PNR 206/PNR206 Exam 2 V2 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A patient with left-sided heart failure is most likely to exhibit which of the following clinical
manifestations?
A. Crackles in the lungs
B. Peripheral edema
C. Jugular venous distension
D. Splenomegaly
Correct Answer: A
Explanation: Left-sided heart failure causes blood to back up into the lungs, leading to
pulmonary congestion and crackles. Systemic symptoms like jugular venous distension and
peripheral edema are more characteristic of right-sided heart failure. Monitoring lung
sounds is a priority nursing assessment for these patients.
2. When administering Digoxin to a patient with heart failure, the nurse should withhold the
medication if the apical pulse is:
A. Below 60 beats per minute
B. Above 100 beats per minute
C. Between 70 and 80 beats per minute
D. Exactly 90 beats per minute
,Correct Answer: A
Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases the
force of contraction. A pulse rate below 60 beats per minute indicates potential toxicity or
excessive bradycardia. The nurse must assess the apical pulse for one full minute before
administration.
3. Which laboratory value is most indicative of Diabetes Insipidus?
A. High urine specific gravity
B. Low urine specific gravity
C. Low serum sodium
D. High serum glucose
Correct Answer: B
Explanation: Diabetes Insipidus is characterized by a deficiency of ADH, leading to the
excretion of large volumes of dilute urine. This results in a very low urine specific gravity,
typically less than 1.005. Patients will also experience intense thirst and polyuria.
4. The nurse is caring for a patient with SIADH. Which of the following interventions should
be included in the plan of care?
A. Encouraging oral fluid intake
B. Fluid restriction
C. Administration of synthetic vasopressin
, D. High-sodium diet restricted to 500mg
Correct Answer: B
Explanation: SIADH involves excessive ADH, causing the body to retain too much water
and leading to dilutional hyponatremia. Fluid restriction is the primary treatment to
prevent further dilution of serum sodium. Monitoring daily weights and intake and output
is essential.
5. A patient with Cushing’s Syndrome is likely to demonstrate which physical characteristic?
A. Moon face and buffalo hump
B. Weight loss and hypotension
C. Bronze skin pigmentation
D. Exophthalmos
Correct Answer: A
Explanation: Cushing’s Syndrome results from an excess of cortisol, which causes a
redistribution of fat. This leads to classic signs such as a rounded moon face and a buffalo
hump on the upper back. These patients also frequently suffer from hypertension and
hyperglycemia.
6. During an Addisonian Crisis, the nurse should expect to administer which of the following
immediately?
A. Insulin and glucose
Nursing II Q&A with Rationale | Fortis College
1. A patient with left-sided heart failure is most likely to exhibit which of the following clinical
manifestations?
A. Crackles in the lungs
B. Peripheral edema
C. Jugular venous distension
D. Splenomegaly
Correct Answer: A
Explanation: Left-sided heart failure causes blood to back up into the lungs, leading to
pulmonary congestion and crackles. Systemic symptoms like jugular venous distension and
peripheral edema are more characteristic of right-sided heart failure. Monitoring lung
sounds is a priority nursing assessment for these patients.
2. When administering Digoxin to a patient with heart failure, the nurse should withhold the
medication if the apical pulse is:
A. Below 60 beats per minute
B. Above 100 beats per minute
C. Between 70 and 80 beats per minute
D. Exactly 90 beats per minute
,Correct Answer: A
Explanation: Digoxin is a cardiac glycoside that slows the heart rate and increases the
force of contraction. A pulse rate below 60 beats per minute indicates potential toxicity or
excessive bradycardia. The nurse must assess the apical pulse for one full minute before
administration.
3. Which laboratory value is most indicative of Diabetes Insipidus?
A. High urine specific gravity
B. Low urine specific gravity
C. Low serum sodium
D. High serum glucose
Correct Answer: B
Explanation: Diabetes Insipidus is characterized by a deficiency of ADH, leading to the
excretion of large volumes of dilute urine. This results in a very low urine specific gravity,
typically less than 1.005. Patients will also experience intense thirst and polyuria.
4. The nurse is caring for a patient with SIADH. Which of the following interventions should
be included in the plan of care?
A. Encouraging oral fluid intake
B. Fluid restriction
C. Administration of synthetic vasopressin
, D. High-sodium diet restricted to 500mg
Correct Answer: B
Explanation: SIADH involves excessive ADH, causing the body to retain too much water
and leading to dilutional hyponatremia. Fluid restriction is the primary treatment to
prevent further dilution of serum sodium. Monitoring daily weights and intake and output
is essential.
5. A patient with Cushing’s Syndrome is likely to demonstrate which physical characteristic?
A. Moon face and buffalo hump
B. Weight loss and hypotension
C. Bronze skin pigmentation
D. Exophthalmos
Correct Answer: A
Explanation: Cushing’s Syndrome results from an excess of cortisol, which causes a
redistribution of fat. This leads to classic signs such as a rounded moon face and a buffalo
hump on the upper back. These patients also frequently suffer from hypertension and
hyperglycemia.
6. During an Addisonian Crisis, the nurse should expect to administer which of the following
immediately?
A. Insulin and glucose
