PNR 206/PNR206 Final Exam V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient diagnosed with Left-sided Heart Failure. Which clinical
manifestation should the nurse prioritize during the assessment?
A. Jugular venous distention (JVD)
B. Hepatic engorgement
C. Peripheral edema in the lower extremities
D. Crackles in the lung bases
Answer: D
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot pump blood efficiently to the body, causing backflow into the lungs. This
results in pulmonary congestion, which is clinically evidenced by crackles, dyspnea, and
orthopnea. In contrast, peripheral edema and JVD are characteristic signs of right-sided
heart failure.
2. A patient is receiving Digoxin for atrial fibrillation. Which laboratory value should the nurse
monitor most closely to prevent toxicity?
A. Serum Calcium
B. Serum Potassium
,C. Serum Sodium
D. Serum Magnesium
Answer: B
Rationale: Hypokalemia increases the risk of digoxin toxicity because potassium and
digoxin compete for the same binding sites on the sodium-potassium ATPase pump. When
potassium levels are low, more digoxin can bind, leading to toxic effects even at therapeutic
serum levels. The nurse must monitor for signs such as yellow-green halos in vision and
bradycardia.
3. The nurse is assessing a patient with a history of COPD who is currently experiencing an
exacerbation. What is the most appropriate oxygen flow rate for this patient?
A. 1-2 L/min via Nasal cannula
B. 10-15 L/min via Non-rebreather mask
C. 5-8 L/min via Simple face mask
D. Venturi mask at 50% FiO2
Answer: A
Rationale: In patients with chronic COPD, the respiratory drive is often triggered by low
oxygen levels rather than high carbon dioxide levels. Providing high concentrations of
oxygen can suppress the hypoxic drive, leading to respiratory arrest. A low flow rate of 1-2
L/min is generally safer to maintain adequate oxygenation without suppressing the drive
to breathe.
, 4. A patient with Type 1 Diabetes Mellitus is found unconscious with a blood glucose level of
42 mg/dL. What is the immediate nursing intervention?
A. Administer 15g of simple carbohydrates orally
B. Administer 10 units of Regular Insulin IV
C. Provide a snack of peanut butter and crackers
D. Administer Glucagon IM or Subcutaneous
Answer: D
Rationale: Since the patient is unconscious, oral carbohydrates cannot be safely
administered due to the risk of aspiration. Glucagon is the emergency medication used to
mobilize glucose from the liver in an unconscious patient. Once the patient regains
consciousness and can swallow, follow-up with a complex carbohydrate and protein snack
is necessary.
5. Which assessment finding in a patient with a chest tube requires immediate notification of
the healthcare provider?
A. Intermittent bubbling in the water seal chamber
B. Fluctuation of the water level with respiration
C. Drainage of 50 mL in the last 8 hours
D. Continuous bubbling in the water seal chamber
Answer: D
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient diagnosed with Left-sided Heart Failure. Which clinical
manifestation should the nurse prioritize during the assessment?
A. Jugular venous distention (JVD)
B. Hepatic engorgement
C. Peripheral edema in the lower extremities
D. Crackles in the lung bases
Answer: D
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot pump blood efficiently to the body, causing backflow into the lungs. This
results in pulmonary congestion, which is clinically evidenced by crackles, dyspnea, and
orthopnea. In contrast, peripheral edema and JVD are characteristic signs of right-sided
heart failure.
2. A patient is receiving Digoxin for atrial fibrillation. Which laboratory value should the nurse
monitor most closely to prevent toxicity?
A. Serum Calcium
B. Serum Potassium
,C. Serum Sodium
D. Serum Magnesium
Answer: B
Rationale: Hypokalemia increases the risk of digoxin toxicity because potassium and
digoxin compete for the same binding sites on the sodium-potassium ATPase pump. When
potassium levels are low, more digoxin can bind, leading to toxic effects even at therapeutic
serum levels. The nurse must monitor for signs such as yellow-green halos in vision and
bradycardia.
3. The nurse is assessing a patient with a history of COPD who is currently experiencing an
exacerbation. What is the most appropriate oxygen flow rate for this patient?
A. 1-2 L/min via Nasal cannula
B. 10-15 L/min via Non-rebreather mask
C. 5-8 L/min via Simple face mask
D. Venturi mask at 50% FiO2
Answer: A
Rationale: In patients with chronic COPD, the respiratory drive is often triggered by low
oxygen levels rather than high carbon dioxide levels. Providing high concentrations of
oxygen can suppress the hypoxic drive, leading to respiratory arrest. A low flow rate of 1-2
L/min is generally safer to maintain adequate oxygenation without suppressing the drive
to breathe.
, 4. A patient with Type 1 Diabetes Mellitus is found unconscious with a blood glucose level of
42 mg/dL. What is the immediate nursing intervention?
A. Administer 15g of simple carbohydrates orally
B. Administer 10 units of Regular Insulin IV
C. Provide a snack of peanut butter and crackers
D. Administer Glucagon IM or Subcutaneous
Answer: D
Rationale: Since the patient is unconscious, oral carbohydrates cannot be safely
administered due to the risk of aspiration. Glucagon is the emergency medication used to
mobilize glucose from the liver in an unconscious patient. Once the patient regains
consciousness and can swallow, follow-up with a complex carbohydrate and protein snack
is necessary.
5. Which assessment finding in a patient with a chest tube requires immediate notification of
the healthcare provider?
A. Intermittent bubbling in the water seal chamber
B. Fluctuation of the water level with respiration
C. Drainage of 50 mL in the last 8 hours
D. Continuous bubbling in the water seal chamber
Answer: D
