NUR 170 Exam 2 V1 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 2) | Galen
1. Mr. Henderson is a 68-year-old patient admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). His oxygen saturation is 86% on room air, and he
appears restless. Which oxygen delivery method should the nurse prioritize to provide a
precise concentration of oxygen?
A. Venturi mask at 28%
B. Nasal cannula at 2 L/min
C. Simple face mask at 6 L/min
D. Non-rebreather mask at 15 L/min
Answer: A
Rationale: The Venturi mask is the most accurate method for delivering precise
concentrations of oxygen, which is critical for COPD patients to avoid suppressing their
hypoxic drive. Patients with COPD often require low, stable levels of supplemental oxygen
to maintain safe saturation levels between 88-92%. The nurse must ensure the adapter is
set correctly to deliver the prescribed FiO2.
2. A 55-year-old female patient, Mrs. Miller, presents to the emergency department with a
history of heart failure. She reports sudden onset of shortness of breath and is coughing up
pink, frothy sputum. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer a prescribed beta-blocker
C. Auscultate bowel sounds
D. Position the patient in high-Fowler’s position
Answer: D
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, a life-
threatening complication of heart failure. Positioning the patient in high-Fowler’s position
immediately helps to decrease venous return (preload) and improve lung expansion. This
intervention addresses the immediate airway and breathing needs before proceeding with
diagnostic tests or secondary medications.
3. The nurse is preparing to administer Lisinopril to a patient with hypertension. Which
assessment finding would require the nurse to hold the medication and notify the healthcare
provider?
A. Blood pressure of 138/88 mmHg
,B. Report of a dry, non-productive cough
C. Heart rate of 62 beats per minute
D. Potassium level of 5.6 mEq/L
Answer: D
Rationale: Lisinopril is an ACE inhibitor that can cause hyperkalemia by inhibiting
aldosterone secretion. A potassium level of 5.6 mEq/L is above the normal range (3.5-5.0
mEq/L) and poses a risk for cardiac dysrhythmias. While a dry cough is a common side
effect, hyperkalemia is a more immediate physiological safety concern requiring
intervention.
4. Mr. Jackson is a 45-year-old male recovering from an abdominal cholecystectomy. To
prevent postoperative atelectasis, which intervention is most effective for the nurse to
implement?
A. Administering prophylactic anticoagulants
B. Applying sequential compression devices (SCDs)
C. Performing chest physiotherapy every 4 hours
D. Encouraging the use of an incentive spirometer 10 times every hour while awake
Answer: D
Rationale: Incentive spirometry encourages deep breathing and lung expansion, which
helps to reopen collapsed alveoli (atelectasis) commonly seen after abdominal surgery. The
nurse should teach the patient to inhale slowly and deeply to reach the target volume. This
intervention is a primary nursing responsibility in postoperative respiratory care.
5. A patient with Type 2 Diabetes Mellitus is scheduled for a CT scan with IV contrast. The
patient currently takes Metformin (Glucophage). What instruction should the nurse provide
to the patient?
A. Take double the dose of Metformin the morning of the procedure.
B. Metformin should be discontinued 48 hours before and after the procedure.
C. Switch to insulin for one week following the CT scan.
D. Metformin does not interact with IV contrast dye.
Answer: B
Rationale: Metformin must be held for 48 hours before and after procedures involving IV
contrast dye to prevent the risk of lactic acidosis. Contrast dye can impair renal function,
leading to the accumulation of Metformin in the body. The nurse should monitor the
patient’s creatinine levels before allowing the patient to resume the medication.
, 6. The nurse is caring for a patient who just returned from a bronchoscopy. Which assessment
is the priority before allowing the patient to consume fluids?
A. Presence of a gag reflex
B. Ability to ambulate to the bathroom
C. Oxygen saturation level
D. Presence of blood-tinged sputum
Answer: A
Rationale: During a bronchoscopy, the throat is typically numbed with a local anesthetic to
suppress the gag reflex. It is essential to verify the return of the gag reflex before the
patient drinks or eats to prevent aspiration. The nurse should use a tongue blade or sip of
water only after the reflex is confirmed.
7. A 72-year-old male with a history of atrial fibrillation is prescribed Warfarin (Coumadin).
Which laboratory value should the nurse monitor to determine the effectiveness of the
therapy?
A. Partial Thromboplastin Time (PTT)
B. Platelet count
C. International Normalized Ratio (INR)
D. Hemoglobin and Hematocrit
Answer: C
Rationale: INR is the standard lab value used to monitor the effectiveness of Warfarin
therapy, with a therapeutic range typically between 2.0 and 3.0 for atrial fibrillation. PTT is
used to monitor Heparin therapy, not Warfarin. The nurse must assess the INR to ensure
the dose is sufficient to prevent clots without causing excessive bleeding.
8. The nurse is caring for a patient with a newly placed chest tube for a pneumothorax. The
nurse notes continuous bubbling in the water-seal chamber. What does this finding indicate?
A. The pneumothorax is resolving normally.
B. The suction pressure is set too high.
C. There is an air leak in the system.
D. The chest tube is occluded.
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates that air is leaking into
the drainage system. Intermittent bubbling is expected in a patient with a pneumothorax as
air is expelled from the pleural space, but continuous bubbling suggests a break in the seal
with Rationale (NUR 170 Exam 2) | Galen
1. Mr. Henderson is a 68-year-old patient admitted with an exacerbation of Chronic
Obstructive Pulmonary Disease (COPD). His oxygen saturation is 86% on room air, and he
appears restless. Which oxygen delivery method should the nurse prioritize to provide a
precise concentration of oxygen?
