NUR 170 Med Surg Assessment 2-V1 and V2 -
Solved |Accurate Verified -Galen
1.
A client with heart failure reports increasing shortness of breath and awakens at
night feeling unable to breathe. Which additional finding should the nurse expect?
A. Decreased jugular venous pressure
B. Bilateral crackles
C. Dry mucous membranes
D. Bradycardia
Rationale: Pulmonary congestion from left-sided heart failure commonly produces
crackles and worsening dyspnea, especially when lying flat.
2.
A client taking furosemide for heart failure has a potassium level of 2.9 mEq/L.
Which finding is most concerning?
A. Increased appetite
B. Muscle weakness
C. Warm skin
D. Increased urinary output
Rationale: Hypokalemia caused by loop diuretics can produce muscle weakness and
potentially life-threatening cardiac dysrhythmias.
3.
A client with acute myocardial infarction suddenly develops severe dyspnea, pink
frothy sputum, and diffuse crackles. Which complication should the nurse suspect?
A. Pulmonary edema
B. Deep-vein thrombosis
C. Pericarditis
D. Hypoglycemia
Rationale: Acute pulmonary edema is characterized by severe respiratory distress,
crackles, and pink frothy sputum.
4.
A client prescribed sublingual nitroglycerin for angina asks when to take the
medication. Which statement demonstrates correct understanding?
A. “I will take it after the chest pain becomes severe.”
,B. “I will take it at the first sign of chest discomfort.”
C. “I will take it every morning regardless of symptoms.”
D. “I will take it only after exercising.”
Rationale: Sublingual nitroglycerin should be taken promptly when anginal pain
begins.
5.
A nurse is assessing a client with peripheral arterial disease. Which finding is most
characteristic?
A. Warm, edematous legs
B. Brown pigmentation around the ankles
C. Pain relieved by leg elevation
D. Cool extremities with diminished pulses
Rationale: Arterial insufficiency reduces blood flow, producing cool skin, diminished
pulses, pallor, and ischemic pain.
6.
A client with deep-vein thrombosis suddenly develops chest pain and severe
shortness of breath. What should the nurse do first?
A. Encourage ambulation
B. Apply oxygen and assess respiratory status
C. Massage the affected leg
D. Place the client in Trendelenburg position
Rationale: Sudden dyspnea and chest pain in a client with DVT suggest pulmonary
embolism. Airway and breathing take priority.
7.
Which assessment finding is most consistent with left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Rationale: Left ventricular failure causes pulmonary vascular congestion, leading to
crackles and dyspnea.
8.
A client taking warfarin should be instructed to immediately report which finding?
A. Mild hunger
B. Occasional sneezing
C. Black, tarry stools
D. Increased thirst
Rationale: Melena can indicate gastrointestinal bleeding, an important complication
of anticoagulant therapy.
, 9.
A client with COPD is receiving oxygen therapy. Which nursing action is most
appropriate?
A. Administer the highest possible oxygen concentration
B. Titrate oxygen according to the prescribed target
C. Discontinue oxygen when the client becomes dyspneic
D. Keep the client completely flat
Rationale: Oxygen should be administered carefully and titrated according to the
prescribed target and the client's clinical condition.
10.
Which position generally promotes the easiest breathing for a client experiencing
acute dyspnea?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Rationale: Upright positioning improves lung expansion and decreases
diaphragmatic pressure.
11.
A client with asthma develops wheezing and chest tightness. Which medication is
typically used for rapid relief of acute bronchospasm?
A. Albuterol
B. Warfarin
C. Furosemide
D. Levothyroxine
Rationale: Albuterol is a short-acting beta₂-agonist used as a rescue bronchodilator.
12.
A client with pneumonia has a temperature of 39°C (102.2°F), respiratory rate of
30/min, and oxygen saturation of 88%. Which intervention is the priority?
A. Encourage oral fluids
B. Administer prescribed oxygen
C. Obtain a dietary history
D. Provide a warm blanket
Rationale: Hypoxemia is an immediate priority because oxygenation is essential for
tissue survival.
13.
A nurse is teaching a client with COPD about pursed-lip breathing. What is the
primary purpose?
