NUR 170 Med Surg Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
Pdf
1.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at
2 L/min by nasal cannula. The client becomes increasingly somnolent and difficult
to arouse. Which assessment finding requires the nurse's priority action?
A. Oxygen saturation of 91%
B. Respiratory rate of 10/min
C. Barrel-shaped chest
D. Productive morning cough
Answer: B. Respiratory rate of 10/min
Rationale: A respiratory rate of 10/min with increasing somnolence suggests
hypoventilation and possible carbon dioxide retention. The nurse should
immediately assess airway and ventilation and notify the provider as indicated.
2.
A client with heart failure receives IV furosemide. Which finding best indicates
that the medication is producing the desired therapeutic response?
A. Heart rate increases from 82 to 104/min
B. Weight decreases by 1 kg over 24 hours
,C. Serum potassium decreases to 3.1 mEq/L
D. Urine specific gravity increases
Answer: B. Weight decreases by 1 kg over 24 hours
Rationale: Daily weight is one of the most reliable indicators of fluid balance. A
1-kg decrease generally represents approximately 1 L of fluid loss.
3.
A client with acute pulmonary edema is extremely dyspneic and coughing pink,
frothy sputum. Which intervention should the nurse implement first?
A. Place the client supine
B. Encourage oral fluids
C. Position the client upright with legs dependent
D. Obtain a routine weight
Answer: C. Position the client upright with legs dependent
Rationale: Upright positioning decreases venous return and improves lung
expansion, helping reduce pulmonary congestion while additional emergency
interventions are initiated.
4.
A client with myocardial infarction suddenly develops hypotension, cool clammy
skin, and altered mental status. Which complication should the nurse suspect?
A. Cardiogenic shock
B. Stable angina
C. Pericarditis
D. Hypertensive crisis
Answer: A. Cardiogenic shock
,Rationale: Cardiogenic shock occurs when the heart cannot generate adequate
cardiac output. Hypotension, poor peripheral perfusion, cool skin, and altered
mental status are characteristic findings.
5.
A client taking digoxin reports nausea and seeing yellow halos around lights. The
apical pulse is 52/min. What should the nurse do?
A. Administer the medication with food
B. Give the prescribed dose and reassess later
C. Hold the dose and notify the provider
D. Encourage increased sodium intake
Answer: C. Hold the dose and notify the provider
Rationale: Bradycardia, nausea, and visual disturbances are classic findings of
possible digoxin toxicity. The medication should be withheld and the provider
notified.
6.
A client with atrial fibrillation is prescribed warfarin. Which laboratory value is
most important for evaluating therapeutic anticoagulation?
A. INR
B. Troponin
C. BNP
D. Serum sodium
Answer: A. INR
Rationale: Warfarin therapy is monitored using the international normalized
ratio (INR). The target range depends on the clinical indication and prescribed
treatment plan.
7.
, A client with a deep vein thrombosis suddenly reports chest pain and severe
shortness of breath. Which complication should the nurse suspect?
A. Pulmonary embolism
B. Pleural effusion
C. Pneumonia
D. Pericarditis
Answer: A. Pulmonary embolism
Rationale: A thrombus can dislodge from a deep vein and travel to the
pulmonary circulation. Sudden dyspnea, pleuritic chest pain, tachycardia, and
hypoxemia are concerning findings.
8.
A client with suspected pulmonary embolism is receiving oxygen. Which
assessment finding is most concerning?
A. Oxygen saturation of 89% despite oxygen therapy
B. Respiratory rate of 20/min
C. Mild anxiety
D. Heart rate of 88/min
Answer: A. Oxygen saturation of 89% despite oxygen therapy
Rationale: Persistent hypoxemia despite supplemental oxygen may indicate
significant ventilation-perfusion impairment and requires immediate
reassessment and escalation of care.
9.
A client with bacterial pneumonia has a temperature of 39.2°C (102.6°F), heart
rate 124/min, respiratory rate 30/min, and blood pressure 86/52 mm Hg. Which
complication should the nurse suspect?
