NSG 302 — Medical-Surgical Nursing II exam
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1. A patient with acute pulmonary edema is experiencing severe
dyspnea and pink, frothy sputum. Which intervention should the
nurse implement first?
A. Encourage oral fluids
B. Place the patient in high-Fowler’s position
C. Administer a sedative
D. Place the patient in a supine position
Answer: B. Place the patient in high-Fowler’s position
Rationale: High-Fowler’s positioning promotes maximum lung
expansion and reduces venous return to the heart, which can decrease
pulmonary congestion. A patient with acute pulmonary edema
requires immediate support of oxygenation and ventilation.
, 2. A patient with chronic heart failure is prescribed furosemide.
Which laboratory value is most important for the nurse to
monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
potassium excretion. Hypokalemia can cause muscle weakness and
potentially life-threatening cardiac dysrhythmias, making potassium
monitoring essential.
3. A patient with myocardial infarction suddenly develops
ventricular fibrillation. What is the priority nursing action?
A. Administer oral aspirin
B. Obtain a 12-lead ECG
C. Initiate cardiopulmonary resuscitation and prepare for defibrillation
D. Administer a prescribed diuretic
Answer: C. Initiate cardiopulmonary resuscitation and prepare for
defibrillation
,Rationale: Ventricular fibrillation produces no effective cardiac output
and is a cardiac arrest rhythm. Immediate CPR and unsynchronized
defibrillation are required to restore an organized rhythm.
4. A patient with left-sided heart failure is most likely to exhibit
which finding?
A. Ascites
B. Jugular venous distention
C. Pulmonary crackles
D. Dependent peripheral edema only
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure causes blood to back up into the
pulmonary circulation, producing pulmonary congestion. Crackles,
dyspnea, orthopnea, and pulmonary edema are common
manifestations.
5. A patient taking digoxin reports nausea, weakness, and seeing
yellow halos around lights. What should the nurse do first?
A. Administer the next dose
B. Hold the medication and notify the provider
C. Encourage increased fluid intake
D. Give an antacid
, Answer: B. Hold the medication and notify the provider
Rationale: Nausea, weakness, and visual disturbances such as yellow
or green halos are classic manifestations of digoxin toxicity. The
medication should be withheld and the provider notified. Serum
digoxin and electrolyte levels may need evaluation.
6. A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen. Which oxygen-delivery approach is generally
appropriate when prescribed for a patient at risk for carbon
dioxide retention?
A. Carefully titrated low-flow oxygen
B. Oxygen at maximum flow continuously
C. No oxygen under any circumstances
D. Oxygen only while sleeping
Answer: A. Carefully titrated low-flow oxygen
Rationale: Some patients with severe COPD are at risk for
hypercapnia, so oxygen is generally titrated to the prescribed target
saturation rather than administered indiscriminately at very high
concentrations. The patient’s respiratory status and prescribed oxygen
target should guide therapy.
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A| Instant
Download Pdf
1. A patient with acute pulmonary edema is experiencing severe
dyspnea and pink, frothy sputum. Which intervention should the
nurse implement first?
A. Encourage oral fluids
B. Place the patient in high-Fowler’s position
C. Administer a sedative
D. Place the patient in a supine position
Answer: B. Place the patient in high-Fowler’s position
Rationale: High-Fowler’s positioning promotes maximum lung
expansion and reduces venous return to the heart, which can decrease
pulmonary congestion. A patient with acute pulmonary edema
requires immediate support of oxygenation and ventilation.
, 2. A patient with chronic heart failure is prescribed furosemide.
Which laboratory value is most important for the nurse to
monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
potassium excretion. Hypokalemia can cause muscle weakness and
potentially life-threatening cardiac dysrhythmias, making potassium
monitoring essential.
3. A patient with myocardial infarction suddenly develops
ventricular fibrillation. What is the priority nursing action?
A. Administer oral aspirin
B. Obtain a 12-lead ECG
C. Initiate cardiopulmonary resuscitation and prepare for defibrillation
D. Administer a prescribed diuretic
Answer: C. Initiate cardiopulmonary resuscitation and prepare for
defibrillation
,Rationale: Ventricular fibrillation produces no effective cardiac output
and is a cardiac arrest rhythm. Immediate CPR and unsynchronized
defibrillation are required to restore an organized rhythm.
4. A patient with left-sided heart failure is most likely to exhibit
which finding?
A. Ascites
B. Jugular venous distention
C. Pulmonary crackles
D. Dependent peripheral edema only
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure causes blood to back up into the
pulmonary circulation, producing pulmonary congestion. Crackles,
dyspnea, orthopnea, and pulmonary edema are common
manifestations.
5. A patient taking digoxin reports nausea, weakness, and seeing
yellow halos around lights. What should the nurse do first?
A. Administer the next dose
B. Hold the medication and notify the provider
C. Encourage increased fluid intake
D. Give an antacid
, Answer: B. Hold the medication and notify the provider
Rationale: Nausea, weakness, and visual disturbances such as yellow
or green halos are classic manifestations of digoxin toxicity. The
medication should be withheld and the provider notified. Serum
digoxin and electrolyte levels may need evaluation.
6. A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen. Which oxygen-delivery approach is generally
appropriate when prescribed for a patient at risk for carbon
dioxide retention?
A. Carefully titrated low-flow oxygen
B. Oxygen at maximum flow continuously
C. No oxygen under any circumstances
D. Oxygen only while sleeping
Answer: A. Carefully titrated low-flow oxygen
Rationale: Some patients with severe COPD are at risk for
hypercapnia, so oxygen is generally titrated to the prescribed target
saturation rather than administered indiscriminately at very high
concentrations. The patient’s respiratory status and prescribed oxygen
target should guide therapy.