A. Increase respiratory rate
Solved |Accurate Verified -Galen
1.
A client with heart failure reports increasing shortness of breath and awakens at
night feeling unable to breathe. Which additional finding should the nurse expect?
A. Decreased jugular venous pressure
B. Bilateral crackles
C. Dry mucous membranes
D. Bradycardia
Rationale: Pulmonary congestion from left-sided heart failure commonly produces
crackles and worsening dyspnea, especially when lying flat.
2.
A client taking furosemide for heart failure has a potassium level of 2.9 mEq/L.
Which finding is most concerning?
A. Increased appetite
B. Muscle weakness
C. Warm skin
D. Increased urinary output
Rationale: Hypokalemia caused by loop diuretics can produce muscle weakness and
potentially life-threatening cardiac dysrhythmias.
3.
A client with acute myocardial infarction suddenly develops severe dyspnea, pink
frothy sputum, and diffuse crackles. Which complication should the nurse suspect?
A. Pulmonary edema
B. Deep-vein thrombosis
C. Pericarditis
D. Hypoglycemia
Rationale: Acute pulmonary edema is characterized by severe respiratory distress,
crackles, and pink frothy sputum.
4.
A client prescribed sublingual nitroglycerin for angina asks when to take the
medication. Which statement demonstrates correct understanding?
A. “I will take it after the chest pain becomes severe.”
,B. “I will take it at the first sign of chest discomfort.”
C. “I will take it every morning regardless of symptoms.”
D. “I will take it only after exercising.”
Rationale: Sublingual nitroglycerin should be taken promptly when anginal pain
begins.
5.
A nurse is assessing a client with peripheral arterial disease. Which finding is most
characteristic?
A. Warm, edematous legs
B. Brown pigmentation around the ankles
C. Pain relieved by leg elevation
D. Cool extremities with diminished pulses
Rationale: Arterial insufficiency reduces blood flow, producing cool skin, diminished
pulses, pallor, and ischemic pain.
6.
A client with deep-vein thrombosis suddenly develops chest pain and severe
shortness of breath. What should the nurse do first?
A. Encourage ambulation
B. Apply oxygen and assess respiratory status
C. Massage the affected leg
D. Place the client in Trendelenburg position
Rationale: Sudden dyspnea and chest pain in a client with DVT suggest pulmonary
embolism. Airway and breathing take priority.
7.
Which assessment finding is most consistent with left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Rationale: Left ventricular failure causes pulmonary vascular congestion, leading to
crackles and dyspnea.
8.
A client taking warfarin should be instructed to immediately report which finding?
A. Mild hunger
B. Occasional sneezing
C. Black, tarry stools
D. Increased thirst
Rationale: Melena can indicate gastrointestinal bleeding, an important complication
of anticoagulant therapy.
, 9.
A client with COPD is receiving oxygen therapy. Which nursing action is most
appropriate?
A. Administer the highest possible oxygen concentration
B. Titrate oxygen according to the prescribed target
C. Discontinue oxygen when the client becomes dyspneic
D. Keep the client completely flat
Rationale: Oxygen should be administered carefully and titrated according to the
prescribed target and the client's clinical condition.
10.
Which position generally promotes the easiest breathing for a client experiencing
acute dyspnea?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Rationale: Upright positioning improves lung expansion and decreases
diaphragmatic pressure.
11.
A client with asthma develops wheezing and chest tightness. Which medication is
typically used for rapid relief of acute bronchospasm?
A. Albuterol
B. Warfarin
C. Furosemide
D. Levothyroxine
Rationale: Albuterol is a short-acting beta₂-agonist used as a rescue bronchodilator.
12.
A client with pneumonia has a temperature of 39°C (102.2°F), respiratory rate of
30/min, and oxygen saturation of 88%. Which intervention is the priority?
A. Encourage oral fluids
B. Administer prescribed oxygen
C. Obtain a dietary history
D. Provide a warm blanket
Rationale: Hypoxemia is an immediate priority because oxygenation is essential for
tissue survival.
13.
A nurse is teaching a client with COPD about pursed-lip breathing. What is the
primary purpose?
A. Increase respiratory rate
