Exam 3: NUR 201 Medical-Surgical Nursing I
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1: A 69-year-old female is admitted with acute decompensated heart failure. She has bilateral
crackles to the apices, severe orthopnea, and 4+ pitting edema to the knees. Her SpO2 is 84% on
room air. Which intervention should the nurse implement first?
A. Administer digoxin 0.125 mg PO
B. Position the patient in high Fowler's and administer oxygen
C. Insert a Foley catheter to monitor urine output
D. Obtain a 12-lead ECG immediately
Correct Answer: B
Rationale: Correct because positioning the patient in high Fowler's (90 degrees) maximizes lung
expansion, reduces venous return to the heart (decreasing preload), and facilitates breathing in
acute pulmonary edema, while supplemental oxygen corrects life-threatening hypoxemia (SpO2
84%). These interventions address the immediate threats to airway and oxygenation before
pharmacological management. The nurse must then prepare to administer loop diuretics as
ordered, initiate continuous cardiac and pulse oximetry monitoring, and assess for signs of
respiratory fatigue that may require non-invasive positive pressure ventilation or intubation.
Q2: A patient with chronic stable angina reports chest tightness while climbing stairs. The nurse
retrieves the patient's sublingual nitroglycerin. Which action by the nurse is correct?
A. Instruct the patient to swallow the tablet with water
B. Have the patient place the tablet under the tongue and stop all activity
C. Tell the patient to chew the tablet for faster absorption
D. Administer the tablet with food to prevent nausea
Correct Answer: D
,Rationale: Correct because sublingual nitroglycerin must be placed under the tongue or in the
buccal pouch to dissolve completely, allowing rapid absorption through the highly vascular oral
mucosa directly into the systemic circulation without first-pass hepatic metabolism. The patient
must stop all activity, sit or lie down to prevent orthostatic hypotension, and take one dose every
5 minutes for up to three doses; if pain persists after three doses, emergency services must be
called immediately. Swallowing the tablet destroys its efficacy, chewing is inappropriate for
sublingual formulations, and food interferes with absorption.
Q3: A patient with new-onset atrial fibrillation has an apical heart rate of 152 bpm and a radial
pulse of 118 bpm. The patient is alert but reports mild dizziness. Blood pressure is 104/68
mmHg. Which is the priority nursing assessment?
A. Calculate the pulse deficit and assess for hemodynamic instability
B. Administer IV adenosine 6 mg rapid push immediately
C. Prepare for immediate synchronized cardioversion
D. Initiate therapeutic hypothermia protocol
Correct Answer: A
Rationale: Correct because the pulse deficit (difference between apical and radial rates, 34 bpm
in this case) indicates ineffective atrial contractions with some beats failing to produce sufficient
stroke volume to generate a peripheral pulse, which is a hallmark of atrial fibrillation. The
priority is to assess for hemodynamic instability (hypotension, altered mental status, chest pain,
signs of shock) to determine if immediate cardioversion is indicated; this patient has borderline
blood pressure and dizziness but remains alert, suggesting stability that warrants rate-control
medications rather than emergent cardioversion. The nurse must initiate continuous telemetry,
obtain a 12-lead ECG, and notify the provider for orders on rate control and anticoagulation.
Q4: A patient prescribed enalapril 10 mg daily reports a dry, hacking cough that started two
weeks after beginning the medication. The nurse notes a potassium of 5.2 mEq/L. Which is the
most appropriate nursing action?
A. Discontinue the enalapril and notify the provider for an alternative
B. Reassure the patient that the cough will resolve with continued use
C. Administer an antitussive and continue the enalapril
D. Increase the enalapril dose to reduce the cough
Correct Answer: C
Rationale: Correct because a dry, persistent cough is a well-documented side effect of ACE
inhibitors such as enalapril, caused by accumulation of bradykinin and substance P from ACE
, inhibition, and while it is not dangerous, it often necessitates switching to an angiotensin receptor
blocker (ARB) such as losartan which does not affect bradykinin metabolism. The mild
hyperkalemia (5.2 mEq/L) also warrants monitoring and possible dietary modification. The nurse
must notify the provider to discuss switching to an ARB, as the cough rarely resolves with
continued ACE inhibitor use and significantly impacts quality of life and medication adherence.
