PNR 206/PNR206 Exam 2 V3 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a diagnosis of left-sided heart failure. Which of the
following assessment findings is most characteristic of this condition?
A. Jugular venous distension
B. Dyspnea and crackles on auscultation
C. Dependent peripheral edema
D. Right upper quadrant pain and hepatomegaly
Correct Answer: B
Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to pulmonary congestion. The primary symptoms include respiratory
issues such as dyspnea, orthopnea, and the presence of adventitious breath sounds like
crackles. Signs like jugular venous distension and peripheral edema are more commonly
associated with right-sided heart failure.
2. A patient is prescribed Digoxin 0.125 mg orally daily for heart failure. Which assessment
finding should lead the nurse to withhold the medication and notify the provider?
A. Apical heart rate of 52 beats per minute
B. Blood pressure of 142/88 mmHg
C. Respiratory rate of 18 breaths per minute
,D. Potassium level of 4.2 mEq/L
Correct Answer: A
Explanation: Digoxin is a cardiac glycoside that slows the heart rate while increasing the
force of contraction. The nurse must assess the apical pulse for one full minute prior to
administration and withhold the dose if the heart rate is below 60 beats per minute.
Bradycardia is a significant clinical indicator of potential digoxin toxicity.
3. A nurse is providing discharge teaching to a patient with a new diagnosis of hypertension.
Which statement by the patient indicates a need for further instruction?
A. ‘I should limit my alcohol intake to one drink per day.’
B. ‘I will use a salt substitute to season my food.’
C. ‘I will try to walk for 30 minutes most days of the week.’
D. ‘I need to monitor my blood pressure at home regularly.’
Correct Answer: B
Explanation: While reducing sodium intake is crucial for managing hypertension, the use
of salt substitutes can be dangerous, especially for patients on ACE inhibitors or potassium-
sparing diuretics. Many salt substitutes contain high levels of potassium, which can lead to
hyperkalemia. The nurse should encourage the use of herbs and spices for flavoring instead
of potassium-based substitutes.
, 4. The nurse is evaluating the effectiveness of Furosemide (Lasix) administration in a patient
with fluid volume excess. Which finding indicates the medication is working?
A. Decreased urinary output
B. Increased weight gain of 2 pounds
C. Reduced crackles in bilateral lung bases
D. Serum potassium level of 3.2 mEq/L
Correct Answer: C
Explanation: Furosemide is a loop diuretic used to reduce fluid volume by increasing urine
excretion. A reduction in pulmonary congestion, evidenced by decreased crackles, indicates
that the excess fluid is being effectively removed from the body. Monitoring for decreased
peripheral edema and weight loss are also essential evaluative steps.
5. A patient who has undergone a total hip replacement is at high risk for a Pulmonary
Embolism (PE). Which sudden clinical manifestation requires immediate intervention?
A. Dry, itchy skin on the lower extremities
B. Bilateral pitting edema in the ankles
C. Sharp chest pain that worsens with deep breathing
D. Gradual increase in blood pressure
Correct Answer: C
Nursing II Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a diagnosis of left-sided heart failure. Which of the
following assessment findings is most characteristic of this condition?
A. Jugular venous distension
B. Dyspnea and crackles on auscultation
C. Dependent peripheral edema
D. Right upper quadrant pain and hepatomegaly
Correct Answer: B
Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to pulmonary congestion. The primary symptoms include respiratory
issues such as dyspnea, orthopnea, and the presence of adventitious breath sounds like
crackles. Signs like jugular venous distension and peripheral edema are more commonly
associated with right-sided heart failure.
2. A patient is prescribed Digoxin 0.125 mg orally daily for heart failure. Which assessment
finding should lead the nurse to withhold the medication and notify the provider?
A. Apical heart rate of 52 beats per minute
B. Blood pressure of 142/88 mmHg
C. Respiratory rate of 18 breaths per minute
,D. Potassium level of 4.2 mEq/L
Correct Answer: A
Explanation: Digoxin is a cardiac glycoside that slows the heart rate while increasing the
force of contraction. The nurse must assess the apical pulse for one full minute prior to
administration and withhold the dose if the heart rate is below 60 beats per minute.
Bradycardia is a significant clinical indicator of potential digoxin toxicity.
3. A nurse is providing discharge teaching to a patient with a new diagnosis of hypertension.
Which statement by the patient indicates a need for further instruction?
A. ‘I should limit my alcohol intake to one drink per day.’
B. ‘I will use a salt substitute to season my food.’
C. ‘I will try to walk for 30 minutes most days of the week.’
D. ‘I need to monitor my blood pressure at home regularly.’
Correct Answer: B
Explanation: While reducing sodium intake is crucial for managing hypertension, the use
of salt substitutes can be dangerous, especially for patients on ACE inhibitors or potassium-
sparing diuretics. Many salt substitutes contain high levels of potassium, which can lead to
hyperkalemia. The nurse should encourage the use of herbs and spices for flavoring instead
of potassium-based substitutes.
, 4. The nurse is evaluating the effectiveness of Furosemide (Lasix) administration in a patient
with fluid volume excess. Which finding indicates the medication is working?
A. Decreased urinary output
B. Increased weight gain of 2 pounds
C. Reduced crackles in bilateral lung bases
D. Serum potassium level of 3.2 mEq/L
Correct Answer: C
Explanation: Furosemide is a loop diuretic used to reduce fluid volume by increasing urine
excretion. A reduction in pulmonary congestion, evidenced by decreased crackles, indicates
that the excess fluid is being effectively removed from the body. Monitoring for decreased
peripheral edema and weight loss are also essential evaluative steps.
5. A patient who has undergone a total hip replacement is at high risk for a Pulmonary
Embolism (PE). Which sudden clinical manifestation requires immediate intervention?
A. Dry, itchy skin on the lower extremities
B. Bilateral pitting edema in the ankles
C. Sharp chest pain that worsens with deep breathing
D. Gradual increase in blood pressure
Correct Answer: C
