NRSG 201 Exam 3 V1 | NRSG 201 Med Surg 1 |
Actual Q&A with Rationale (NRSG201 Exam 3) | Ivy
Tech
1. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Crackles in the lung bases
C. Peripheral edema in the lower extremities
D. Hepatomegaly and abdominal girth increase
Correct Answer: B
Explanation: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood efficiently into the systemic circulation. This leads to
increased pressure in the pulmonary veins and capillaries, causing fluid to leak into the
alveoli. The presence of crackles is a hallmark sign of pulmonary edema associated with
left-sided failure, whereas the other options relate to right-sided failure.
2. A client is prescribed lisinopril for hypertension. Which side effect should the nurse instruct
the client to report immediately to the healthcare provider?
A. A persistent dry cough
B. Mild fatigue in the evening
,C. Swelling of the lips or tongue
D. Increased urinary frequency
Correct Answer: C
Explanation: Swelling of the lips or tongue indicates angioedema, which is a life-
threatening adverse effect of ACE inhibitors like lisinopril. While a dry cough is a common
side effect, it is not an emergency, but angioedema can compromise the airway. The nurse
must prioritize patient safety and immediate intervention for potential airway obstruction.
3. Which laboratory value is most indicative of a myocardial infarction (MI)?
A. Troponin T level of 0.8 ng/mL
B. B-type natriuretic peptide (BNP) of 400 pg/mL
C. Creatine kinase (CK) of 150 units/L
D. C-reactive protein (CRP) of 5 mg/L
Correct Answer: A
Explanation: Troponin levels are highly specific markers for myocardial injury and are the
preferred test for diagnosing an MI. BNP is used to assess heart failure severity, and while
CK can rise with muscle damage, it is less specific than Troponin. Elevated Troponin levels
indicate that cardiac muscle cell death has occurred and requires immediate medical
attention.
,4. A client with a history of COPD is receiving oxygen at 2L/min via nasal cannula. The nurse
notes the client’s oxygen saturation is 89%. What is the most appropriate nursing action?
A. Increase the oxygen flow to 6L/min immediately
B. Continue to monitor and document the finding as stable
C. Prepare for endotracheal intubation
D. Place the client in a supine position
Correct Answer: B
Explanation: For many clients with chronic obstructive pulmonary disease (COPD), an
oxygen saturation (SpO2) between 88% and 92% is considered an acceptable target range.
Increasing oxygen excessively can suppress the hypoxic drive in some COPD patients,
potentially leading to carbon dioxide retention. The nurse should continue to monitor the
client’s respiratory effort and overall clinical status rather than intervening for this specific
saturation level.
5. The nurse is caring for a client who is 2 hours post-op following a bronchoscopy. Which
assessment finding is the priority to report to the provider?
A. Absence of a gag reflex
B. Slightly blood-tinged sputum
C. Dry, non-productive cough
D. Sore throat and hoarseness
, Correct Answer: A
Explanation: The absence of a gag reflex post-bronchoscopy is a critical safety concern
because the patient is at high risk for aspiration. The gag reflex must return before the
client is allowed to have anything by mouth (NPO status). While blood-tinged sputum and a
sore throat are expected findings, the lack of a protective airway reflex takes priority.
6. A client is diagnosed with iron deficiency anemia. Which dietary choice by the client
indicates a need for further teaching?
A. Taking the iron supplement with a glass of milk
B. Increasing intake of leafy green vegetables
C. Consuming red meat three times a week
D. Drinking orange juice with iron supplements
Correct Answer: A
Explanation: Calcium in milk can interfere with the absorption of iron, so iron
supplements should not be taken with dairy products. Conversely, Vitamin C (found in
orange juice) enhances iron absorption and is encouraged. The client needs to understand
that timing and beverage choice significantly impact the effectiveness of their treatment for
anemia.
7. When assessing a client with Peripheral Artery Disease (PAD), which finding should the
nurse expect?