A. Venturi mask at 28%
B. Nasal cannula at 2 L/min
C. Simple face mask at 6 L/min
D. Non-rebreather mask at 15 L/min
Answer: A
Rationale: The Venturi mask is the most accurate method for delivering precise
concentrations of oxygen, which is critical for COPD patients to avoid suppressing their
hypoxic drive. Patients with COPD often require low, stable levels of supplemental oxygen
to maintain safe saturation levels between 88-92%. The nurse must ensure the adapter is
set correctly to deliver the prescribed FiO2.
2. A 55-year-old female patient, Mrs. Miller, presents to the emergency department with a
history of heart failure. She reports sudden onset of shortness of breath and is coughing up
pink, frothy sputum. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer a prescribed beta-blocker
C. Auscultate bowel sounds
D. Position the patient in high-Fowler’s position
Answer: D
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, a life-
threatening complication of heart failure. Positioning the patient in high-Fowler’s position
immediately helps to decrease venous return (preload) and improve lung expansion. This
intervention addresses the immediate airway and breathing needs before proceeding with
diagnostic tests or secondary medications.
3. The nurse is preparing to administer Lisinopril to a patient with hypertension. Which
assessment finding would require the nurse to hold the medication and notify the healthcare
provider?
A. Blood pressure of 138/88 mmHg
,B. Report of a dry, non-productive cough
C. Heart rate of 62 beats per minute
D. Potassium level of 5.6 mEq/L
Answer: D
Rationale: Lisinopril is an ACE inhibitor that can cause hyperkalemia by inhibiting
aldosterone secretion. A potassium level of 5.6 mEq/L is above the normal range (3.5-5.0
mEq/L) and poses a risk for cardiac dysrhythmias. While a dry cough is a common side
effect, hyperkalemia is a more immediate physiological safety concern requiring
intervention.
4. Mr. Jackson is a 45-year-old male recovering from an abdominal cholecystectomy. To
prevent postoperative atelectasis, which intervention is most effective for the nurse to
implement?
A. Administering prophylactic anticoagulants
B. Applying sequential compression devices (SCDs)
C. Performing chest physiotherapy every 4 hours
D. Encouraging the use of an incentive spirometer 10 times every hour while awake
Answer: D
Rationale: Incentive spirometry encourages deep breathing and lung expansion, which
helps to reopen collapsed alveoli (atelectasis) commonly seen after abdominal surgery. The
nurse should teach the patient to inhale slowly and deeply to reach the target volume. This
intervention is a primary nursing responsibility in postoperative respiratory care.
5. A patient with Type 2 Diabetes Mellitus is scheduled for a CT scan with IV contrast. The
patient currently takes Metformin (Glucophage). What instruction should the nurse provide
to the patient?
A. Take double the dose of Metformin the morning of the procedure.
B. Metformin should be discontinued 48 hours before and after the procedure.
C. Switch to insulin for one week following the CT scan.
D. Metformin does not interact with IV contrast dye.
Answer: B
Rationale: Metformin must be held for 48 hours before and after procedures involving IV
contrast dye to prevent the risk of lactic acidosis. Contrast dye can impair renal function,
leading to the accumulation of Metformin in the body. The nurse should monitor the
patient’s creatinine levels before allowing the patient to resume the medication.
, 6. The nurse is caring for a patient who just returned from a bronchoscopy. Which assessment
is the priority before allowing the patient to consume fluids?
A. Presence of a gag reflex
B. Ability to ambulate to the bathroom
C. Oxygen saturation level
D. Presence of blood-tinged sputum
Answer: A
Rationale: During a bronchoscopy, the throat is typically numbed with a local anesthetic to
suppress the gag reflex. It is essential to verify the return of the gag reflex before the
patient drinks or eats to prevent aspiration. The nurse should use a tongue blade or sip of
water only after the reflex is confirmed.
7. A 72-year-old male with a history of atrial fibrillation is prescribed Warfarin (Coumadin).
Which laboratory value should the nurse monitor to determine the effectiveness of the
therapy?
A. Partial Thromboplastin Time (PTT)
B. Platelet count
C. International Normalized Ratio (INR)
D. Hemoglobin and Hematocrit
Answer: C
Rationale: INR is the standard lab value used to monitor the effectiveness of Warfarin
therapy, with a therapeutic range typically between 2.0 and 3.0 for atrial fibrillation. PTT is
used to monitor Heparin therapy, not Warfarin. The nurse must assess the INR to ensure
the dose is sufficient to prevent clots without causing excessive bleeding.
8. The nurse is caring for a patient with a newly placed chest tube for a pneumothorax. The
nurse notes continuous bubbling in the water-seal chamber. What does this finding indicate?
A. The pneumothorax is resolving normally.
B. The suction pressure is set too high.
C. There is an air leak in the system.
D. The chest tube is occluded.
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates that air is leaking into
the drainage system. Intermittent bubbling is expected in a patient with a pneumothorax as
air is expelled from the pleural space, but continuous bubbling suggests a break in the seal
