NU 186 Final Exam V3 | NU 186 Medical-
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Final Exam) | Galen
1. A nurse is providing discharge teaching to a client diagnosed with Chronic Obstructive
Pulmonary Disease (COPD). Which of the following instructions should the nurse include to
promote effective gas exchange? Select all that apply.
A. Perform pursed-lip breathing exercises.
B. Increase fluid intake to 2 to 3 liters per day if not contraindicated.
C. Limit caloric intake to prevent excessive weight gain.
D. Practice diaphragmatic breathing to reduce the work of breathing.
E. Use oxygen at 6 L/min via nasal cannula for shortness of breath.
F. Receive the annual influenza and pneumococcal vaccines.
Correct Answer: A, B, D, F
Explanation: Pursed-lip breathing helps maintain airway pressure and prevents airway
collapse during exhalation. Increased fluid intake helps thin pulmonary secretions for
easier expectoration. Diaphragmatic breathing focuses on using the diaphragm rather than
accessory muscles, while vaccinations prevent respiratory infections that could exacerbate
COPD. Oxygen should be used cautiously in COPD patients, typically not exceeding 2-4
L/min to avoid suppressing the hypoxic drive.
,2. A nurse is monitoring a client who is receiving a continuous intravenous infusion of heparin
for the treatment of deep vein thrombosis (DVT). Which laboratory value should the nurse
prioritize to monitor the effectiveness of the therapy?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Platelet count
D. Activated partial thromboplastin time (aPTT)
Correct Answer: D
Explanation: The aPTT is the standard laboratory test used to monitor the effectiveness of
unfractionated heparin therapy. PT and INR are used primarily to monitor warfarin
therapy rather than heparin. While the platelet count is monitored to screen for heparin-
induced thrombocytopenia, it does not measure the anticoagulant effect of the heparin
itself.
3. A client is admitted to the emergency department with a suspected myocardial infarction.
Which of the following clinical manifestations should the nurse expect to assess?
A. Substernal chest pain radiating to the left arm
B. Bradypnea and increased appetite
C. Diaphoresis and nausea
D. Sharp pleuritic pain that increases with inspiration
,E. Feelings of intense anxiety or impending doom
Correct Answer: A, C, E
Explanation: Myocardial infarction typically presents with crushing substernal chest pain
that may radiate to the jaw, neck, or left arm. Sympathetic nervous system activation often
causes diaphoresis, nausea, and a sense of impending doom. Pleuritic pain is more
characteristic of pericarditis or pulmonary embolism rather than an acute MI.
4. The nurse is caring for a client with Type 1 Diabetes Mellitus who was found unresponsive.
The fingerstick blood glucose is 48 mg/dL. Which action should the nurse take first?
A. Administer 15 grams of simple carbohydrates orally.
B. Administer 1 mg of glucagon intramuscularly.
C. Recheck the blood glucose in 15 minutes.
D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: Because the client is unresponsive, oral carbohydrates are contraindicated
due to the risk of aspiration. Glucagon should be administered intramuscularly or
subcutaneously to stimulate the liver to release glucose. Once the client is awake and able
to swallow, a complex carbohydrate and protein snack should be provided.
5. A client is diagnosed with right-sided heart failure. Which of the following assessment
findings are consistent with this diagnosis? Select all that apply.
A. Jugular venous distention (JVD)
, B. Crackles in the lung bases
C. Dependent peripheral edema
D. Ascites and abdominal girth increase
E. Pink, frothy sputum
F. Hepatomegaly
Correct Answer: A, C, D, F
Explanation: Right-sided heart failure causes systemic venous congestion, leading to JVD,
peripheral edema, ascites, and liver enlargement. Crackles and pink frothy sputum are
classic signs of left-sided heart failure due to pulmonary congestion. Management focuses
on reducing fluid volume and improving cardiac contractility.
6. A nurse is caring for a client with a Glascow Coma Scale (GCS) score of 7. Which is the
nurse’s priority action?
A. Monitor urine output hourly.
B. Prepare for endotracheal intubation.
C. Assess the client’s pupillary response.
D. Perform a complete neurological exam.
Correct Answer: B
Explanation: A GCS score of 8 or less typically indicates that the client is in a coma and
may not be able to maintain a patent airway. The priority in this situation is to secure the
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Final Exam) | Galen
1. A nurse is providing discharge teaching to a client diagnosed with Chronic Obstructive
Pulmonary Disease (COPD). Which of the following instructions should the nurse include to
promote effective gas exchange? Select all that apply.
