NUR 425 Final Exam: Medical Surgical V1 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. Which clinical manifestation should a nurse expect to find in a patient with left-sided heart failure?
A. Peripheral edema
B. Crackles in the lungs
C. Jugular venous distention
D. Hepatomegaly
Ans: B
Explanation: Left-sided heart failure leads to pulmonary congestion because the left ventricle cannot
pump blood efficiently. This causes fluid to back up into the lungs, resulting in crackles and shortness of
breath. Peripheral edema and jugular venous distention are primarily associated with right-sided heart
failure. Nurses must monitor respiratory status closely to detect worsening pulmonary edema. Early
intervention with diuretics helps manage the fluid volume in the alveolar spaces.
2. A patient with Type 1 Diabetes is experiencing shakiness, sweating, and confusion. What is the priority
action?
A. Call the rapid response team
B. Administer scheduled insulin
C. Provide a high-protein snack
D. Check blood glucose level
Ans: D
,Explanation: Shakiness, sweating, and confusion are classic signs of hypoglycemia in diabetic patients.
The nurse must first confirm the blood glucose level to determine the severity of the drop. Administering
insulin would further lower blood glucose and worsen the patient’s condition. If the level is low, a fast-
acting carbohydrate should be provided immediately. Continuous monitoring is required until the patient
is stable and glucose levels normalize.
3. Which nursing intervention is most appropriate for a patient with Chronic Obstructive Pulmonary Disease
(COPD) using oxygen?
A. Maintain oxygen flow at 10 liters per minute
B. Keep oxygen saturation between 88% and 92%
C. Encourage rapid shallow breathing
D. Place the patient in a supine position
Ans: B
Explanation: Patients with COPD often rely on a hypoxic drive to breathe due to chronic carbon dioxide
retention. Maintaining oxygen saturation between 88% and 92% prevents the suppression of this
respiratory drive. High levels of oxygen can lead to oxygen-induced hypercapnia in these patients. The
nurse should use low-flow oxygen delivery devices like a nasal cannula. Position the patient in High-
Fowler’s to maximize lung expansion and comfort.
4. A patient with hypertension is prescribed a DASH diet. Which food choice indicates the patient
understands the diet?
A. Canned vegetable soup
B. Fresh fruits and vegetables
C. Processed deli meats
, D. Pickled cucumbers
Ans: B
Explanation: The DASH diet emphasizes high intake of fresh fruits, vegetables, and low-fat dairy. It is
designed to lower blood pressure by reducing sodium and increasing potassium and magnesium. Canned
soups and processed meats are high in sodium and should be avoided. Successful adherence to this diet
significantly reduces cardiovascular risk factors. Nurses should provide education on reading food labels
to identify hidden sodium sources.
5. Which postoperative intervention is most effective for preventing Deep Vein Thrombosis (DVT)?
A. Massaging the calves daily
B. Placing a pillow under the knees
C. Restricting fluid intake
D. Early ambulation
Ans: D
Explanation: Early ambulation is the gold standard for promoting venous return and preventing blood
stasis after surgery. Massaging calves is contraindicated as it may dislodge an existing clot. Placing
pillows under the knees can compress veins and actually increase the risk of DVT. Hydration is also
important to maintain blood viscosity and prevent thrombus formation. Sequential compression devices
are often used as an adjunct to early movement.
6. What should the nurse instruct a patient with GERD to avoid before bedtime?
A. Sleeping with two pillows
B. Drinking plain water
C. Eating large meals
Updated and Latest Questions and Correct Answers with
Rationale
1. Which clinical manifestation should a nurse expect to find in a patient with left-sided heart failure?
A. Peripheral edema
B. Crackles in the lungs
C. Jugular venous distention
D. Hepatomegaly
Ans: B
Explanation: Left-sided heart failure leads to pulmonary congestion because the left ventricle cannot
pump blood efficiently. This causes fluid to back up into the lungs, resulting in crackles and shortness of
breath. Peripheral edema and jugular venous distention are primarily associated with right-sided heart
failure. Nurses must monitor respiratory status closely to detect worsening pulmonary edema. Early
intervention with diuretics helps manage the fluid volume in the alveolar spaces.
2. A patient with Type 1 Diabetes is experiencing shakiness, sweating, and confusion. What is the priority
action?
A. Call the rapid response team
B. Administer scheduled insulin
C. Provide a high-protein snack
D. Check blood glucose level
Ans: D
,Explanation: Shakiness, sweating, and confusion are classic signs of hypoglycemia in diabetic patients.
The nurse must first confirm the blood glucose level to determine the severity of the drop. Administering
insulin would further lower blood glucose and worsen the patient’s condition. If the level is low, a fast-
acting carbohydrate should be provided immediately. Continuous monitoring is required until the patient
is stable and glucose levels normalize.
3. Which nursing intervention is most appropriate for a patient with Chronic Obstructive Pulmonary Disease
(COPD) using oxygen?
A. Maintain oxygen flow at 10 liters per minute
B. Keep oxygen saturation between 88% and 92%
C. Encourage rapid shallow breathing
D. Place the patient in a supine position
Ans: B
Explanation: Patients with COPD often rely on a hypoxic drive to breathe due to chronic carbon dioxide
retention. Maintaining oxygen saturation between 88% and 92% prevents the suppression of this
respiratory drive. High levels of oxygen can lead to oxygen-induced hypercapnia in these patients. The
nurse should use low-flow oxygen delivery devices like a nasal cannula. Position the patient in High-
Fowler’s to maximize lung expansion and comfort.
4. A patient with hypertension is prescribed a DASH diet. Which food choice indicates the patient
understands the diet?
A. Canned vegetable soup
B. Fresh fruits and vegetables
C. Processed deli meats
, D. Pickled cucumbers
Ans: B
Explanation: The DASH diet emphasizes high intake of fresh fruits, vegetables, and low-fat dairy. It is
designed to lower blood pressure by reducing sodium and increasing potassium and magnesium. Canned
soups and processed meats are high in sodium and should be avoided. Successful adherence to this diet
significantly reduces cardiovascular risk factors. Nurses should provide education on reading food labels
to identify hidden sodium sources.
5. Which postoperative intervention is most effective for preventing Deep Vein Thrombosis (DVT)?
A. Massaging the calves daily
B. Placing a pillow under the knees
C. Restricting fluid intake
D. Early ambulation
Ans: D
Explanation: Early ambulation is the gold standard for promoting venous return and preventing blood
stasis after surgery. Massaging calves is contraindicated as it may dislodge an existing clot. Placing
pillows under the knees can compress veins and actually increase the risk of DVT. Hydration is also
important to maintain blood viscosity and prevent thrombus formation. Sequential compression devices
are often used as an adjunct to early movement.
6. What should the nurse instruct a patient with GERD to avoid before bedtime?
A. Sleeping with two pillows
B. Drinking plain water
C. Eating large meals
