Evolve Elsevier HESI Med Surg Final Exam Test Bank | 125
Complete Practice Questions & Rationales (NCLEX Style) |
Instant pdf download
(Respiratory & Cardiovascular Systems: Q1 - 30)
1. A patient with an acute exacerbation of COPD is receiving oxygen therapy. Which
clinical manifestation should indicate to the nurse that the patient is experiencing
oxygen-induced hypoventilation?
A. Increased restlessness and anxiety
B. Tachycardia and elevated blood pressure
C. Decreased respiratory rate and increased lethargy
D. Productive cough with thick green sputum
Explanation: In patients with chronic hypercapnia (like severe COPD), the
respiratory drive shifts from hypercapnia to hypoxia. Giving too much oxygen
eliminates their stimulus to breathe, leading to hypoventilation, respiratory clearance
failure, and carbon dioxide narcosis.
2. The nurse is caring for a patient who returned from a cardiac catheterization via the
right femoral artery. Which assessment finding requires immediate intervention?
A. Right groin discomfort scored as 3 out of 10
B. Absence of a palpable right dorsalis pedis pulse
C. Fibrotic scarring at the insertion site
D. Restlessness and a mild headache
Explanation: Loss of a peripheral pulse distal to a catheterization site
indicates acute arterial occlusion or severe hematoma compression, which is an
immediate threat to the limb's viability.
3. A patient is admitted to the emergency department with a suspected acute
myocardial infarction (MI). Which cardiac biomarker should the nurse expect to
elevate first?
A. Creatinine kinase-MB (CK-MB)
B. Troponin I
C. Myoglobin
, D. Lactate dehydrogenase (LDH)
Explanation: Troponin I is highly specific to cardiac tissue and begins to rise
within 3 to 4 hours following myocardial injury, remaining elevated for up to 10-14
days.
4. The nurse notes several premature ventricular contractions (PVCs) on a patient's
cardiac monitor. Which serum laboratory value is the priority for the nurse to review?
A. Potassium
B. Sodium
C. Glucose
D. Blood urea nitrogen (BUN)
Explanation: Hypokalemia or hyperkalemia can irritate myocardial cells,
directly causing ectopy such as premature ventricular contractions (PVCs), which
can degenerate into lethal ventricular arrhythmias.
5. A patient with permanent atrial fibrillation is prescribed warfarin. What laboratory test
must the nurse monitor to evaluate the therapeutic effectiveness of this medication?
A. Activated partial thromboplastin time (aPTT)
B. International Normalized Ratio (INR)
C. Platelet count
D. Bleeding time
Explanation: Warfarin therapy is monitored using the Prothrombin Time (PT)
and the International Normalized Ratio (INR). The general therapeutic target for atrial
fibrillation is an INR between 2.0 and 3.0.
6. Which assessment finding is a classic hallmark sign of a patient experiencing a
tension pneumothorax?
A. Bilateral vesicular breath sounds
B. Tracheal deviation toward the unaffected side
C. Productive cough with pink frothy sputum
D. Resonant percussion tones over the chest wall
Explanation: A tension pneumothorax causes massive air accumulation in the
pleural space, building intrathoracic pressure that pushes the mediastinum and
deviates the trachea toward the opposite, uninjured side.
7. The nurse is preparing to administer digoxin to a patient with heart failure. Which
clinical finding should prompt the nurse to hold the medication?
, A. Blood pressure of 140/90 mmHg
B. Apical pulse rate of 52 beats per minute
C. Serum potassium level of 4.5 mEq/L
D. Respiratory rate of 16 breaths per minute
Explanation: Digoxin is a negative chronotrope that slows the heart rate. It
should be withheld if the adult apical pulse is below 60 beats per minute to prevent
dangerous bradyarrhythmias.
8. A patient is diagnosed with left-sided heart failure. Which clinical manifestation
should the nurse expect to observe during the physical assessment?
A. Jugular venous distention (JVD)
B. Crackles in the bilateral lung bases
C. Dependent pitting peripheral edema
D. Hepatosplenomegaly
Explanation: Left-sided heart failure leads to back-up of blood into the
pulmonary circulation, increasing pulmonary hydrostatic pressure and causing fluid
leakage into alveoli, presenting as pulmonary crackles and dyspnea.
9. A nurse evaluates a patient's arterial blood gas (ABG) results: pH 7.48, PaCO2 30
mmHg, HCO3 24 mEq/L. What acid-base imbalance is occurring?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis
Explanation: The pH is high (>7.45), indicating alkalosis. The PaCO2 is low
(<35 mmHg), which accounts for the alkaline pH, while the HCO3 is normal,
confirming an uncompensated respiratory alkalosis.
