NRSG 110 Exam 2 V1 | NRSG 110 Medical Surgical
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 2) | Ivy Tech
1. A nurse is assessing a client diagnosed with right-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Pulmonary crackles
B. Jugular venous distention
C. Orthopnea
D. Dyspnea on exertion
Correct Answer: B
Explanation: Right-sided heart failure results in the inability of the right ventricle to pump
blood effectively into the pulmonary circulation. This causes blood to back up into the
systemic venous system, leading to jugular venous distention, peripheral edema, and
hepatomegaly. Left-sided heart failure is primarily associated with pulmonary symptoms
like crackles and dyspnea.
2. A patient with atrial fibrillation is prescribed Digoxin. Which of the following findings
would suggest the patient is experiencing Digoxin toxicity?
A. Hyperkalemia
B. Hypertension
,C. Tachycardia
D. Increased appetite
E. Yellow-green halos around lights
Correct Answer: E
Explanation: Digoxin toxicity often manifests with visual disturbances, specifically seeing
yellow, green, or white halos around objects. Other common symptoms include
bradycardia, nausea, vomiting, and anorexia. It is critical for the nurse to monitor serum
digoxin levels and potassium levels, as hypokalemia can potentiate toxicity.
3. A nurse is interpreting the Arterial Blood Gas (ABG) results for a client with COPD: pH 7.31,
PaCO2 52 mmHg, HCO3 26 mEq/L. How should the nurse document these results?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The bicarbonate (HCO3) is within the normal
range, suggesting that compensation has not yet occurred. This profile is classic for chronic
obstructive pulmonary disease (COPD) patients who retain carbon dioxide.
, 4. Which of the following interventions is a priority for a patient suspected of having a
Pulmonary Embolism (PE)?
A. Apply supplemental oxygen
B. Ambulate the patient immediately
C. Administer an oral anticoagulant
D. Perform a massage on the lower extremities
Correct Answer: A
Explanation: A pulmonary embolism impairs gas exchange, making the maintenance of
adequate oxygenation the highest priority. The nurse must stabilize the patient’s
respiratory status before proceeding with diagnostic tests or pharmacological treatments
like heparin. Restricting activity is also necessary to prevent further dislodgment of clots
from the deep veins.
5. A client presents with a history of stable angina. Which statement by the client indicates a
need for further teaching regarding Nitroglycerin administration?
A. I will keep the tablets in the original dark glass bottle.
B. I will take one tablet every 15 minutes until the pain stops.
C. I should sit down before taking the medication.
D. I might get a headache after taking this medicine.
Correct Answer: B
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 2) | Ivy Tech
1. A nurse is assessing a client diagnosed with right-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Pulmonary crackles
B. Jugular venous distention
C. Orthopnea
D. Dyspnea on exertion
Correct Answer: B
Explanation: Right-sided heart failure results in the inability of the right ventricle to pump
blood effectively into the pulmonary circulation. This causes blood to back up into the
systemic venous system, leading to jugular venous distention, peripheral edema, and
hepatomegaly. Left-sided heart failure is primarily associated with pulmonary symptoms
like crackles and dyspnea.
2. A patient with atrial fibrillation is prescribed Digoxin. Which of the following findings
would suggest the patient is experiencing Digoxin toxicity?
A. Hyperkalemia
B. Hypertension
,C. Tachycardia
D. Increased appetite
E. Yellow-green halos around lights
Correct Answer: E
Explanation: Digoxin toxicity often manifests with visual disturbances, specifically seeing
yellow, green, or white halos around objects. Other common symptoms include
bradycardia, nausea, vomiting, and anorexia. It is critical for the nurse to monitor serum
digoxin levels and potassium levels, as hypokalemia can potentiate toxicity.
3. A nurse is interpreting the Arterial Blood Gas (ABG) results for a client with COPD: pH 7.31,
PaCO2 52 mmHg, HCO3 26 mEq/L. How should the nurse document these results?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The bicarbonate (HCO3) is within the normal
range, suggesting that compensation has not yet occurred. This profile is classic for chronic
obstructive pulmonary disease (COPD) patients who retain carbon dioxide.
, 4. Which of the following interventions is a priority for a patient suspected of having a
Pulmonary Embolism (PE)?
A. Apply supplemental oxygen
B. Ambulate the patient immediately
C. Administer an oral anticoagulant
D. Perform a massage on the lower extremities
Correct Answer: A
Explanation: A pulmonary embolism impairs gas exchange, making the maintenance of
adequate oxygenation the highest priority. The nurse must stabilize the patient’s
respiratory status before proceeding with diagnostic tests or pharmacological treatments
like heparin. Restricting activity is also necessary to prevent further dislodgment of clots
from the deep veins.
5. A client presents with a history of stable angina. Which statement by the client indicates a
need for further teaching regarding Nitroglycerin administration?
A. I will keep the tablets in the original dark glass bottle.
B. I will take one tablet every 15 minutes until the pain stops.
C. I should sit down before taking the medication.
D. I might get a headache after taking this medicine.
Correct Answer: B
