NUR 209 MEDICAL SURGICAL NURSING
II - EXAM 2 MASTER QUESTIONS AND
ANSWERS
1. A client is admitted with an exacerbation of Left-Sided Heart Failure. Which clinical
manifestation should the nurse prioritize during the assessment?
A. Jugular venous distension (JVD)
B. Dependent edema in the lower extremities
C. Bilateral crackles in the lungs
D. Ascites and abdominal girth increase
Answer: C
Conceptual Explanation: Left-sided heart failure leads to pulmonary congestion because
the left ventricle cannot pump blood effectively to the systemic circulation, causing fluid to
back up into the lungs. JVD, edema, and ascites are symptoms of right-sided heart failure.
2. A patient with a history of Atrial Fibrillation is prescribed Warfarin. Which lab value should
the nurse monitor to determine the therapeutic effectiveness of this medication?
A. Activated Partial Thromboplastin Time (aPTT)
B. International Normalized Ratio (INR)
,C. Platelet count
D. Hemoglobin and Hematocrit
Answer: B
Conceptual Explanation: INR is the standardized measurement used to monitor the
effectiveness of Warfarin (Coumadin). aPTT is used for Heparin. Platelets and H&H monitor
for bleeding complications but do not measure the drug’s therapeutic effect.
3. A client presents to the ED with a suspected Myocardial Infarction. Which cardiac enzyme
is the most sensitive and specific indicator of myocardial injury?
A. Troponin I
B. Myoglobin
C. CK-MB
D. LDH
Answer: A
Conceptual Explanation: Troponin I is highly specific to cardiac muscle and remains
elevated for several days after an MI, making it the gold standard for diagnosis.
4. The nurse is caring for a patient with COPD who is receiving oxygen via nasal cannula at
2L/min. The patient’s SpO2 is 89%. What is the most appropriate nursing action?
A. Continue to monitor; this is an acceptable range for a COPD patient
B. Increase the oxygen flow to 6L/min immediately
, C. Prepare for emergency endotracheal intubation
D. Change the delivery device to a non-rebreather mask
Answer: A
Conceptual Explanation: For patients with COPD, a target SpO2 of 88-92% is often
acceptable because high levels of oxygen can suppress their hypoxic drive to breathe.
5. A patient with Type 1 Diabetes is found unresponsive and diaphoretic. What should be the
nurse’s first action?
A. Check the patient’s blood glucose level
B. Administer IM Glucagon or IV Dextrose 50%
C. Administer 15g of oral carbohydrates
D. Call the healthcare provider to report the status
Answer: B
Conceptual Explanation: If a diabetic patient is unresponsive, the nurse must assume
hypoglycemia and treat aggressively with Glucagon or D50 since the patient cannot safely
swallow oral glucose.
6. A client is diagnosed with Cushing’s Syndrome. Which electrolyte imbalance is the nurse
most likely to observe?
A. Hyperkalemia and Hyponatremia
B. Hypercalcemia and Hypernatremia
II - EXAM 2 MASTER QUESTIONS AND
ANSWERS
1. A client is admitted with an exacerbation of Left-Sided Heart Failure. Which clinical
manifestation should the nurse prioritize during the assessment?
A. Jugular venous distension (JVD)
B. Dependent edema in the lower extremities
C. Bilateral crackles in the lungs
D. Ascites and abdominal girth increase
Answer: C
Conceptual Explanation: Left-sided heart failure leads to pulmonary congestion because
the left ventricle cannot pump blood effectively to the systemic circulation, causing fluid to
back up into the lungs. JVD, edema, and ascites are symptoms of right-sided heart failure.
2. A patient with a history of Atrial Fibrillation is prescribed Warfarin. Which lab value should
the nurse monitor to determine the therapeutic effectiveness of this medication?
A. Activated Partial Thromboplastin Time (aPTT)
B. International Normalized Ratio (INR)
,C. Platelet count
D. Hemoglobin and Hematocrit
Answer: B
Conceptual Explanation: INR is the standardized measurement used to monitor the
effectiveness of Warfarin (Coumadin). aPTT is used for Heparin. Platelets and H&H monitor
for bleeding complications but do not measure the drug’s therapeutic effect.
3. A client presents to the ED with a suspected Myocardial Infarction. Which cardiac enzyme
is the most sensitive and specific indicator of myocardial injury?
A. Troponin I
B. Myoglobin
C. CK-MB
D. LDH
Answer: A
Conceptual Explanation: Troponin I is highly specific to cardiac muscle and remains
elevated for several days after an MI, making it the gold standard for diagnosis.
4. The nurse is caring for a patient with COPD who is receiving oxygen via nasal cannula at
2L/min. The patient’s SpO2 is 89%. What is the most appropriate nursing action?
A. Continue to monitor; this is an acceptable range for a COPD patient
B. Increase the oxygen flow to 6L/min immediately
, C. Prepare for emergency endotracheal intubation
D. Change the delivery device to a non-rebreather mask
Answer: A
Conceptual Explanation: For patients with COPD, a target SpO2 of 88-92% is often
acceptable because high levels of oxygen can suppress their hypoxic drive to breathe.
5. A patient with Type 1 Diabetes is found unresponsive and diaphoretic. What should be the
nurse’s first action?
A. Check the patient’s blood glucose level
B. Administer IM Glucagon or IV Dextrose 50%
C. Administer 15g of oral carbohydrates
D. Call the healthcare provider to report the status
Answer: B
Conceptual Explanation: If a diabetic patient is unresponsive, the nurse must assume
hypoglycemia and treat aggressively with Glucagon or D50 since the patient cannot safely
swallow oral glucose.
6. A client is diagnosed with Cushing’s Syndrome. Which electrolyte imbalance is the nurse
most likely to observe?
A. Hyperkalemia and Hyponatremia
B. Hypercalcemia and Hypernatremia
