NSG223/NSG 223 Exam 3 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is assessing a client with left-sided heart failure. Which of the following findings
should the nurse prioritize?
A. Crackles in the lung bases
B. Dependent edema
C. Jugular venous distension
D. Right upper quadrant pain
Correct Answer: A
Rationale: Left-sided heart failure results in pulmonary congestion because the left
ventricle fails to pump blood efficiently into the systemic circulation. This causes fluid to
back up into the lungs, leading to crackles, dyspnea, and cough. The other options are
symptoms typically associated with right-sided heart failure.
2. A client is prescribed Digoxin for heart failure. Which laboratory value should the nurse
monitor most closely to prevent toxicity?
A. Serum Calcium
B. Serum Magnesium
C. Serum Sodium
,D. Serum Potassium
Correct Answer: D
Rationale: Hypokalemia significantly increases the risk of digoxin toxicity because
potassium and digoxin compete for binding sites on the sodium-potassium ATPase pump.
The nurse must ensure potassium levels are within the normal range of 3.5 to 5.0 mEq/L. If
the potassium is low, the nurse should hold the medication and notify the provider
immediately.
3. The nurse is caring for a client with an Arteriovenous (AV) fistula in the left arm. Which
action is appropriate for the nurse to take?
A. Perform blood pressure checks on the left arm
B. Draw blood samples from the fistula
C. Palpate for a thrill over the fistula site
D. Apply a tight dressing to the site after dialysis
Correct Answer: C
Rationale: Assessing for a thrill and auscultating for a bruit are essential nursing actions to
ensure the patency of the AV fistula. Blood pressure readings and venipunctures should
never be performed on the arm with the fistula to prevent clotting or damage. Ensuring the
site is not constricted helps maintain long-term access for hemodialysis.
, 4. A client with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation with PEEP. What is the primary purpose of PEEP in this client?
A. To decrease the work of breathing
B. To keep the alveoli open at the end of expiration
C. To prevent barotrauma
D. To increase the respiratory rate
Correct Answer: B
Rationale: Positive End-Expiratory Pressure (PEEP) is used in ARDS to prevent alveolar
collapse and improve oxygenation by keeping the alveoli open. This recruitment of alveoli
increases the surface area available for gas exchange. While it helps oxygenation, high
levels of PEEP must be monitored for potential complications like decreased cardiac
output.
5. A nurse observes a client’s EKG strip and notes a ‘sawtooth’ pattern between QRS
complexes. Which rhythm is the client experiencing?
A. Atrial Fibrillation
B. Ventricular Tachycardia
C. Atrial Flutter
D. Premature Ventricular Contractions
Correct Answer: C
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is assessing a client with left-sided heart failure. Which of the following findings
should the nurse prioritize?
A. Crackles in the lung bases
B. Dependent edema
C. Jugular venous distension
D. Right upper quadrant pain
Correct Answer: A
Rationale: Left-sided heart failure results in pulmonary congestion because the left
ventricle fails to pump blood efficiently into the systemic circulation. This causes fluid to
back up into the lungs, leading to crackles, dyspnea, and cough. The other options are
symptoms typically associated with right-sided heart failure.
2. A client is prescribed Digoxin for heart failure. Which laboratory value should the nurse
monitor most closely to prevent toxicity?
A. Serum Calcium
B. Serum Magnesium
C. Serum Sodium
,D. Serum Potassium
Correct Answer: D
Rationale: Hypokalemia significantly increases the risk of digoxin toxicity because
potassium and digoxin compete for binding sites on the sodium-potassium ATPase pump.
The nurse must ensure potassium levels are within the normal range of 3.5 to 5.0 mEq/L. If
the potassium is low, the nurse should hold the medication and notify the provider
immediately.
3. The nurse is caring for a client with an Arteriovenous (AV) fistula in the left arm. Which
action is appropriate for the nurse to take?
A. Perform blood pressure checks on the left arm
B. Draw blood samples from the fistula
C. Palpate for a thrill over the fistula site
D. Apply a tight dressing to the site after dialysis
Correct Answer: C
Rationale: Assessing for a thrill and auscultating for a bruit are essential nursing actions to
ensure the patency of the AV fistula. Blood pressure readings and venipunctures should
never be performed on the arm with the fistula to prevent clotting or damage. Ensuring the
site is not constricted helps maintain long-term access for hemodialysis.
, 4. A client with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation with PEEP. What is the primary purpose of PEEP in this client?
A. To decrease the work of breathing
B. To keep the alveoli open at the end of expiration
C. To prevent barotrauma
D. To increase the respiratory rate
Correct Answer: B
Rationale: Positive End-Expiratory Pressure (PEEP) is used in ARDS to prevent alveolar
collapse and improve oxygenation by keeping the alveoli open. This recruitment of alveoli
increases the surface area available for gas exchange. While it helps oxygenation, high
levels of PEEP must be monitored for potential complications like decreased cardiac
output.
5. A nurse observes a client’s EKG strip and notes a ‘sawtooth’ pattern between QRS
complexes. Which rhythm is the client experiencing?
A. Atrial Fibrillation
B. Ventricular Tachycardia
C. Atrial Flutter
D. Premature Ventricular Contractions
Correct Answer: C
