NSG 233 MED SURG 2 EXAM 2 QUESTIONS AND ANSWERS
() (VERIFIED ANSWERS) 100% CORRECT ALREADY
GRADED A+
1.
A nurse is caring for a client with left-sided heart failure. Which assessment
finding requires immediate intervention?
A. Bibasilar crackles
B. Fatigue and weakness
C. Orthopnea when lying flat
D. Frothy, pink-tinged sputum
Correct Answer: D. Frothy, pink-tinged sputum
Rationale: This indicates pulmonary edema, a medical emergency due to
fluid accumulation in the alveoli. It requires immediate diuretic
administration and oxygen support.
2.
A client with COPD reports shortness of breath. The nurse notes an oxygen
saturation of 88% on room air. What is the most appropriate nursing action?
A. Increase oxygen flow to 6 L/min
B. Encourage pursed-lip breathing
C. Instruct the client to take deep breaths quickly
D. Place the client in a supine position
Correct Answer: B. Encourage pursed-lip breathing
Rationale: Pursed-lip breathing slows exhalation, prevents alveolar
collapse, and improves gas exchange. High oxygen levels can depress
respiratory drive in COPD.
,3.
A nurse is reviewing the ECG of a client experiencing chest pain. Which
finding suggests a myocardial infarction (MI)?
A. U wave elevation
B. ST-segment elevation
C. Sinus bradycardia
D. Peaked P waves
Correct Answer: B. ST-segment elevation
Rationale: ST elevation is the hallmark of an acute MI indicating
myocardial injury from ischemia. Requires immediate cardiac intervention.
4.
A patient with diabetes insipidus (DI) is being treated with desmopressin
(DDAVP). Which finding indicates effective therapy?
A. Decreased urine output
B. Increased thirst
C. Elevated serum sodium
D. Low urine specific gravity
Correct Answer: A. Decreased urine output
Rationale: DDAVP reduces urine volume by promoting water reabsorption.
A positive response is decreased urine output and increased specific gravity.
5.
A client with chronic kidney disease (CKD) reports pruritus. Which nursing
action is most appropriate?
A. Encourage daily hot baths
B. Apply moisturizing lotion
C. Restrict protein intake completely
D. Provide high-phosphate foods
,Correct Answer: B. Apply moisturizing lotion
Rationale: CKD causes dry skin and uremic toxins buildup. Moisturizers
relieve itching; hot baths worsen dryness.
6.
A nurse is caring for a client after thyroidectomy. Which finding is most
concerning?
A. Hoarseness
B. Mild neck swelling
C. Difficulty swallowing
D. Positive Chvostek’s sign
Correct Answer: D. Positive Chvostek’s sign
Rationale: Indicates hypocalcemia due to parathyroid injury, which can
lead to tetany or laryngeal spasms. Requires IV calcium replacement.
7.
A client with DKA has blood glucose 450 mg/dL and serum potassium 3.1
mEq/L. Which order should the nurse question?
A. 0.9% normal saline IV
B. IV regular insulin
C. Continuous ECG monitoring
D. Cardiac enzymes test
Correct Answer: B. IV regular insulin
Rationale: Insulin will further lower potassium, worsening hypokalemia.
Potassium must be corrected before insulin infusion begins.
8.
A nurse is assessing a client with pericarditis. Which finding indicates
cardiac tamponade?
, A. Bradycardia
B. Hypertension
C. Pulsus paradoxus
D. Bounding peripheral pulses
Correct Answer: C. Pulsus paradoxus
Rationale: A hallmark sign of cardiac tamponade due to pressure on the
heart, causing drop in systolic BP during inspiration.
9.
A client with Cushing’s syndrome is being discharged. Which statement
shows understanding of teaching?
A. “I’ll avoid contact with people who are sick.”
B. “I can stop taking my steroid medication if I feel better.”
C. “I will increase my salt intake.”
D. “I should exercise vigorously every day.”
Correct Answer: A. I’ll avoid contact with people who are sick.
Rationale: Cushing’s causes immunosuppression; infection prevention is a
priority. Steroids should never be stopped abruptly.
10.
Which laboratory result is most concerning in a client with chest pain?
A. Troponin I = 0.01 ng/mL
B. Troponin I = 1.5 ng/mL
C. CK-MB = 2%
D. WBC = 9,000/mm³
Correct Answer: B. Troponin I = 1.5 ng/mL
Rationale: Elevated troponin indicates myocardial damage, requiring
urgent cardiac care.
