NU 186 Exam 2 V1 | NU 186 Medical-
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 2) | Galen
1. A nurse is providing discharge teaching to a client with Chronic Obstructive Pulmonary
Disease (COPD). Which of the following instructions should be included to help manage the
disease and prevent exacerbations? (Select All That Apply)
A. Eat several small, high-calorie meals throughout the day.
B. Use pursed-lip breathing during periods of dyspnea.
C. Administer high-flow oxygen (6-10 L/min) when feeling short of breath.
D. Avoid crowds and people with respiratory infections.
E. Limit fluid intake to 1 liter per day to prevent fluid overload.
F. Schedule a flu vaccination and pneumonia vaccine as recommended.
Correct Answer: A, B, D, F
Explanation; Clients with COPD should consume small, frequent, high-calorie meals to
provide energy without causing excessive fatigue or abdominal distention. Pursed-lip
breathing helps to maintain airway pressure and prevent collapse during expiration.
Avoiding crowds and keeping vaccinations up to date are essential preventive measures
against infections that can trigger life-threatening exacerbations. High-flow oxygen is
,typically contraindicated in COPD as it can suppress the hypoxic drive, and fluids should
generally be encouraged to thin secretions unless heart failure is present.
2. The nurse is monitoring a client receiving Digoxin for heart failure. Which clinical finding is
the most sensitive early indicator of Digoxin toxicity?
A. Blurred vision or yellow-green halos
B. Photophobia
C. Third-degree heart block
D. Anorexia and nausea
Correct Answer: D
Explanation; Early signs of Digoxin toxicity are typically gastrointestinal, such as anorexia,
nausea, and vomiting. While visual disturbances like yellow-green halos are classic signs,
they usually occur later than the GI symptoms. Cardiac dysrhythmias are the most serious
complications, but they are not the earliest indicators of toxicity.
3. A client presents to the emergency department with suspected Left-sided heart failure.
Which assessment findings should the nurse expect? (Select All That Apply)
A. Crackles heard in the lung bases
B. Peripheral edema in the lower extremities
C. Orthopnea
D. Jugular venous distention
,E. Dyspnea on exertion
Correct Answer: A, C, E
Explanation; Left-sided heart failure involves failure of the left ventricle to pump blood
efficiently, leading to pulmonary congestion. Crackles, orthopnea, and dyspnea are all
indicators of pulmonary involvement caused by fluid backing up into the lungs. In contrast,
peripheral edema and jugular venous distention are primary indicators of Right-sided
heart failure.
4. A client is prescribed Spironolactone. Which laboratory value requires immediate follow-up
by the nurse?
A. Sodium 138 mEq/L
B. Creatinine 1.1 mg/dL
C. Potassium 5.8 mEq/L
D. Calcium 9.5 mg/dL
Correct Answer: C
Explanation; Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia.
A potassium level of 5.8 mEq/L is significantly elevated (normal range is 3.5 to 5.0 mEq/L)
and poses a risk for lethal cardiac dysrhythmias. The other laboratory values listed are
within normal physiological ranges for an adult client.
, 5. Which of the following interventions are appropriate for a client diagnosed with deep vein
thrombosis (DVT) in the left calf? (Select All That Apply)
A. Elevate the affected leg when sitting or lying down.
B. Massage the calf muscle to improve circulation.
C. Apply warm, moist compresses to the area.
D. Monitor for sudden chest pain or shortness of breath.
E. Encourage the client to ambulate as tolerated if anticoagulation has started.
Correct Answer: A, C, D, E
Explanation; Elevation of the extremity helps reduce edema and facilitates venous return.
Warm compresses help relieve pain and inflammation. Monitoring for chest pain is critical
as it indicates a potential pulmonary embolism, which is a major complication of DVT.
Massaging the area is strictly contraindicated because it can dislodge the thrombus and
cause an embolism.