A. Perform pursed-lip breathing exercises.
B. Increase fluid intake to 2 to 3 liters per day if not contraindicated.
C. Limit caloric intake to prevent excessive weight gain.
D. Practice diaphragmatic breathing to reduce the work of breathing.
E. Use oxygen at 6 L/min via nasal cannula for shortness of breath.
F. Receive the annual influenza and pneumococcal vaccines.
Correct Answer: A, B, D, F
Explanation: Pursed-lip breathing helps maintain airway pressure and prevents airway
collapse during exhalation. Increased fluid intake helps thin pulmonary secretions for
easier expectoration. Diaphragmatic breathing focuses on using the diaphragm rather than
accessory muscles, while vaccinations prevent respiratory infections that could exacerbate
COPD. Oxygen should be used cautiously in COPD patients, typically not exceeding 2-4
L/min to avoid suppressing the hypoxic drive.
,2. A nurse is monitoring a client who is receiving a continuous intravenous infusion of heparin
for the treatment of deep vein thrombosis (DVT). Which laboratory value should the nurse
prioritize to monitor the effectiveness of the therapy?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Platelet count
D. Activated partial thromboplastin time (aPTT)
Correct Answer: D
Explanation: The aPTT is the standard laboratory test used to monitor the effectiveness of
unfractionated heparin therapy. PT and INR are used primarily to monitor warfarin
therapy rather than heparin. While the platelet count is monitored to screen for heparin-
induced thrombocytopenia, it does not measure the anticoagulant effect of the heparin
itself.
3. A client is admitted to the emergency department with a suspected myocardial infarction.
Which of the following clinical manifestations should the nurse expect to assess?
A. Substernal chest pain radiating to the left arm
B. Bradypnea and increased appetite
C. Diaphoresis and nausea
D. Sharp pleuritic pain that increases with inspiration
,E. Feelings of intense anxiety or impending doom
Correct Answer: A, C, E
Explanation: Myocardial infarction typically presents with crushing substernal chest pain
that may radiate to the jaw, neck, or left arm. Sympathetic nervous system activation often
causes diaphoresis, nausea, and a sense of impending doom. Pleuritic pain is more
characteristic of pericarditis or pulmonary embolism rather than an acute MI.
4. The nurse is caring for a client with Type 1 Diabetes Mellitus who was found unresponsive.
The fingerstick blood glucose is 48 mg/dL. Which action should the nurse take first?
A. Administer 15 grams of simple carbohydrates orally.
B. Administer 1 mg of glucagon intramuscularly.
C. Recheck the blood glucose in 15 minutes.
D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: Because the client is unresponsive, oral carbohydrates are contraindicated
due to the risk of aspiration. Glucagon should be administered intramuscularly or
subcutaneously to stimulate the liver to release glucose. Once the client is awake and able
to swallow, a complex carbohydrate and protein snack should be provided.
5. A client is diagnosed with right-sided heart failure. Which of the following assessment
findings are consistent with this diagnosis? Select all that apply.
A. Jugular venous distention (JVD)
, B. Crackles in the lung bases
C. Dependent peripheral edema
D. Ascites and abdominal girth increase
E. Pink, frothy sputum
F. Hepatomegaly
Correct Answer: A, C, D, F
Explanation: Right-sided heart failure causes systemic venous congestion, leading to JVD,
peripheral edema, ascites, and liver enlargement. Crackles and pink frothy sputum are
classic signs of left-sided heart failure due to pulmonary congestion. Management focuses
on reducing fluid volume and improving cardiac contractility.
6. A nurse is caring for a client with a Glascow Coma Scale (GCS) score of 7. Which is the
nurse’s priority action?
A. Monitor urine output hourly.
B. Prepare for endotracheal intubation.
C. Assess the client’s pupillary response.
D. Perform a complete neurological exam.
Correct Answer: B
Explanation: A GCS score of 8 or less typically indicates that the client is in a coma and
may not be able to maintain a patent airway. The priority in this situation is to secure the
