PNR 206/PNR206 Exam 1 V1 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of Chronic Obstructive Pulmonary Disease
(COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client’s oxygen saturation is
89%. Which action should the nurse take first?
A. Increase the oxygen flow rate to 6 L/min.
B. Administer a PRN dose of albuterol.
C. Place the client in a high-Fowler’s position.
D. Notify the healthcare provider immediately.
Correct Answer: C
Explanation: Positioning the client in high-Fowler’s allows for maximum chest expansion
and improves gas exchange. In COPD patients, a baseline oxygen saturation of 88-92% is
often normal due to their chronic state. Increasing oxygen too high can suppress the
hypoxic drive which is their stimulus to breathe.
2. A client is admitted with suspected right-sided heart failure. Which clinical manifestation
should the nurse expect to find during the physical assessment?
A. Peripheral edema and jugular vein distention.
B. Dyspnea on exertion.
C. Crackles in the lung bases.
,D. Orthopnea and cough.
Correct Answer: A
Explanation: Right-sided heart failure results in the backup of blood into the systemic
circulation. This leads to systemic symptoms such as peripheral edema, hepatomegaly, and
jugular venous distention. Left-sided failure, by contrast, primarily causes pulmonary
symptoms like crackles and dyspnea.
3. The nurse is preparing to administer Digoxin to a client with heart failure. Which
assessment finding would require the nurse to withhold the medication?
A. Blood pressure of 110/70 mmHg.
B. Respiratory rate of 18 breaths per minute.
C. Apical pulse of 52 beats per minute.
D. Potassium level of 4.2 mEq/L.
Correct Answer: C
Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases the
force of contraction. The apical pulse must be checked for one full minute before
administration. If the pulse is below 60 beats per minute in an adult, the dose should be
held and the provider notified.
4. A client with deep vein thrombosis (DVT) is receiving a heparin infusion. Which laboratory
value should the nurse monitor to evaluate the effectiveness of the therapy?
A. Prothrombin time (PT).
, B. International Normalized Ratio (INR).
C. Hemoglobin level.
D. Platelet count.
E. Activated partial thromboplastin time (aPTT).
Correct Answer: E
Explanation: The aPTT is the specific lab used to monitor the therapeutic effect of heparin.
The goal is typically 1.5 to 2.5 times the normal control value. PT and INR are used to
monitor Warfarin therapy, not Heparin.
5. A nurse is teaching a client about the use of a metered-dose inhaler (MDI) for asthma.
Which instruction is correct regarding the use of a spacer?
A. The spacer increases the taste of the medication.
B. The spacer allows more medication to reach the lungs.
C. The spacer is only used if the inhaler is empty.
D. The spacer makes the inhaler act faster.
Correct Answer: B
Explanation: Spacers help coordinate the delivery of the medication with inhalation. This
device ensures that the droplets are smaller and can travel deeper into the bronchioles.
Without a spacer, much of the medication often ends up on the back of the throat or tongue.
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of Chronic Obstructive Pulmonary Disease
(COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client’s oxygen saturation is
89%. Which action should the nurse take first?
A. Increase the oxygen flow rate to 6 L/min.
B. Administer a PRN dose of albuterol.
C. Place the client in a high-Fowler’s position.
D. Notify the healthcare provider immediately.
Correct Answer: C
Explanation: Positioning the client in high-Fowler’s allows for maximum chest expansion
and improves gas exchange. In COPD patients, a baseline oxygen saturation of 88-92% is
often normal due to their chronic state. Increasing oxygen too high can suppress the
hypoxic drive which is their stimulus to breathe.
2. A client is admitted with suspected right-sided heart failure. Which clinical manifestation
should the nurse expect to find during the physical assessment?
A. Peripheral edema and jugular vein distention.
B. Dyspnea on exertion.
C. Crackles in the lung bases.
,D. Orthopnea and cough.
Correct Answer: A
Explanation: Right-sided heart failure results in the backup of blood into the systemic
circulation. This leads to systemic symptoms such as peripheral edema, hepatomegaly, and
jugular venous distention. Left-sided failure, by contrast, primarily causes pulmonary
symptoms like crackles and dyspnea.
3. The nurse is preparing to administer Digoxin to a client with heart failure. Which
assessment finding would require the nurse to withhold the medication?
A. Blood pressure of 110/70 mmHg.
B. Respiratory rate of 18 breaths per minute.
C. Apical pulse of 52 beats per minute.
D. Potassium level of 4.2 mEq/L.
Correct Answer: C
Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases the
force of contraction. The apical pulse must be checked for one full minute before
administration. If the pulse is below 60 beats per minute in an adult, the dose should be
held and the provider notified.
4. A client with deep vein thrombosis (DVT) is receiving a heparin infusion. Which laboratory
value should the nurse monitor to evaluate the effectiveness of the therapy?
A. Prothrombin time (PT).
, B. International Normalized Ratio (INR).
C. Hemoglobin level.
D. Platelet count.
E. Activated partial thromboplastin time (aPTT).
Correct Answer: E
Explanation: The aPTT is the specific lab used to monitor the therapeutic effect of heparin.
The goal is typically 1.5 to 2.5 times the normal control value. PT and INR are used to
monitor Warfarin therapy, not Heparin.
5. A nurse is teaching a client about the use of a metered-dose inhaler (MDI) for asthma.
Which instruction is correct regarding the use of a spacer?
A. The spacer increases the taste of the medication.
B. The spacer allows more medication to reach the lungs.
C. The spacer is only used if the inhaler is empty.
D. The spacer makes the inhaler act faster.
Correct Answer: B
Explanation: Spacers help coordinate the delivery of the medication with inhalation. This
device ensures that the droplets are smaller and can travel deeper into the bronchioles.
Without a spacer, much of the medication often ends up on the back of the throat or tongue.