6. A nurse is caring for a client with an acute myocardial infarction (MI). The nurse knows that
the primary goal of thrombolytic therapy is to:
A. Prevent further platelet aggregation.
B. Dissolve the existing clot and restore blood flow.
C. Lower the client’s blood pressure.
D. Reduce the oxygen demand of the heart.
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 2) | Galen
1. A nurse is providing discharge teaching to a client with Chronic Obstructive Pulmonary
Disease (COPD). Which of the following instructions should be included to help manage the
disease and prevent exacerbations? (Select All That Apply)
A. Eat several small, high-calorie meals throughout the day.
B. Use pursed-lip breathing during periods of dyspnea.
C. Administer high-flow oxygen (6-10 L/min) when feeling short of breath.
D. Avoid crowds and people with respiratory infections.
E. Limit fluid intake to 1 liter per day to prevent fluid overload.
F. Schedule a flu vaccination and pneumonia vaccine as recommended.
Correct Answer: A, B, D, F
Explanation; Clients with COPD should consume small, frequent, high-calorie meals to
provide energy without causing excessive fatigue or abdominal distention. Pursed-lip
breathing helps to maintain airway pressure and prevent collapse during expiration.
Avoiding crowds and keeping vaccinations up to date are essential preventive measures
against infections that can trigger life-threatening exacerbations. High-flow oxygen is
,typically contraindicated in COPD as it can suppress the hypoxic drive, and fluids should
generally be encouraged to thin secretions unless heart failure is present.
2. The nurse is monitoring a client receiving Digoxin for heart failure. Which clinical finding is
the most sensitive early indicator of Digoxin toxicity?
A. Blurred vision or yellow-green halos
B. Photophobia
C. Third-degree heart block
D. Anorexia and nausea
Correct Answer: D
Explanation; Early signs of Digoxin toxicity are typically gastrointestinal, such as anorexia,
nausea, and vomiting. While visual disturbances like yellow-green halos are classic signs,
they usually occur later than the GI symptoms. Cardiac dysrhythmias are the most serious
complications, but they are not the earliest indicators of toxicity.
3. A client presents to the emergency department with suspected Left-sided heart failure.
Which assessment findings should the nurse expect? (Select All That Apply)
A. Crackles heard in the lung bases
B. Peripheral edema in the lower extremities
C. Orthopnea
D. Jugular venous distention
,E. Dyspnea on exertion
Correct Answer: A, C, E
Explanation; Left-sided heart failure involves failure of the left ventricle to pump blood
efficiently, leading to pulmonary congestion. Crackles, orthopnea, and dyspnea are all
indicators of pulmonary involvement caused by fluid backing up into the lungs. In contrast,
peripheral edema and jugular venous distention are primary indicators of Right-sided
heart failure.
4. A client is prescribed Spironolactone. Which laboratory value requires immediate follow-up
by the nurse?
A. Sodium 138 mEq/L
B. Creatinine 1.1 mg/dL
C. Potassium 5.8 mEq/L
D. Calcium 9.5 mg/dL
Correct Answer: C
Explanation; Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia.
A potassium level of 5.8 mEq/L is significantly elevated (normal range is 3.5 to 5.0 mEq/L)
and poses a risk for lethal cardiac dysrhythmias. The other laboratory values listed are
within normal physiological ranges for an adult client.
, 5. Which of the following interventions are appropriate for a client diagnosed with deep vein
thrombosis (DVT) in the left calf? (Select All That Apply)
A. Elevate the affected leg when sitting or lying down.
B. Massage the calf muscle to improve circulation.
C. Apply warm, moist compresses to the area.
D. Monitor for sudden chest pain or shortness of breath.
E. Encourage the client to ambulate as tolerated if anticoagulation has started.
Correct Answer: A, C, D, E
Explanation; Elevation of the extremity helps reduce edema and facilitates venous return.
Warm compresses help relieve pain and inflammation. Monitoring for chest pain is critical
as it indicates a potential pulmonary embolism, which is a major complication of DVT.
Massaging the area is strictly contraindicated because it can dislodge the thrombus and
cause an embolism.
6. A nurse is caring for a client with an acute myocardial infarction (MI). The nurse knows that
the primary goal of thrombolytic therapy is to:
A. Prevent further platelet aggregation.
B. Dissolve the existing clot and restore blood flow.
C. Lower the client’s blood pressure.
D. Reduce the oxygen demand of the heart.
