PNR 206/PNR206 Final Exam V2 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen. Which oxygen delivery setting is most appropriate to maintain the patient’s
respiratory drive?
A. Nasal cannula at 2 L/min
B. Simple face mask at 8 L/min
C. Non-rebreather mask at 15 L/min
D. Venturi mask at 50%
Correct Answer: A
Explanation: Patients with COPD often rely on a hypoxic drive to breathe because their
bodies have become accustomed to high carbon dioxide levels. Providing high
concentrations of oxygen can signal the brain to stop the breathing process, potentially
leading to respiratory arrest. A low flow rate of 1-2 L/min via nasal cannula is typically the
safest starting point for these patients.
2. A patient with heart failure is prescribed Digoxin 0.25 mg daily. Which assessment finding
should the nurse prioritize as an early sign of Digoxin toxicity?
A. Anorexia and nausea
B. Increased urinary output
,C. Yellow-green halos in vision
D. Tachycardia
Correct Answer: A
Explanation: Gastrointestinal disturbances such as anorexia, nausea, and vomiting are
often the first indicators that Digoxin levels have reached toxic ranges. While visual
disturbances like yellow halos are classic signs, they usually occur after the onset of GI
symptoms. The nurse must monitor for these early cues to prevent severe cardiac
arrhythmias associated with toxicity.
3. Which electrolyte imbalance should the nurse monitor for most closely in a patient
receiving Furosemide (Lasix) for fluid volume excess?
A. Hypernatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypokalemia
Correct Answer: D
Explanation: Furosemide is a loop diuretic that promotes the excretion of water, sodium,
and potassium through the kidneys. Because it does not spare potassium, the patient is at
significant risk for hypokalemia, which can lead to life-threatening cardiac dysrhythmias.
Monitoring serum potassium levels and encouraging potassium-rich foods are standard
nursing interventions for this therapy.
,4. A patient is admitted with a suspected diagnosis of Tuberculosis (TB). Which type of
isolation precautions must the nurse implement immediately?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions only
Correct Answer: C
Explanation: Tuberculosis is caused by Mycobacterium tuberculosis, which is transmitted
through very small droplets that remain suspended in the air. Airborne precautions require
the use of a negative-pressure room and N95 respirators for all staff entering the room.
Prompt implementation of these measures is critical to prevent the spread of the pathogen
to other patients and staff.
5. A nurse is teaching a patient with Type 1 Diabetes about the peak action of Regular insulin.
At what time should the patient be most alert for signs of hypoglycemia if the dose is given at
0800?
A. 0830 to 0900
B. 1800 to 2000
C. 1400 to 1600
D. 1000 to 1200
, Correct Answer: D
Explanation: Regular insulin is short-acting and typically peaks 2 to 4 hours after
administration. Since the peak is when the insulin is most effective, the risk for
hypoglycemia is highest during this window. The nurse must educate the patient to
recognize symptoms like shakiness and diaphoresis between 1000 and 1200 if the injection
was at 0800.
6. A patient presents with a history of Left-Sided Heart Failure. Which clinical manifestation is
the nurse most likely to observe?
A. Crackles in the lungs
B. Jugular venous distention
C. Peripheral edema
D. Hepatomegaly
Correct Answer: A
Explanation: Left-sided heart failure occurs when the left ventricle cannot pump blood
effectively to the systemic circulation, causing blood to back up into the lungs. This
pulmonary congestion results in symptoms such as dyspnea, orthopnea, and audible
crackles upon auscultation. In contrast, right-sided heart failure typically presents with
systemic symptoms like peripheral edema and jugular venous distention.
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen. Which oxygen delivery setting is most appropriate to maintain the patient’s
respiratory drive?
A. Nasal cannula at 2 L/min
B. Simple face mask at 8 L/min
C. Non-rebreather mask at 15 L/min
D. Venturi mask at 50%
Correct Answer: A
Explanation: Patients with COPD often rely on a hypoxic drive to breathe because their
bodies have become accustomed to high carbon dioxide levels. Providing high
concentrations of oxygen can signal the brain to stop the breathing process, potentially
leading to respiratory arrest. A low flow rate of 1-2 L/min via nasal cannula is typically the
safest starting point for these patients.
2. A patient with heart failure is prescribed Digoxin 0.25 mg daily. Which assessment finding
should the nurse prioritize as an early sign of Digoxin toxicity?
A. Anorexia and nausea
B. Increased urinary output
,C. Yellow-green halos in vision
D. Tachycardia
Correct Answer: A
Explanation: Gastrointestinal disturbances such as anorexia, nausea, and vomiting are
often the first indicators that Digoxin levels have reached toxic ranges. While visual
disturbances like yellow halos are classic signs, they usually occur after the onset of GI
symptoms. The nurse must monitor for these early cues to prevent severe cardiac
arrhythmias associated with toxicity.
3. Which electrolyte imbalance should the nurse monitor for most closely in a patient
receiving Furosemide (Lasix) for fluid volume excess?
A. Hypernatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypokalemia
Correct Answer: D
Explanation: Furosemide is a loop diuretic that promotes the excretion of water, sodium,
and potassium through the kidneys. Because it does not spare potassium, the patient is at
significant risk for hypokalemia, which can lead to life-threatening cardiac dysrhythmias.
Monitoring serum potassium levels and encouraging potassium-rich foods are standard
nursing interventions for this therapy.
,4. A patient is admitted with a suspected diagnosis of Tuberculosis (TB). Which type of
isolation precautions must the nurse implement immediately?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions only
Correct Answer: C
Explanation: Tuberculosis is caused by Mycobacterium tuberculosis, which is transmitted
through very small droplets that remain suspended in the air. Airborne precautions require
the use of a negative-pressure room and N95 respirators for all staff entering the room.
Prompt implementation of these measures is critical to prevent the spread of the pathogen
to other patients and staff.
5. A nurse is teaching a patient with Type 1 Diabetes about the peak action of Regular insulin.
At what time should the patient be most alert for signs of hypoglycemia if the dose is given at
0800?
A. 0830 to 0900
B. 1800 to 2000
C. 1400 to 1600
D. 1000 to 1200
, Correct Answer: D
Explanation: Regular insulin is short-acting and typically peaks 2 to 4 hours after
administration. Since the peak is when the insulin is most effective, the risk for
hypoglycemia is highest during this window. The nurse must educate the patient to
recognize symptoms like shakiness and diaphoresis between 1000 and 1200 if the injection
was at 0800.
6. A patient presents with a history of Left-Sided Heart Failure. Which clinical manifestation is
the nurse most likely to observe?
A. Crackles in the lungs
B. Jugular venous distention
C. Peripheral edema
D. Hepatomegaly
Correct Answer: A
Explanation: Left-sided heart failure occurs when the left ventricle cannot pump blood
effectively to the systemic circulation, causing blood to back up into the lungs. This
pulmonary congestion results in symptoms such as dyspnea, orthopnea, and audible
crackles upon auscultation. In contrast, right-sided heart failure typically presents with
systemic symptoms like peripheral edema and jugular venous distention.
