Medical-Surgical
Nursing and Adult
Health (Part 4)
### Question 1
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving
oxygen at 2 L/min via nasal cannula. The patient's oxygen saturation is 88%. Which action should the
nurse take first?
A. Increase the oxygen flow rate to 4 L/min
B. Assess the patient's respiratory effort and lung sounds
C. Notify the healthcare provider immediately
D. Apply a non-rebreather mask at 15 L/min
,💫RATIONALE✔️✔️: The nurse should first assess the patient's respiratory effort and lung sounds to
determine the cause of the decreased oxygen saturation. For patients with COPD, the target oxygen
saturation is typically 88-92%. The nurse should evaluate the patient's overall clinical status, including
level of consciousness and work of breathing, before adjusting oxygen therapy or notifying the provider.
💫ANSWER✔️✔️: B. Assess the patient's respiratory effort and lung sounds
---
### Question 2
A patient with heart failure is prescribed furosemide. Which assessment finding indicates the
medication is effective?
A. Decreased peripheral edema
B. Increased blood pressure
C. Decreased urine output
D. Weight gain of 2 pounds
💫RATIONALE✔️✔️: Furosemide is a loop diuretic used to reduce fluid volume overload in heart
failure. Decreased peripheral edema indicates the medication is effective. The nurse should also monitor
for decreased dyspnea, weight loss, and increased urine output. Daily weights are essential for
monitoring fluid status in heart failure patients.
💫ANSWER✔️✔️: A. Decreased peripheral edema
---
, ### Question 3
The nurse is caring for a patient with a newly placed tracheostomy. Which finding requires immediate
intervention?
A. The patient has a productive cough with yellow sputum
B. The tracheostomy tube is securely in place with a clean dressing
C. The patient is able to speak in a whisper
D. The patient has a heart rate of 88 beats per minute
💫RATIONALE✔️✔️: A productive cough with yellow sputum indicates possible infection, which can
lead to pneumonia or sepsis. This finding requires immediate intervention including culture and
sensitivity of the sputum and potential antibiotic therapy. The nurse should also assess for signs of
respiratory distress and notify the healthcare provider.
💫ANSWER✔️✔️: A. The patient has a productive cough with yellow sputum
---
### Question 4
A patient with acute pancreatitis is experiencing severe abdominal pain. Which position should the
nurse encourage to promote comfort?
A. Supine position
B. Side-lying position with knees flexed
C. Prone position
Nursing and Adult
Health (Part 4)
### Question 1
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving
oxygen at 2 L/min via nasal cannula. The patient's oxygen saturation is 88%. Which action should the
nurse take first?
A. Increase the oxygen flow rate to 4 L/min
B. Assess the patient's respiratory effort and lung sounds
C. Notify the healthcare provider immediately
D. Apply a non-rebreather mask at 15 L/min
,💫RATIONALE✔️✔️: The nurse should first assess the patient's respiratory effort and lung sounds to
determine the cause of the decreased oxygen saturation. For patients with COPD, the target oxygen
saturation is typically 88-92%. The nurse should evaluate the patient's overall clinical status, including
level of consciousness and work of breathing, before adjusting oxygen therapy or notifying the provider.
💫ANSWER✔️✔️: B. Assess the patient's respiratory effort and lung sounds
---
### Question 2
A patient with heart failure is prescribed furosemide. Which assessment finding indicates the
medication is effective?
A. Decreased peripheral edema
B. Increased blood pressure
C. Decreased urine output
D. Weight gain of 2 pounds
💫RATIONALE✔️✔️: Furosemide is a loop diuretic used to reduce fluid volume overload in heart
failure. Decreased peripheral edema indicates the medication is effective. The nurse should also monitor
for decreased dyspnea, weight loss, and increased urine output. Daily weights are essential for
monitoring fluid status in heart failure patients.
💫ANSWER✔️✔️: A. Decreased peripheral edema
---
, ### Question 3
The nurse is caring for a patient with a newly placed tracheostomy. Which finding requires immediate
intervention?
A. The patient has a productive cough with yellow sputum
B. The tracheostomy tube is securely in place with a clean dressing
C. The patient is able to speak in a whisper
D. The patient has a heart rate of 88 beats per minute
💫RATIONALE✔️✔️: A productive cough with yellow sputum indicates possible infection, which can
lead to pneumonia or sepsis. This finding requires immediate intervention including culture and
sensitivity of the sputum and potential antibiotic therapy. The nurse should also assess for signs of
respiratory distress and notify the healthcare provider.
💫ANSWER✔️✔️: A. The patient has a productive cough with yellow sputum
---
### Question 4
A patient with acute pancreatitis is experiencing severe abdominal pain. Which position should the
nurse encourage to promote comfort?
A. Supine position
B. Side-lying position with knees flexed
C. Prone position
