of digoxin toxicity?
A. Hypercalcemia
B. Hypokalemia
C. Hyponatremia
D. Hypermagnesemia
Correct Answer: B
Rationale: Hypokalemia sensitizes the myocardium to digitalis, thereby increasing the risk
of toxicity even if the drug levels are within a therapeutic range. It is essential for the nurse
to monitor potassium levels closely, especially if the patient is also taking potassium-
wasting diuretics. Symptoms of toxicity may include visual disturbances, nausea, and
bradycardia.
,4. A patient is prescribed Spironolactone for the management of hypertension and heart
failure. What is the priority education for this patient regarding diet?
A. Increase intake of bananas and orange juice
B. Limit fluid intake to 500 mL per day
C. Maintain a high-protein diet
D. Avoid salt substitutes containing potassium
Correct Answer: D
Rationale: Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia if
potassium intake is excessive. Salt substitutes often use potassium chloride, which can
significantly raise serum potassium levels when combined with this medication. Patients
should be taught to recognize signs of hyperkalemia, such as muscle weakness and cardiac
arrhythmias.
5. A nurse is assessing a patient for a suspected Pulmonary Embolism (PE). Which of the
following is considered the gold standard diagnostic test for confirming this condition?
A. Chest X-ray
B. Computed Tomographic Angiography (CTA)
C. Electrocardiogram (ECG)
D. D-dimer assay
Correct Answer: B
, Rationale: Computed Tomographic Angiography (CTA), also known as a spiral CT, is the
preferred diagnostic test for PE because it provides high-resolution visualization of the
pulmonary vasculature. While D-dimer is helpful for screening, a positive result only
indicates that fibrinolysis is occurring and is not specific to PE. Chest X-rays and ECGs are
used to rule out other conditions but cannot definitively diagnose a PE.
6. A patient is admitted with Chronic Obstructive Pulmonary Disease (COPD) exacerbation.
The nurse notes the patient has a barrel chest. This physical finding is a result of:
A. Alveolar destruction and air trapping
B. Chronic inflammation of the bronchial tubes
C. Fluid accumulation in the pleural space
D. Hypertrophy of the diaphragm
Correct Answer: A
Rationale: The barrel chest appearance in COPD patients is caused by chronic
hyperinflation of the lungs due to air trapping in the alveoli. As the alveoli lose their elastic
recoil, they remain partially inflated even during expiration, leading to an increased
anteroposterior diameter of the chest. This structural change reflects the long-term
progression of emphysematous changes in the lung tissue.