A. Stable pneumonia
B. Septic shock
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at
2 L/min by nasal cannula. The client becomes increasingly somnolent and difficult
to arouse. Which assessment finding requires the nurse's priority action?
A. Oxygen saturation of 91%
B. Respiratory rate of 10/min
C. Barrel-shaped chest
D. Productive morning cough
Answer: B. Respiratory rate of 10/min
Rationale: A respiratory rate of 10/min with increasing somnolence suggests
hypoventilation and possible carbon dioxide retention. The nurse should
immediately assess airway and ventilation and notify the provider as indicated.
2.
A client with heart failure receives IV furosemide. Which finding best indicates
that the medication is producing the desired therapeutic response?
A. Heart rate increases from 82 to 104/min
B. Weight decreases by 1 kg over 24 hours
,C. Serum potassium decreases to 3.1 mEq/L
D. Urine specific gravity increases
Answer: B. Weight decreases by 1 kg over 24 hours
Rationale: Daily weight is one of the most reliable indicators of fluid balance. A
1-kg decrease generally represents approximately 1 L of fluid loss.
3.
A client with acute pulmonary edema is extremely dyspneic and coughing pink,
frothy sputum. Which intervention should the nurse implement first?
A. Place the client supine
B. Encourage oral fluids
C. Position the client upright with legs dependent
D. Obtain a routine weight
Answer: C. Position the client upright with legs dependent
Rationale: Upright positioning decreases venous return and improves lung
expansion, helping reduce pulmonary congestion while additional emergency
interventions are initiated.
4.
A client with myocardial infarction suddenly develops hypotension, cool clammy
skin, and altered mental status. Which complication should the nurse suspect?
A. Cardiogenic shock
B. Stable angina
C. Pericarditis
D. Hypertensive crisis
Answer: A. Cardiogenic shock
,Rationale: Cardiogenic shock occurs when the heart cannot generate adequate
cardiac output. Hypotension, poor peripheral perfusion, cool skin, and altered
mental status are characteristic findings.
5.
A client taking digoxin reports nausea and seeing yellow halos around lights. The
apical pulse is 52/min. What should the nurse do?
A. Administer the medication with food
B. Give the prescribed dose and reassess later
C. Hold the dose and notify the provider
D. Encourage increased sodium intake
Answer: C. Hold the dose and notify the provider
Rationale: Bradycardia, nausea, and visual disturbances are classic findings of
possible digoxin toxicity. The medication should be withheld and the provider
notified.
6.
A client with atrial fibrillation is prescribed warfarin. Which laboratory value is
most important for evaluating therapeutic anticoagulation?
A. INR
B. Troponin
C. BNP
D. Serum sodium
Answer: A. INR
Rationale: Warfarin therapy is monitored using the international normalized
ratio (INR). The target range depends on the clinical indication and prescribed
treatment plan.
7.
, A client with a deep vein thrombosis suddenly reports chest pain and severe
shortness of breath. Which complication should the nurse suspect?
A. Pulmonary embolism
B. Pleural effusion
C. Pneumonia
D. Pericarditis
Answer: A. Pulmonary embolism
Rationale: A thrombus can dislodge from a deep vein and travel to the
pulmonary circulation. Sudden dyspnea, pleuritic chest pain, tachycardia, and
hypoxemia are concerning findings.
8.
A client with suspected pulmonary embolism is receiving oxygen. Which
assessment finding is most concerning?
A. Oxygen saturation of 89% despite oxygen therapy
B. Respiratory rate of 20/min
C. Mild anxiety
D. Heart rate of 88/min
Answer: A. Oxygen saturation of 89% despite oxygen therapy
Rationale: Persistent hypoxemia despite supplemental oxygen may indicate
significant ventilation-perfusion impairment and requires immediate
reassessment and escalation of care.
9.
A client with bacterial pneumonia has a temperature of 39.2°C (102.6°F), heart
rate 124/min, respiratory rate 30/min, and blood pressure 86/52 mm Hg. Which
complication should the nurse suspect?
A. Stable pneumonia
B. Septic shock
