PNR 201/PNR201 Final Exam V2 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient with fluid volume excess. Which of the following clinical
manifestations should the nurse expect to find during the assessment?
A. Distended neck veins and crackles
B. Tachycardia and thready pulse
C. Dry skin and decreased turgor
D. Hypotension and lightheadedness
Correct Answer: A
Explanation: Distended neck veins and crackles in the lungs are classic indicators of fluid
volume excess due to increased venous pressure and pulmonary edema. These findings
suggest that the heart is unable to circulate the extra fluid volume effectively. Conversely, a
thready pulse and dry skin are symptoms associated with fluid volume deficit.
2. When providing discharge teaching to a patient newly diagnosed with Type 2 Diabetes, the
nurse should include which instruction regarding foot care?
A. Soak feet daily in hot water to improve circulation.
B. Apply lotion between the toes to prevent cracking.
C. Wear open-toed sandals to allow the skin to breathe.
D. Inspect the feet daily using a mirror if necessary.
,Correct Answer: D
Explanation: Daily foot inspection is critical for diabetic patients because neuropathy can
mask injuries that may lead to ulcers or infections. Patients should be taught to use a
mirror to see the bottom of their feet if they cannot reach them. Lotion should not be
applied between the toes as the moisture promotes fungal growth.
3. A patient who underwent a total hip replacement 24 hours ago reports sudden shortness
of breath and chest pain. What is the priority nursing action?
A. Apply oxygen and notify the healthcare provider.
B. Check the patient’s surgical dressing for bleeding.
C. Administer prescribed pain medication.
D. Perform passive range of motion on the affected leg.
Correct Answer: A
Explanation: Sudden shortness of breath and chest pain in a post-operative orthopedic
patient suggest a pulmonary embolism, which is a medical emergency. The nurse must
prioritize oxygenation and immediate medical notification to stabilize the patient. Delayed
treatment of an embolism can be fatal for post-surgical patients.
4. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically recommended for this patient?
A. As much as the patient requests
B. 6 to 10 L/min
, C. 10 to 15 L/min
D. 1 to 2 L/min
Correct Answer: D
Explanation: For patients with COPD, high concentrations of oxygen can suppress the
hypoxic drive, which is their primary stimulus for breathing. Low-flow oxygen, usually 1 to
2 L/min, helps maintain adequate saturation without causing carbon dioxide retention.
Monitoring respiratory rate and mental status is essential when administering oxygen to
these patients.
5. The nurse is monitoring a patient receiving Lisinopril for hypertension. Which side effect is
a common reason for patients to discontinue this medication?
A. Increased appetite
B. High blood glucose levels
C. Excessive hair growth
D. Persistent dry cough
Correct Answer: D
Explanation: A persistent, non-productive dry cough is a well-known side effect of ACE
inhibitors like Lisinopril due to the accumulation of bradykinin in the lungs. While not
harmful, it is often bothersome enough for patients to require a change in medication.
Patients should be switched to an Angiotensin II Receptor Blocker (ARB) if the cough
becomes intolerable.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient with fluid volume excess. Which of the following clinical
manifestations should the nurse expect to find during the assessment?
A. Distended neck veins and crackles
B. Tachycardia and thready pulse
C. Dry skin and decreased turgor
D. Hypotension and lightheadedness
Correct Answer: A
Explanation: Distended neck veins and crackles in the lungs are classic indicators of fluid
volume excess due to increased venous pressure and pulmonary edema. These findings
suggest that the heart is unable to circulate the extra fluid volume effectively. Conversely, a
thready pulse and dry skin are symptoms associated with fluid volume deficit.
2. When providing discharge teaching to a patient newly diagnosed with Type 2 Diabetes, the
nurse should include which instruction regarding foot care?
A. Soak feet daily in hot water to improve circulation.
B. Apply lotion between the toes to prevent cracking.
C. Wear open-toed sandals to allow the skin to breathe.
D. Inspect the feet daily using a mirror if necessary.
,Correct Answer: D
Explanation: Daily foot inspection is critical for diabetic patients because neuropathy can
mask injuries that may lead to ulcers or infections. Patients should be taught to use a
mirror to see the bottom of their feet if they cannot reach them. Lotion should not be
applied between the toes as the moisture promotes fungal growth.
3. A patient who underwent a total hip replacement 24 hours ago reports sudden shortness
of breath and chest pain. What is the priority nursing action?
A. Apply oxygen and notify the healthcare provider.
B. Check the patient’s surgical dressing for bleeding.
C. Administer prescribed pain medication.
D. Perform passive range of motion on the affected leg.
Correct Answer: A
Explanation: Sudden shortness of breath and chest pain in a post-operative orthopedic
patient suggest a pulmonary embolism, which is a medical emergency. The nurse must
prioritize oxygenation and immediate medical notification to stabilize the patient. Delayed
treatment of an embolism can be fatal for post-surgical patients.
4. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically recommended for this patient?
A. As much as the patient requests
B. 6 to 10 L/min
, C. 10 to 15 L/min
D. 1 to 2 L/min
Correct Answer: D
Explanation: For patients with COPD, high concentrations of oxygen can suppress the
hypoxic drive, which is their primary stimulus for breathing. Low-flow oxygen, usually 1 to
2 L/min, helps maintain adequate saturation without causing carbon dioxide retention.
Monitoring respiratory rate and mental status is essential when administering oxygen to
these patients.
5. The nurse is monitoring a patient receiving Lisinopril for hypertension. Which side effect is
a common reason for patients to discontinue this medication?
A. Increased appetite
B. High blood glucose levels
C. Excessive hair growth
D. Persistent dry cough
Correct Answer: D
Explanation: A persistent, non-productive dry cough is a well-known side effect of ACE
inhibitors like Lisinopril due to the accumulation of bradykinin in the lungs. While not
harmful, it is often bothersome enough for patients to require a change in medication.
Patients should be switched to an Angiotensin II Receptor Blocker (ARB) if the cough
becomes intolerable.
