NUR 201/NUR201 Exam 4 V1 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A nurse is assessing a client with left-sided heart failure. Which of the following findings
should the nurse expect?
A. Jugular vein distention
B. Dependent edema
C. Hepatosplenomegaly
D. Crackles in the lung bases
Correct Answer: D
Explanation: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood effectively into the systemic circulation. This leads to
symptoms such as crackles, dyspnea, and orthopnea. The other choices are manifestations
of right-sided heart failure caused by systemic venous congestion.
2. A client is admitted with a potassium level of 6.2 mEq/L. Which of the following ECG
changes is the priority for the nurse to monitor?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Inverted T waves
,Correct Answer: A
Explanation: Hyperkalemia is characterized by a potassium level greater than 5.0 mEq/L
and can cause life-threatening cardiac dysrhythmias. Tall, peaked T waves and a widened
QRS complex are classic signs of this electrolyte imbalance. Prominent U waves and ST-
segment depression are more commonly associated with hypokalemia.
3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which
oxygen delivery rate is most appropriate to prevent respiratory depression?
A. 1 to 2 L/min via nasal cannula
B. 6 to 10 L/min via simple mask
C. 10 to 15 L/min via non-rebreather mask
D. Venturi mask at 50% FiO2
Correct Answer: A
Explanation: In clients with chronic COPD, the stimulus to breathe is often a low oxygen
level rather than a high carbon dioxide level. Providing high concentrations of oxygen can
abolish this hypoxic drive, leading to respiratory arrest. Therefore, low-flow oxygen is
typically titrated to maintain an oxygen saturation between 88% and 92%.
4. A nurse is preparing to administer digoxin to a client with heart failure. Which assessment
must be performed prior to administration?
A. Check the radial pulse for 30 seconds
B. Measure blood pressure in both arms
, C. Auscultate the apical pulse for 1 full minute
D. Assess for peripheral edema
Correct Answer: C
Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
myocardial contractility. The nurse must auscultate the apical pulse for a full minute and
withhold the medication if the heart rate is less than 60 beats per minute in an adult. This
safety measure prevents further bradycardia and potential digoxin toxicity.
5. Which clinical manifestation should a nurse identify as an early sign of hypoxia in a client
with pneumonia?
A. Cyanosis of the lips
B. Clubbing of the fingers
C. Restlessness and agitation
D. Bradypnea
Correct Answer: C
Explanation: Restlessness, agitation, and confusion are early signs of hypoxia as the brain
is sensitive to falling oxygen levels. Cyanosis and clubbing are late signs, representing
prolonged or severe oxygen deprivation. Recognizing early neurological changes allows for
prompt intervention to improve oxygenation status.
Nursing I Q&A with Rationale | Fortis College
1. A nurse is assessing a client with left-sided heart failure. Which of the following findings
should the nurse expect?
A. Jugular vein distention
B. Dependent edema
C. Hepatosplenomegaly
D. Crackles in the lung bases
Correct Answer: D
Explanation: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood effectively into the systemic circulation. This leads to
symptoms such as crackles, dyspnea, and orthopnea. The other choices are manifestations
of right-sided heart failure caused by systemic venous congestion.
2. A client is admitted with a potassium level of 6.2 mEq/L. Which of the following ECG
changes is the priority for the nurse to monitor?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Inverted T waves
,Correct Answer: A
Explanation: Hyperkalemia is characterized by a potassium level greater than 5.0 mEq/L
and can cause life-threatening cardiac dysrhythmias. Tall, peaked T waves and a widened
QRS complex are classic signs of this electrolyte imbalance. Prominent U waves and ST-
segment depression are more commonly associated with hypokalemia.
3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which
oxygen delivery rate is most appropriate to prevent respiratory depression?
A. 1 to 2 L/min via nasal cannula
B. 6 to 10 L/min via simple mask
C. 10 to 15 L/min via non-rebreather mask
D. Venturi mask at 50% FiO2
Correct Answer: A
Explanation: In clients with chronic COPD, the stimulus to breathe is often a low oxygen
level rather than a high carbon dioxide level. Providing high concentrations of oxygen can
abolish this hypoxic drive, leading to respiratory arrest. Therefore, low-flow oxygen is
typically titrated to maintain an oxygen saturation between 88% and 92%.
4. A nurse is preparing to administer digoxin to a client with heart failure. Which assessment
must be performed prior to administration?
A. Check the radial pulse for 30 seconds
B. Measure blood pressure in both arms
, C. Auscultate the apical pulse for 1 full minute
D. Assess for peripheral edema
Correct Answer: C
Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases
myocardial contractility. The nurse must auscultate the apical pulse for a full minute and
withhold the medication if the heart rate is less than 60 beats per minute in an adult. This
safety measure prevents further bradycardia and potential digoxin toxicity.
5. Which clinical manifestation should a nurse identify as an early sign of hypoxia in a client
with pneumonia?
A. Cyanosis of the lips
B. Clubbing of the fingers
C. Restlessness and agitation
D. Bradypnea
Correct Answer: C
Explanation: Restlessness, agitation, and confusion are early signs of hypoxia as the brain
is sensitive to falling oxygen levels. Cyanosis and clubbing are late signs, representing
prolonged or severe oxygen deprivation. Recognizing early neurological changes allows for
prompt intervention to improve oxygenation status.