Q5: A patient with peripheral artery disease reports burning pain in the feet at rest, especially at
night. The nurse notes dependent rubor, absent dorsalis pedis pulses, and cool skin temperature.
Which nursing instruction is most appropriate?
A. Elevate the legs above the heart to reduce swelling
B. Keep the legs dependent and avoid all physical activity
C. Walk to the point of claudication daily to build collateral circulation
D. Apply warm compresses to the feet before bedtime
Correct Answer: D
Rationale: Correct because dependent rubor, absent pulses, cool skin, and rest pain indicate
critical limb ischemia (severe PAD), and the patient must keep legs in a dependent position to
maximize gravity-assisted arterial perfusion to the ischemic tissues. Warm compresses are
absolutely contraindicated due to decreased sensation and high burn risk; leg elevation worsens
arterial perfusion and is appropriate for venous insufficiency, not PAD; and while supervised
walking programs are beneficial for intermittent claudication, rest pain indicates advanced
disease requiring vascular surgery evaluation. The nurse must also emphasize smoking cessation,
diabetes and lipid control, and daily foot inspection to prevent ulceration and amputation.
Q6: A nurse is delegating tasks for a patient with a stable tracheostomy. Which task is
appropriate to assign to an experienced LPN?
A. Perform the initial comprehensive dysphagia screening
B. Conduct patient and family education on emergency decannulation
C. Perform routine tracheostomy suctioning using sterile technique
D. Assess the stoma for granulation tissue and skin breakdown
Correct Answer: A
Rationale: Correct because routine tracheostomy suctioning using sterile technique is within the
scope of practice for an experienced LPN/LVN under RN supervision, as it is a delegated skill-
based task that does not require complex clinical judgment or initial patient assessment. The
initial comprehensive dysphagia screening, patient and family education on emergency
management, and assessment of the stoma for complications remain the responsibility of the RN,
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Q1: A 69-year-old female is admitted with acute decompensated heart failure. She has bilateral
crackles to the apices, severe orthopnea, and 4+ pitting edema to the knees. Her SpO2 is 84% on
room air. Which intervention should the nurse implement first?
A. Administer digoxin 0.125 mg PO
B. Position the patient in high Fowler's and administer oxygen
C. Insert a Foley catheter to monitor urine output
D. Obtain a 12-lead ECG immediately
Correct Answer: B
Rationale: Correct because positioning the patient in high Fowler's (90 degrees) maximizes lung
expansion, reduces venous return to the heart (decreasing preload), and facilitates breathing in
acute pulmonary edema, while supplemental oxygen corrects life-threatening hypoxemia (SpO2
84%). These interventions address the immediate threats to airway and oxygenation before
pharmacological management. The nurse must then prepare to administer loop diuretics as
ordered, initiate continuous cardiac and pulse oximetry monitoring, and assess for signs of
respiratory fatigue that may require non-invasive positive pressure ventilation or intubation.
Q2: A patient with chronic stable angina reports chest tightness while climbing stairs. The nurse
retrieves the patient's sublingual nitroglycerin. Which action by the nurse is correct?
A. Instruct the patient to swallow the tablet with water
B. Have the patient place the tablet under the tongue and stop all activity
C. Tell the patient to chew the tablet for faster absorption
D. Administer the tablet with food to prevent nausea
Correct Answer: D
,Rationale: Correct because sublingual nitroglycerin must be placed under the tongue or in the
buccal pouch to dissolve completely, allowing rapid absorption through the highly vascular oral
mucosa directly into the systemic circulation without first-pass hepatic metabolism. The patient
must stop all activity, sit or lie down to prevent orthostatic hypotension, and take one dose every
5 minutes for up to three doses; if pain persists after three doses, emergency services must be
called immediately. Swallowing the tablet destroys its efficacy, chewing is inappropriate for
sublingual formulations, and food interferes with absorption.