A. Pitting edema in the ankles
Actual Q&A with Rationale (NRSG201 Exam 3) | Ivy
Tech
1. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Crackles in the lung bases
C. Peripheral edema in the lower extremities
D. Hepatomegaly and abdominal girth increase
Correct Answer: B
Explanation: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood efficiently into the systemic circulation. This leads to
increased pressure in the pulmonary veins and capillaries, causing fluid to leak into the
alveoli. The presence of crackles is a hallmark sign of pulmonary edema associated with
left-sided failure, whereas the other options relate to right-sided failure.
2. A client is prescribed lisinopril for hypertension. Which side effect should the nurse instruct
the client to report immediately to the healthcare provider?
A. A persistent dry cough
B. Mild fatigue in the evening
,C. Swelling of the lips or tongue
D. Increased urinary frequency
Correct Answer: C
Explanation: Swelling of the lips or tongue indicates angioedema, which is a life-
threatening adverse effect of ACE inhibitors like lisinopril. While a dry cough is a common
side effect, it is not an emergency, but angioedema can compromise the airway. The nurse
must prioritize patient safety and immediate intervention for potential airway obstruction.
3. Which laboratory value is most indicative of a myocardial infarction (MI)?
A. Troponin T level of 0.8 ng/mL
B. B-type natriuretic peptide (BNP) of 400 pg/mL
C. Creatine kinase (CK) of 150 units/L
D. C-reactive protein (CRP) of 5 mg/L
Correct Answer: A
Explanation: Troponin levels are highly specific markers for myocardial injury and are the
preferred test for diagnosing an MI. BNP is used to assess heart failure severity, and while
CK can rise with muscle damage, it is less specific than Troponin. Elevated Troponin levels
indicate that cardiac muscle cell death has occurred and requires immediate medical
attention.
,4. A client with a history of COPD is receiving oxygen at 2L/min via nasal cannula. The nurse
notes the client’s oxygen saturation is 89%. What is the most appropriate nursing action?
A. Increase the oxygen flow to 6L/min immediately
B. Continue to monitor and document the finding as stable
C. Prepare for endotracheal intubation
D. Place the client in a supine position
Correct Answer: B
Explanation: For many clients with chronic obstructive pulmonary disease (COPD), an
oxygen saturation (SpO2) between 88% and 92% is considered an acceptable target range.
Increasing oxygen excessively can suppress the hypoxic drive in some COPD patients,
potentially leading to carbon dioxide retention. The nurse should continue to monitor the
client’s respiratory effort and overall clinical status rather than intervening for this specific
saturation level.
5. The nurse is caring for a client who is 2 hours post-op following a bronchoscopy. Which
assessment finding is the priority to report to the provider?
A. Absence of a gag reflex
B. Slightly blood-tinged sputum
C. Dry, non-productive cough
D. Sore throat and hoarseness
, Correct Answer: A
Explanation: The absence of a gag reflex post-bronchoscopy is a critical safety concern
because the patient is at high risk for aspiration. The gag reflex must return before the
client is allowed to have anything by mouth (NPO status). While blood-tinged sputum and a
sore throat are expected findings, the lack of a protective airway reflex takes priority.
6. A client is diagnosed with iron deficiency anemia. Which dietary choice by the client
indicates a need for further teaching?
A. Taking the iron supplement with a glass of milk
B. Increasing intake of leafy green vegetables
C. Consuming red meat three times a week
D. Drinking orange juice with iron supplements
Correct Answer: A
Explanation: Calcium in milk can interfere with the absorption of iron, so iron
supplements should not be taken with dairy products. Conversely, Vitamin C (found in
orange juice) enhances iron absorption and is encouraged. The client needs to understand
that timing and beverage choice significantly impact the effectiveness of their treatment for
anemia.
7. When assessing a client with Peripheral Artery Disease (PAD), which finding should the
nurse expect?
A. Pitting edema in the ankles
