NR324/NR 324 Exam 2 V2 | Adult Health I
Q&A with Rationale | Chamberlain
University
1. A patient with a history of heart failure reports a sudden weight gain of 3 pounds in two
days. Which action should the nurse take first?
A. Check the patient’s blood pressure.
B. Administer a PRN dose of a loop diuretic.
C. Inform the patient to restrict fluid intake to 1000 mL/day.
D. Assess the patient for peripheral edema and lung sounds.
Correct Answer: D
Rationale: Sudden weight gain is a primary indicator of fluid volume excess in heart failure
patients. The nurse must first assess the clinical status of the patient by checking for
crackles in the lungs and the presence of edema. This assessment data is necessary before
notifying the provider or implementing further interventions.
2. When teaching a patient about a new prescription for Lisinopril, which side effect should
the nurse emphasize as a reason to stop the medication and call the provider?
A. Swelling of the lips and tongue.
B. A persistent dry cough.
C. Increased urinary frequency.
,D. Dizziness when standing up.
Correct Answer: A
Rationale: Swelling of the lips and tongue indicates angioedema, which is a life-
threatening adverse effect of ACE inhibitors. While a dry cough is common and annoying, it
is not immediately life-threatening. The nurse must ensure the patient understands that
angioedema requires immediate medical attention to protect the airway.
3. A nurse is caring for a patient with Peripheral Artery Disease (PAD) who reports leg pain
while walking. What should the nurse recommend?
A. Walk until the point of pain, rest, and then continue walking.
B. Elevate the legs above the heart level when resting.
C. Apply a heating pad to the legs to increase blood flow.
D. Wear compression stockings throughout the day.
Correct Answer: A
Rationale: Exercise therapy is the primary non-pharmacological treatment for
intermittent claudication in PAD. Walking increases collateral circulation, which helps
improve symptoms over time. Patients should walk until they feel pain, rest until it
subsides, and then resume to build endurance.
4. Which clinical manifestation is most characteristic of Right-Sided Heart Failure?
A. Jugular venous distention (JVD).
, B. Crackles and wheezes in the lungs.
C. Orthopnea and paroxysmal nocturnal dyspnea.
D. Pink frothy sputum.
Correct Answer: A
Rationale: Right-sided heart failure causes blood to back up into the systemic venous
system. This results in signs such as JVD, peripheral edema, and hepatomegaly. Left-sided
failure, conversely, causes pulmonary symptoms like crackles and pink frothy sputum due
to fluid backing up into the lungs.
5. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. Which finding is the most concerning?
A. Oxygen saturation of 91%.
B. Clubbing of the fingernails.
C. Barrel-shaped chest.
D. Respiratory rate of 10 breaths/min.
Correct Answer: D
Rationale: A respiratory rate of 10 breaths/min in a COPD patient receiving oxygen may
indicate CO2 narcosis or the suppression of the hypoxic drive. Patients with chronic
hypercapnia rely on low oxygen levels to stimulate breathing. If too much oxygen is
provided, their respiratory drive may decrease dangerously, leading to respiratory arrest.
Q&A with Rationale | Chamberlain
University
1. A patient with a history of heart failure reports a sudden weight gain of 3 pounds in two
days. Which action should the nurse take first?
A. Check the patient’s blood pressure.
B. Administer a PRN dose of a loop diuretic.
C. Inform the patient to restrict fluid intake to 1000 mL/day.
D. Assess the patient for peripheral edema and lung sounds.
Correct Answer: D
Rationale: Sudden weight gain is a primary indicator of fluid volume excess in heart failure
patients. The nurse must first assess the clinical status of the patient by checking for
crackles in the lungs and the presence of edema. This assessment data is necessary before
notifying the provider or implementing further interventions.
2. When teaching a patient about a new prescription for Lisinopril, which side effect should
the nurse emphasize as a reason to stop the medication and call the provider?
A. Swelling of the lips and tongue.
B. A persistent dry cough.
C. Increased urinary frequency.
,D. Dizziness when standing up.
Correct Answer: A
Rationale: Swelling of the lips and tongue indicates angioedema, which is a life-
threatening adverse effect of ACE inhibitors. While a dry cough is common and annoying, it
is not immediately life-threatening. The nurse must ensure the patient understands that
angioedema requires immediate medical attention to protect the airway.
3. A nurse is caring for a patient with Peripheral Artery Disease (PAD) who reports leg pain
while walking. What should the nurse recommend?
A. Walk until the point of pain, rest, and then continue walking.
B. Elevate the legs above the heart level when resting.
C. Apply a heating pad to the legs to increase blood flow.
D. Wear compression stockings throughout the day.
Correct Answer: A
Rationale: Exercise therapy is the primary non-pharmacological treatment for
intermittent claudication in PAD. Walking increases collateral circulation, which helps
improve symptoms over time. Patients should walk until they feel pain, rest until it
subsides, and then resume to build endurance.
4. Which clinical manifestation is most characteristic of Right-Sided Heart Failure?
A. Jugular venous distention (JVD).
, B. Crackles and wheezes in the lungs.
C. Orthopnea and paroxysmal nocturnal dyspnea.
D. Pink frothy sputum.
Correct Answer: A
Rationale: Right-sided heart failure causes blood to back up into the systemic venous
system. This results in signs such as JVD, peripheral edema, and hepatomegaly. Left-sided
failure, conversely, causes pulmonary symptoms like crackles and pink frothy sputum due
to fluid backing up into the lungs.
5. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. Which finding is the most concerning?
A. Oxygen saturation of 91%.
B. Clubbing of the fingernails.
C. Barrel-shaped chest.
D. Respiratory rate of 10 breaths/min.
Correct Answer: D
Rationale: A respiratory rate of 10 breaths/min in a COPD patient receiving oxygen may
indicate CO2 narcosis or the suppression of the hypoxic drive. Patients with chronic
hypercapnia rely on low oxygen levels to stimulate breathing. If too much oxygen is
provided, their respiratory drive may decrease dangerously, leading to respiratory arrest.