10. A patient presenting with a deep vein thrombosis (DVT) suddenly develops sharp
chest pain and severe shortness of breath. What complication should the nurse
suspect?
A. Myocardial infarction
B. Pulmonary embolism
C. Pneumonia
D. Acute pericarditis
Explanation: A detached deep vein thrombus travels through the systemic
, venous circulation, passing through the right side of the heart and lodging into the
pulmonary arterial bed, obstructing pulmonary blood flow.
11. What is the priority nursing action for a patient presenting with an active nosebleed
(epistaxis)?
A. Have the patient tilt their head back and apply heat to the neck
B. Lean the patient forward and apply direct pressure to the soft part of the
nose
C. Insert sterile nasal packing tightly into both nares
D. Position the patient flat on their back to rest
Explanation: Tilting the head forward prevents the swallowing or aspiration of
blood. Applying direct pressure to the nasal septum controls bleeding from
Kiesselbach's plexus.
12. A patient with asthma is prescribed a maintenance fluticasone metered-dose inhaler.
Which instruction is vital to include in the patient's discharge teaching?
A. Use this inhaler immediately during an acute asthma attack
B. Rinse your mouth with water and spit it out after each use
C. Take the medication only when you experience wheezing
D. Double the dose if you miss a scheduled application
Explanation: Inhaled corticosteroids can deposit in the oral cavity,
predisposing the patient to local immunosuppression and the development of oral
candidiasis (thrush). Rinsing helps prevent this.
13. The nurse is caring for a patient on a mechanical ventilator when the high-pressure
limit alarm sounds. What could be the cause?
A. The patient is biting the endotracheal tube or needs suctioning
B. The ventilator circuit has become disconnected
C. There is a leak in the endotracheal tube cuff
D. The patient has been extubated spontaneously
Explanation: High-pressure alarms are triggered by increased resistance
within the circuit, which can be caused by secretions, bronchospasm, biting the tube,
or kinks in the tubing. Disconnections trigger low-pressure alarms.
14. A patient with infective endocarditis develops sudden left-sided weakness and facial
drooping. What should the nurse recognize as the cause?
A. A secondary toxic drug reaction to long-term IV antibiotics
B. Systemic embolization of vegetative heart valve lesions to the brain
Complete Practice Questions & Rationales (NCLEX Style) |
Instant pdf download
(Respiratory & Cardiovascular Systems: Q1 - 30)
1. A patient with an acute exacerbation of COPD is receiving oxygen therapy. Which
clinical manifestation should indicate to the nurse that the patient is experiencing
oxygen-induced hypoventilation?
A. Increased restlessness and anxiety
B. Tachycardia and elevated blood pressure
C. Decreased respiratory rate and increased lethargy
D. Productive cough with thick green sputum
Explanation: In patients with chronic hypercapnia (like severe COPD), the
respiratory drive shifts from hypercapnia to hypoxia. Giving too much oxygen
eliminates their stimulus to breathe, leading to hypoventilation, respiratory clearance
failure, and carbon dioxide narcosis.
2. The nurse is caring for a patient who returned from a cardiac catheterization via the
right femoral artery. Which assessment finding requires immediate intervention?
A. Right groin discomfort scored as 3 out of 10
B. Absence of a palpable right dorsalis pedis pulse
C. Fibrotic scarring at the insertion site
D. Restlessness and a mild headache
Explanation: Loss of a peripheral pulse distal to a catheterization site
indicates acute arterial occlusion or severe hematoma compression, which is an
immediate threat to the limb's viability.
3. A patient is admitted to the emergency department with a suspected acute
myocardial infarction (MI). Which cardiac biomarker should the nurse expect to
elevate first?
A. Creatinine kinase-MB (CK-MB)
B. Troponin I
C. Myoglobin
, D. Lactate dehydrogenase (LDH)
Explanation: Troponin I is highly specific to cardiac tissue and begins to rise
within 3 to 4 hours following myocardial injury, remaining elevated for up to 10-14
days.
4. The nurse notes several premature ventricular contractions (PVCs) on a patient's
cardiac monitor. Which serum laboratory value is the priority for the nurse to review?
A. Potassium
B. Sodium
C. Glucose
D. Blood urea nitrogen (BUN)
Explanation: Hypokalemia or hyperkalemia can irritate myocardial cells,
directly causing ectopy such as premature ventricular contractions (PVCs), which
can degenerate into lethal ventricular arrhythmias.