Q3: A patient with new-onset atrial fibrillation has an apical heart rate of 152 bpm and a radial
pulse of 118 bpm. The patient is alert but reports mild dizziness. Blood pressure is 104/68
mmHg. Which is the priority nursing assessment?
A. Calculate the pulse deficit and assess for hemodynamic instability
B. Administer IV adenosine 6 mg rapid push immediately
C. Prepare for immediate synchronized cardioversion
D. Initiate therapeutic hypothermia protocol
Correct Answer: A
Rationale: Correct because the pulse deficit (difference between apical and radial rates, 34 bpm
in this case) indicates ineffective atrial contractions with some beats failing to produce sufficient
stroke volume to generate a peripheral pulse, which is a hallmark of atrial fibrillation. The
priority is to assess for hemodynamic instability (hypotension, altered mental status, chest pain,
signs of shock) to determine if immediate cardioversion is indicated; this patient has borderline
blood pressure and dizziness but remains alert, suggesting stability that warrants rate-control
medications rather than emergent cardioversion. The nurse must initiate continuous telemetry,
obtain a 12-lead ECG, and notify the provider for orders on rate control and anticoagulation.
Q4: A patient prescribed enalapril 10 mg daily reports a dry, hacking cough that started two
weeks after beginning the medication. The nurse notes a potassium of 5.2 mEq/L. Which is the
most appropriate nursing action?
A. Discontinue the enalapril and notify the provider for an alternative
B. Reassure the patient that the cough will resolve with continued use
C. Administer an antitussive and continue the enalapril
D. Increase the enalapril dose to reduce the cough
Correct Answer: C
Rationale: Correct because a dry, persistent cough is a well-documented side effect of ACE
inhibitors such as enalapril, caused by accumulation of bradykinin and substance P from ACE
, inhibition, and while it is not dangerous, it often necessitates switching to an angiotensin receptor
blocker (ARB) such as losartan which does not affect bradykinin metabolism. The mild
hyperkalemia (5.2 mEq/L) also warrants monitoring and possible dietary modification. The nurse
must notify the provider to discuss switching to an ARB, as the cough rarely resolves with
continued ACE inhibitor use and significantly impacts quality of life and medication adherence.
Q5: A patient with peripheral artery disease reports burning pain in the feet at rest, especially at
night. The nurse notes dependent rubor, absent dorsalis pedis pulses, and cool skin temperature.
Which nursing instruction is most appropriate?
A. Elevate the legs above the heart to reduce swelling
B. Keep the legs dependent and avoid all physical activity
C. Walk to the point of claudication daily to build collateral circulation
D. Apply warm compresses to the feet before bedtime
Correct Answer: D
Rationale: Correct because dependent rubor, absent pulses, cool skin, and rest pain indicate
critical limb ischemia (severe PAD), and the patient must keep legs in a dependent position to
maximize gravity-assisted arterial perfusion to the ischemic tissues. Warm compresses are
absolutely contraindicated due to decreased sensation and high burn risk; leg elevation worsens
arterial perfusion and is appropriate for venous insufficiency, not PAD; and while supervised
walking programs are beneficial for intermittent claudication, rest pain indicates advanced
disease requiring vascular surgery evaluation. The nurse must also emphasize smoking cessation,
diabetes and lipid control, and daily foot inspection to prevent ulceration and amputation.
Q6: A nurse is delegating tasks for a patient with a stable tracheostomy. Which task is
appropriate to assign to an experienced LPN?
A. Perform the initial comprehensive dysphagia screening
B. Conduct patient and family education on emergency decannulation
C. Perform routine tracheostomy suctioning using sterile technique
D. Assess the stoma for granulation tissue and skin breakdown
Correct Answer: A
Rationale: Correct because routine tracheostomy suctioning using sterile technique is within the
scope of practice for an experienced LPN/LVN under RN supervision, as it is a delegated skill-
based task that does not require complex clinical judgment or initial patient assessment. The
initial comprehensive dysphagia screening, patient and family education on emergency
management, and assessment of the stoma for complications remain the responsibility of the RN,
