NSG 301 — Medical-Surgical Nursing I exam
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1. A nurse is assessing a client with left-sided heart failure. Which
finding is most characteristic of pulmonary congestion?
A. Peripheral edema
B. Jugular venous distention
C. Crackles in the lung bases
D. Enlarged liver
Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure causes blood to back up into the
pulmonary circulation, increasing pulmonary capillary pressure and
producing pulmonary edema. Crackles are commonly heard at the lung
bases. Peripheral edema, jugular venous distention, and hepatomegaly
are more commonly associated with right-sided heart failure.
, 2. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which oxygen-delivery approach is
generally most appropriate for a client who requires a controlled
low concentration of oxygen?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen
concentration and is useful for clients with COPD who require carefully
titrated oxygen therapy. Excessive oxygen administration in some COPD
clients can worsen carbon dioxide retention. Nonrebreather and partial-
rebreather masks deliver higher oxygen concentrations and are
generally used for more severe hypoxemia.
3. A client with pneumonia has a temperature of 39°C (102.2°F),
productive cough, and tachypnea. Which nursing intervention is
the priority?
A. Encourage adequate fluid intake if not contraindicated
B. Restrict oral fluids
,C. Place the client in a flat supine position
D. Encourage prolonged bed rest without activity
Answer: A. Encourage adequate fluid intake if not contraindicated
Rationale: Adequate hydration helps thin respiratory secretions, making
them easier to expectorate. The nurse should also monitor respiratory
status, administer prescribed antimicrobial therapy, encourage
coughing and deep breathing, and provide oxygen as indicated. A flat
position can impair ventilation, and unnecessary fluid restriction may
make secretions more difficult to clear.
4. Which assessment finding in a client with asthma requires
immediate nursing attention?
A. Mild expiratory wheezing
B. Productive cough
C. Inability to speak in complete sentences
D. Respiratory rate of 20 breaths/min
Answer: C. Inability to speak in complete sentences
Rationale: Inability to speak in complete sentences indicates significant
respiratory distress and potentially severe airway obstruction. The client
may have inadequate ventilation and impending respiratory failure.
Mild wheezing may occur during an asthma exacerbation, but a
, severely distressed client may eventually have diminished or absent
breath sounds as airflow becomes critically limited.
5. A client with tuberculosis is admitted to the hospital. Which
infection-control measure is most appropriate?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions only
Answer: C. Airborne precautions
Rationale: Pulmonary tuberculosis is transmitted through airborne
particles. The client should be placed in an appropriate airborne
infection isolation room, and healthcare workers should use a fit-tested
respirator such as an N95 or equivalent according to facility policy.
Droplet and contact precautions alone are insufficient for suspected or
confirmed infectious pulmonary tuberculosis.
6. A nurse is caring for a client experiencing an acute myocardial
infarction. Which symptom is most concerning for ongoing
myocardial ischemia?
A. Mild fatigue
B. Persistent crushing chest pressure
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A| Instant
Download Pdf
1. A nurse is assessing a client with left-sided heart failure. Which
finding is most characteristic of pulmonary congestion?
A. Peripheral edema
B. Jugular venous distention
C. Crackles in the lung bases
D. Enlarged liver
Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure causes blood to back up into the
pulmonary circulation, increasing pulmonary capillary pressure and
producing pulmonary edema. Crackles are commonly heard at the lung
bases. Peripheral edema, jugular venous distention, and hepatomegaly
are more commonly associated with right-sided heart failure.
, 2. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which oxygen-delivery approach is
generally most appropriate for a client who requires a controlled
low concentration of oxygen?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen
concentration and is useful for clients with COPD who require carefully
titrated oxygen therapy. Excessive oxygen administration in some COPD
clients can worsen carbon dioxide retention. Nonrebreather and partial-
rebreather masks deliver higher oxygen concentrations and are
generally used for more severe hypoxemia.
3. A client with pneumonia has a temperature of 39°C (102.2°F),
productive cough, and tachypnea. Which nursing intervention is
the priority?
A. Encourage adequate fluid intake if not contraindicated
B. Restrict oral fluids
,C. Place the client in a flat supine position
D. Encourage prolonged bed rest without activity
Answer: A. Encourage adequate fluid intake if not contraindicated
Rationale: Adequate hydration helps thin respiratory secretions, making
them easier to expectorate. The nurse should also monitor respiratory
status, administer prescribed antimicrobial therapy, encourage
coughing and deep breathing, and provide oxygen as indicated. A flat
position can impair ventilation, and unnecessary fluid restriction may
make secretions more difficult to clear.
4. Which assessment finding in a client with asthma requires
immediate nursing attention?
A. Mild expiratory wheezing
B. Productive cough
C. Inability to speak in complete sentences
D. Respiratory rate of 20 breaths/min
Answer: C. Inability to speak in complete sentences
Rationale: Inability to speak in complete sentences indicates significant
respiratory distress and potentially severe airway obstruction. The client
may have inadequate ventilation and impending respiratory failure.
Mild wheezing may occur during an asthma exacerbation, but a
, severely distressed client may eventually have diminished or absent
breath sounds as airflow becomes critically limited.
5. A client with tuberculosis is admitted to the hospital. Which
infection-control measure is most appropriate?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions only
Answer: C. Airborne precautions
Rationale: Pulmonary tuberculosis is transmitted through airborne
particles. The client should be placed in an appropriate airborne
infection isolation room, and healthcare workers should use a fit-tested
respirator such as an N95 or equivalent according to facility policy.
Droplet and contact precautions alone are insufficient for suspected or
confirmed infectious pulmonary tuberculosis.
6. A nurse is caring for a client experiencing an acute myocardial
infarction. Which symptom is most concerning for ongoing
myocardial ischemia?
A. Mild fatigue
B. Persistent crushing chest pressure