5. A patient with permanent atrial fibrillation is prescribed warfarin. What laboratory test
must the nurse monitor to evaluate the therapeutic effectiveness of this medication?
A. Activated partial thromboplastin time (aPTT)
B. International Normalized Ratio (INR)
C. Platelet count
D. Bleeding time
Explanation: Warfarin therapy is monitored using the Prothrombin Time (PT)
and the International Normalized Ratio (INR). The general therapeutic target for atrial
fibrillation is an INR between 2.0 and 3.0.
6. Which assessment finding is a classic hallmark sign of a patient experiencing a
tension pneumothorax?
A. Bilateral vesicular breath sounds
B. Tracheal deviation toward the unaffected side
C. Productive cough with pink frothy sputum
D. Resonant percussion tones over the chest wall
Explanation: A tension pneumothorax causes massive air accumulation in the
pleural space, building intrathoracic pressure that pushes the mediastinum and
deviates the trachea toward the opposite, uninjured side.
7. The nurse is preparing to administer digoxin to a patient with heart failure. Which
clinical finding should prompt the nurse to hold the medication?
, A. Blood pressure of 140/90 mmHg
B. Apical pulse rate of 52 beats per minute
C. Serum potassium level of 4.5 mEq/L
D. Respiratory rate of 16 breaths per minute
Explanation: Digoxin is a negative chronotrope that slows the heart rate. It
should be withheld if the adult apical pulse is below 60 beats per minute to prevent
dangerous bradyarrhythmias.
8. A patient is diagnosed with left-sided heart failure. Which clinical manifestation
should the nurse expect to observe during the physical assessment?
A. Jugular venous distention (JVD)
B. Crackles in the bilateral lung bases
C. Dependent pitting peripheral edema
D. Hepatosplenomegaly
Explanation: Left-sided heart failure leads to back-up of blood into the
pulmonary circulation, increasing pulmonary hydrostatic pressure and causing fluid
leakage into alveoli, presenting as pulmonary crackles and dyspnea.
9. A nurse evaluates a patient's arterial blood gas (ABG) results: pH 7.48, PaCO2 30
mmHg, HCO3 24 mEq/L. What acid-base imbalance is occurring?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis
Explanation: The pH is high (>7.45), indicating alkalosis. The PaCO2 is low
(<35 mmHg), which accounts for the alkaline pH, while the HCO3 is normal,
confirming an uncompensated respiratory alkalosis.
10. A patient presenting with a deep vein thrombosis (DVT) suddenly develops sharp
chest pain and severe shortness of breath. What complication should the nurse
suspect?
A. Myocardial infarction
B. Pulmonary embolism
C. Pneumonia
D. Acute pericarditis
Explanation: A detached deep vein thrombus travels through the systemic
, venous circulation, passing through the right side of the heart and lodging into the
pulmonary arterial bed, obstructing pulmonary blood flow.
11. What is the priority nursing action for a patient presenting with an active nosebleed
(epistaxis)?
A. Have the patient tilt their head back and apply heat to the neck
B. Lean the patient forward and apply direct pressure to the soft part of the
nose
C. Insert sterile nasal packing tightly into both nares
D. Position the patient flat on their back to rest
Explanation: Tilting the head forward prevents the swallowing or aspiration of
blood. Applying direct pressure to the nasal septum controls bleeding from
Kiesselbach's plexus.
12. A patient with asthma is prescribed a maintenance fluticasone metered-dose inhaler.
Which instruction is vital to include in the patient's discharge teaching?
A. Use this inhaler immediately during an acute asthma attack
B. Rinse your mouth with water and spit it out after each use
C. Take the medication only when you experience wheezing
D. Double the dose if you miss a scheduled application
Explanation: Inhaled corticosteroids can deposit in the oral cavity,
predisposing the patient to local immunosuppression and the development of oral
candidiasis (thrush). Rinsing helps prevent this.
13. The nurse is caring for a patient on a mechanical ventilator when the high-pressure
limit alarm sounds. What could be the cause?
A. The patient is biting the endotracheal tube or needs suctioning
B. The ventilator circuit has become disconnected
C. There is a leak in the endotracheal tube cuff
D. The patient has been extubated spontaneously
Explanation: High-pressure alarms are triggered by increased resistance
within the circuit, which can be caused by secretions, bronchospasm, biting the tube,
or kinks in the tubing. Disconnections trigger low-pressure alarms.
14. A patient with infective endocarditis develops sudden left-sided weakness and facial
drooping. What should the nurse recognize as the cause?
A. A secondary toxic drug reaction to long-term IV antibiotics
B. Systemic embolization of vegetative heart valve lesions to the brain
