NUR 425 Exam 2: Medical Surgical V1 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient with COPD who is receiving supplemental oxygen. Which flow rate is
typically recommended to prevent respiratory depression?
A. 6-10 L/min via simple mask
B. 10-15 L/min via non-rebreather
C. 8 L/min via partial rebreather
D. 1-2 L/min via nasal cannula
Ans: D
Explanation: The correct choice is C because low-flow oxygen is vital for COPD patients to avoid
suppressing their hypoxic drive to breathe. High concentrations of oxygen can lead to carbon dioxide
retention and respiratory arrest in this population. The nurse must monitor oxygen saturation levels
closely to ensure they remain within the prescribed target range. Other delivery methods like high-flow
masks are usually reserved for acute respiratory distress under strict supervision. Proper titration of
oxygen ensures the patient receives enough oxygenation without causing harm.
2. Which assessment finding is most characteristic of right-sided heart failure?
A. Crackles in the lungs
B. Peripheral edema
C. Dyspnea on exertion
D. Productive cough
Ans: B
,Explanation: The nurse should recognize that peripheral edema is a classic sign of right-sided heart
failure due to systemic venous congestion. This occurs because the right ventricle cannot effectively
pump blood into the pulmonary circulation. Crackles and dyspnea are more commonly associated with
left-sided heart failure as fluid backs up into the lungs. Assessing the patient for jugular venous distention
is also a key nursing action in this scenario. Understanding the difference between right and left heart
failure helps the nurse prioritize the physical assessment.
3. A patient with Type 1 Diabetes is experiencing shakiness, sweating, and confusion. What is the nurse’s
priority action?
A. Administer 15g of fast-acting carbohydrates
B. Give a long-acting insulin injection
C. Encourage the patient to take a nap
D. Check the patient’s urine for ketones
Ans: A
Explanation: The correct action is to provide 15 grams of fast-acting carbohydrates to treat the patient’s
immediate hypoglycemia. These symptoms indicate that the blood glucose level has dropped below the
normal range. Giving insulin would be dangerous as it would lower the blood sugar even further and
potentially cause a coma. After the initial treatment, the nurse should recheck the blood glucose in fifteen
minutes to ensure it is rising. Patient safety is the primary goal when managing acute glycemic
imbalances in the clinical setting.
4. A nurse is reviewing lab results for a patient and notes a potassium level of 6.2 mEq/L. Which
intervention is the priority?
A. Monitor the patient for muscle cramps
B. Place the patient on a cardiac monitor
, C. Administer a potassium supplement
D. Encourage increased intake of bananas
Ans: B
Explanation: The nurse must place the patient on a cardiac monitor because hyperkalemia can cause
life-threatening cardiac dysrhythmias. A potassium level of 6.2 mEq/L is significantly elevated and
requires immediate medical attention. Administering a supplement or increasing dietary intake would
worsen the condition and increase the risk of cardiac arrest. The healthcare provider may order
medications like sodium polystyrene sulfonate or insulin with glucose to lower the levels. Frequent
monitoring of the electrocardiogram is essential for detecting changes such as peaked T waves.
5. A patient is 2 days post-operative from abdominal surgery. Which action by the nurse best prevents deep
vein thrombosis (DVT)?
A. Assisting the patient with early ambulation
B. Restricting fluids to prevent edema
C. Massaging the patient’s calves daily
D. Keeping the patient’s knees in a flexed position
Ans: A
Explanation: Assisting the patient with early and frequent ambulation is the most effective way to
prevent the formation of blood clots. Movement promotes blood flow in the lower extremities and
prevents the stasis that leads to DVT. Massaging the legs is contraindicated because it could dislodge an
existing clot and cause a pulmonary embolism. The nurse should also encourage the patient to perform
ankle pumps while resting in bed. Consistent implementation of these preventive measures is a standard
part of post-operative nursing care.
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient with COPD who is receiving supplemental oxygen. Which flow rate is
typically recommended to prevent respiratory depression?
A. 6-10 L/min via simple mask
B. 10-15 L/min via non-rebreather
C. 8 L/min via partial rebreather
D. 1-2 L/min via nasal cannula
Ans: D
Explanation: The correct choice is C because low-flow oxygen is vital for COPD patients to avoid
suppressing their hypoxic drive to breathe. High concentrations of oxygen can lead to carbon dioxide
retention and respiratory arrest in this population. The nurse must monitor oxygen saturation levels
closely to ensure they remain within the prescribed target range. Other delivery methods like high-flow
masks are usually reserved for acute respiratory distress under strict supervision. Proper titration of
oxygen ensures the patient receives enough oxygenation without causing harm.
2. Which assessment finding is most characteristic of right-sided heart failure?
A. Crackles in the lungs
B. Peripheral edema
C. Dyspnea on exertion
D. Productive cough
Ans: B
,Explanation: The nurse should recognize that peripheral edema is a classic sign of right-sided heart
failure due to systemic venous congestion. This occurs because the right ventricle cannot effectively
pump blood into the pulmonary circulation. Crackles and dyspnea are more commonly associated with
left-sided heart failure as fluid backs up into the lungs. Assessing the patient for jugular venous distention
is also a key nursing action in this scenario. Understanding the difference between right and left heart
failure helps the nurse prioritize the physical assessment.
3. A patient with Type 1 Diabetes is experiencing shakiness, sweating, and confusion. What is the nurse’s
priority action?
A. Administer 15g of fast-acting carbohydrates
B. Give a long-acting insulin injection
C. Encourage the patient to take a nap
D. Check the patient’s urine for ketones
Ans: A
Explanation: The correct action is to provide 15 grams of fast-acting carbohydrates to treat the patient’s
immediate hypoglycemia. These symptoms indicate that the blood glucose level has dropped below the
normal range. Giving insulin would be dangerous as it would lower the blood sugar even further and
potentially cause a coma. After the initial treatment, the nurse should recheck the blood glucose in fifteen
minutes to ensure it is rising. Patient safety is the primary goal when managing acute glycemic
imbalances in the clinical setting.
4. A nurse is reviewing lab results for a patient and notes a potassium level of 6.2 mEq/L. Which
intervention is the priority?
A. Monitor the patient for muscle cramps
B. Place the patient on a cardiac monitor
, C. Administer a potassium supplement
D. Encourage increased intake of bananas
Ans: B
Explanation: The nurse must place the patient on a cardiac monitor because hyperkalemia can cause
life-threatening cardiac dysrhythmias. A potassium level of 6.2 mEq/L is significantly elevated and
requires immediate medical attention. Administering a supplement or increasing dietary intake would
worsen the condition and increase the risk of cardiac arrest. The healthcare provider may order
medications like sodium polystyrene sulfonate or insulin with glucose to lower the levels. Frequent
monitoring of the electrocardiogram is essential for detecting changes such as peaked T waves.
5. A patient is 2 days post-operative from abdominal surgery. Which action by the nurse best prevents deep
vein thrombosis (DVT)?
A. Assisting the patient with early ambulation
B. Restricting fluids to prevent edema
C. Massaging the patient’s calves daily
D. Keeping the patient’s knees in a flexed position
Ans: A
Explanation: Assisting the patient with early and frequent ambulation is the most effective way to
prevent the formation of blood clots. Movement promotes blood flow in the lower extremities and
prevents the stasis that leads to DVT. Massaging the legs is contraindicated because it could dislodge an
existing clot and cause a pulmonary embolism. The nurse should also encourage the patient to perform
ankle pumps while resting in bed. Consistent implementation of these preventive measures is a standard
part of post-operative nursing care.