() (VERIFIED ANSWERS) 100% CORRECT ALREADY
GRADED A+
1.
A nurse is caring for a client with left-sided heart failure. Which assessment
finding requires immediate intervention?
A. Bibasilar crackles
B. Fatigue and weakness
C. Orthopnea when lying flat
D. Frothy, pink-tinged sputum
Correct Answer: D. Frothy, pink-tinged sputum
Rationale: This indicates pulmonary edema, a medical emergency due to
fluid accumulation in the alveoli. It requires immediate diuretic
administration and oxygen support.
2.
A client with COPD reports shortness of breath. The nurse notes an oxygen
saturation of 88% on room air. What is the most appropriate nursing action?
A. Increase oxygen flow to 6 L/min
B. Encourage pursed-lip breathing
C. Instruct the client to take deep breaths quickly
D. Place the client in a supine position
Correct Answer: B. Encourage pursed-lip breathing
Rationale: Pursed-lip breathing slows exhalation, prevents alveolar
collapse, and improves gas exchange. High oxygen levels can depress
respiratory drive in COPD.
,3.
A nurse is reviewing the ECG of a client experiencing chest pain. Which
finding suggests a myocardial infarction (MI)?
A. U wave elevation
B. ST-segment elevation
C. Sinus bradycardia
D. Peaked P waves
Correct Answer: B. ST-segment elevation
Rationale: ST elevation is the hallmark of an acute MI indicating
myocardial injury from ischemia. Requires immediate cardiac intervention.
4.
A patient with diabetes insipidus (DI) is being treated with desmopressin
(DDAVP). Which finding indicates effective therapy?
A. Decreased urine output
B. Increased thirst
C. Elevated serum sodium
D. Low urine specific gravity
Correct Answer: A. Decreased urine output
Rationale: DDAVP reduces urine volume by promoting water reabsorption.
A positive response is decreased urine output and increased specific gravity.
5.
A client with chronic kidney disease (CKD) reports pruritus. Which nursing
action is most appropriate?
A. Encourage daily hot baths
B. Apply moisturizing lotion
C. Restrict protein intake completely
D. Provide high-phosphate foods
,Correct Answer: B. Apply moisturizing lotion
Rationale: CKD causes dry skin and uremic toxins buildup. Moisturizers
relieve itching; hot baths worsen dryness.
6.
A nurse is caring for a client after thyroidectomy. Which finding is most
concerning?
A. Hoarseness
B. Mild neck swelling
C. Difficulty swallowing
D. Positive Chvostek’s sign
Correct Answer: D. Positive Chvostek’s sign
Rationale: Indicates hypocalcemia due to parathyroid injury, which can
lead to tetany or laryngeal spasms. Requires IV calcium replacement.
7.
A client with DKA has blood glucose 450 mg/dL and serum potassium 3.1
mEq/L. Which order should the nurse question?
A. 0.9% normal saline IV
B. IV regular insulin
C. Continuous ECG monitoring
D. Cardiac enzymes test
Correct Answer: B. IV regular insulin
Rationale: Insulin will further lower potassium, worsening hypokalemia.
Potassium must be corrected before insulin infusion begins.
8.
A nurse is assessing a client with pericarditis. Which finding indicates
cardiac tamponade?
, A. Bradycardia
B. Hypertension
C. Pulsus paradoxus
D. Bounding peripheral pulses
Correct Answer: C. Pulsus paradoxus
Rationale: A hallmark sign of cardiac tamponade due to pressure on the
heart, causing drop in systolic BP during inspiration.
9.
A client with Cushing’s syndrome is being discharged. Which statement
shows understanding of teaching?
A. “I’ll avoid contact with people who are sick.”
B. “I can stop taking my steroid medication if I feel better.”
C. “I will increase my salt intake.”
D. “I should exercise vigorously every day.”
Correct Answer: A. I’ll avoid contact with people who are sick.
Rationale: Cushing’s causes immunosuppression; infection prevention is a
priority. Steroids should never be stopped abruptly.
10.
Which laboratory result is most concerning in a client with chest pain?
A. Troponin I = 0.01 ng/mL
B. Troponin I = 1.5 ng/mL
C. CK-MB = 2%
D. WBC = 9,000/mm³
Correct Answer: B. Troponin I = 1.5 ng/mL
Rationale: Elevated troponin indicates myocardial damage, requiring
urgent cardiac care.
