PNR 206/PNR206 Exam 2 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with congestive heart failure who is prescribed furosemide.
Which laboratory value should the nurse monitor most closely for potential complications?
A. Serum sodium level
B. Serum potassium level
C. Serum calcium level
D. Serum glucose level
Answer: B
Rationale: Furosemide is a loop diuretic that causes the excretion of water, sodium, and
potassium. Hypokalemia is a significant and common side effect that can lead to life-
threatening cardiac dysrhythmias. The nurse must monitor the potassium level to ensure it
remains within the therapeutic range of 3.5 to 5.0 mEq/L.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy.
The nurse understands that which of the following is the primary drive for breathing in this
client?
A. High carbon dioxide levels
B. Low carbon dioxide levels
,C. High pH levels
D. Low oxygen levels
Answer: D
Rationale: In clients with chronic hypercapnia, the chemoreceptors become insensitive to
high CO2 levels. Therefore, their stimulus to breathe shifts to a ‘hypoxic drive,’ where low
arterial oxygen levels trigger respiration. Providing too much supplemental oxygen can
potentially suppress this drive and cause respiratory arrest.
3. When assessing a client for signs of digitalis toxicity, the nurse should prioritize which of
the following clinical manifestations?
A. Significant weight gain over 24 hours
B. Increased urinary output
C. Visual disturbances such as yellow-green halos
D. Elevated blood pressure
Answer: C
Rationale: Digitalis toxicity often manifests as gastrointestinal distress and neurological
changes. Specifically, clients may report blurred vision or seeing colored halos around
lights. Prompt recognition of these symptoms is essential to prevent severe bradycardia or
heart block.
, 4. A nurse is teaching a client about the administration of regular insulin. Which statement by
the client indicates a need for further teaching?
A. I will inject the insulin into my abdomen.
B. I will rotate my injection sites within the same anatomical area.
C. I will shake the vial vigorously before drawing up the dose.
D. I will check my blood sugar before the injection.
Answer: C
Rationale: Insulin vials should be gently rolled between the palms rather than shaken to
avoid creating air bubbles. Shaking can also damage the protein molecules in certain types
of insulin. Correct handling ensures accurate dosing and maintains the medication’s
effectiveness.
5. Which arterial blood gas (ABG) result is most indicative of respiratory acidosis?
A. pH 7.50, PaCO2 40, HCO3 32
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.30, PaCO2 50, HCO3 24
Answer: D
Rationale: Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated
PaCO2 (above 45 mmHg). In choice A, the pH is acidic and the CO2 is high, which confirms a
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with congestive heart failure who is prescribed furosemide.
Which laboratory value should the nurse monitor most closely for potential complications?
A. Serum sodium level
B. Serum potassium level
C. Serum calcium level
D. Serum glucose level
Answer: B
Rationale: Furosemide is a loop diuretic that causes the excretion of water, sodium, and
potassium. Hypokalemia is a significant and common side effect that can lead to life-
threatening cardiac dysrhythmias. The nurse must monitor the potassium level to ensure it
remains within the therapeutic range of 3.5 to 5.0 mEq/L.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy.
The nurse understands that which of the following is the primary drive for breathing in this
client?
A. High carbon dioxide levels
B. Low carbon dioxide levels
,C. High pH levels
D. Low oxygen levels
Answer: D
Rationale: In clients with chronic hypercapnia, the chemoreceptors become insensitive to
high CO2 levels. Therefore, their stimulus to breathe shifts to a ‘hypoxic drive,’ where low
arterial oxygen levels trigger respiration. Providing too much supplemental oxygen can
potentially suppress this drive and cause respiratory arrest.
3. When assessing a client for signs of digitalis toxicity, the nurse should prioritize which of
the following clinical manifestations?
A. Significant weight gain over 24 hours
B. Increased urinary output
C. Visual disturbances such as yellow-green halos
D. Elevated blood pressure
Answer: C
Rationale: Digitalis toxicity often manifests as gastrointestinal distress and neurological
changes. Specifically, clients may report blurred vision or seeing colored halos around
lights. Prompt recognition of these symptoms is essential to prevent severe bradycardia or
heart block.
, 4. A nurse is teaching a client about the administration of regular insulin. Which statement by
the client indicates a need for further teaching?
A. I will inject the insulin into my abdomen.
B. I will rotate my injection sites within the same anatomical area.
C. I will shake the vial vigorously before drawing up the dose.
D. I will check my blood sugar before the injection.
Answer: C
Rationale: Insulin vials should be gently rolled between the palms rather than shaken to
avoid creating air bubbles. Shaking can also damage the protein molecules in certain types
of insulin. Correct handling ensures accurate dosing and maintains the medication’s
effectiveness.
5. Which arterial blood gas (ABG) result is most indicative of respiratory acidosis?
A. pH 7.50, PaCO2 40, HCO3 32
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.30, PaCO2 50, HCO3 24
Answer: D
Rationale: Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated
PaCO2 (above 45 mmHg). In choice A, the pH is acidic and the CO2 is high, which confirms a
