,NUR 209 Exam 3 | Medical - Surgical Nursing II (2026) Actual
Q&A PDF | Fortis College
1. Which assessment finding most strongly indicates left - sided heart failure?
A) Jugular venous distention
B) Hepatomegaly
C) Bibasilar crackles
D) Peripheral edema
Correct Answer: Bibasilar crackles
Rationale: Left - sided heart failure causes blood to back up into the pulmonary
circulation, resulting in pulmonary congestion and crackles at the lung bases.
Jugular venous distention, hepatomegaly, and peripheral edema are classic signs of
right - sided heart failure . Recognizing these distinctions guides immediate nursing
interventions.
2. A patient receiving thrombolytic therapy for myocardial infarction develops
reperfusion dysrhythmias. Which interpretation is correct?
A) The therapy has failed and should be discontinued
B) The dysrhythmias indicate successful reperfusion
C) The patient is experiencing an allergic reaction
D) The dysrhythmias require immediate defibrillation
Correct Answer: The dysrhythmias indicate successful reperfusion
Rationale: Reperfusion dysrhythmias, such as accelerated idioventricular rhythm
or PVCs, are objective indicators that blood flow is being restored to ischemic
,myocardium. Resolution of chest pain is subjective and less reliable. These
dysrhythmias typically resolve without intervention and signal therapeutic success.
3. Which modifiable risk factor should a nurse include in a community education
program for cardiovascular disease?
A) Family history of cardiac disease
B) Increasing age
C) Cigarette smoking
D) Diagnosis of diabetes mellitus
Correct Answer: Cigarette smoking
Rationale: Cigarette smoking is a modifiable risk factor that individuals can
change to reduce cardiovascular risk. Family history, age, and diabetes diagnosis
are non - modifiable or require medical management. Focusing on modifiable
behaviors empowers patients to ta ke actionable steps toward prevention.
4. A patient who has a 35 - pack - year smoking history reports hoarseness, throat
tightness, and difficulty swallowing. Which question is most important for the nurse
to ask?
A) "How much alcohol do you drink in an average week?"
B) "Have you had a recent upper respiratory infection?"
C) "Do you have a family history of throat cancer?"
D) "Have you experienced any recent weight loss?"
Correct Answer: "How much alcohol do you drink in an average week?"
, Rationale: The combination of heavy smoking and symptoms of laryngeal or
esophageal pathology makes alcohol consumption a critical risk factor to quantify.
Alcohol synergistically increases the risk of head and neck cancers in smokers. A
complete assessment includes both smoking and alcohol history.
5. Which action should the nurse take first when a patient develops epistaxis?
A) Apply squeezing pressure to the nostrils for 10 minutes
B) Apply ice to the bridge of the nose
C) Tilt the patient's head backward
D) Insert nasal packing
Correct Answer: Apply squeezing pressure to the nostrils for 10 minutes
Rationale: Initial management of epistaxis involves firm, continuous pressure to
the nostrils with the patient leaning forward. Tilting the head backward allows blood
to flow down the throat, increasing aspiration risk. Ice and nasal packing are
secondary interventi ons if pressure fails.
6. Which patient in the ENT clinic should the nurse assess first?
A) A patient who reports a sore throat and a muffled voice
B) A patient with seasonal allergies and sneezing
C) A patient with a history of chronic sinusitis
D) A patient with a foreign body in the ear canal
Correct Answer: A patient who reports a sore throat and a muffled voice
Rationale: A muffled "hot potato" voice with sore throat is a hallmark of
peritonsillar abscess, which can rapidly progress to airway obstruction. This patient
Q&A PDF | Fortis College
1. Which assessment finding most strongly indicates left - sided heart failure?
A) Jugular venous distention
B) Hepatomegaly
C) Bibasilar crackles
D) Peripheral edema
Correct Answer: Bibasilar crackles
Rationale: Left - sided heart failure causes blood to back up into the pulmonary
circulation, resulting in pulmonary congestion and crackles at the lung bases.
Jugular venous distention, hepatomegaly, and peripheral edema are classic signs of
right - sided heart failure . Recognizing these distinctions guides immediate nursing
interventions.
2. A patient receiving thrombolytic therapy for myocardial infarction develops
reperfusion dysrhythmias. Which interpretation is correct?
A) The therapy has failed and should be discontinued
B) The dysrhythmias indicate successful reperfusion
C) The patient is experiencing an allergic reaction
D) The dysrhythmias require immediate defibrillation
Correct Answer: The dysrhythmias indicate successful reperfusion
Rationale: Reperfusion dysrhythmias, such as accelerated idioventricular rhythm
or PVCs, are objective indicators that blood flow is being restored to ischemic
,myocardium. Resolution of chest pain is subjective and less reliable. These
dysrhythmias typically resolve without intervention and signal therapeutic success.
3. Which modifiable risk factor should a nurse include in a community education
program for cardiovascular disease?
A) Family history of cardiac disease
B) Increasing age
C) Cigarette smoking
D) Diagnosis of diabetes mellitus
Correct Answer: Cigarette smoking
Rationale: Cigarette smoking is a modifiable risk factor that individuals can
change to reduce cardiovascular risk. Family history, age, and diabetes diagnosis
are non - modifiable or require medical management. Focusing on modifiable
behaviors empowers patients to ta ke actionable steps toward prevention.
4. A patient who has a 35 - pack - year smoking history reports hoarseness, throat
tightness, and difficulty swallowing. Which question is most important for the nurse
to ask?
A) "How much alcohol do you drink in an average week?"
B) "Have you had a recent upper respiratory infection?"
C) "Do you have a family history of throat cancer?"
D) "Have you experienced any recent weight loss?"
Correct Answer: "How much alcohol do you drink in an average week?"
, Rationale: The combination of heavy smoking and symptoms of laryngeal or
esophageal pathology makes alcohol consumption a critical risk factor to quantify.
Alcohol synergistically increases the risk of head and neck cancers in smokers. A
complete assessment includes both smoking and alcohol history.
5. Which action should the nurse take first when a patient develops epistaxis?
A) Apply squeezing pressure to the nostrils for 10 minutes
B) Apply ice to the bridge of the nose
C) Tilt the patient's head backward
D) Insert nasal packing
Correct Answer: Apply squeezing pressure to the nostrils for 10 minutes
Rationale: Initial management of epistaxis involves firm, continuous pressure to
the nostrils with the patient leaning forward. Tilting the head backward allows blood
to flow down the throat, increasing aspiration risk. Ice and nasal packing are
secondary interventi ons if pressure fails.
6. Which patient in the ENT clinic should the nurse assess first?
A) A patient who reports a sore throat and a muffled voice
B) A patient with seasonal allergies and sneezing
C) A patient with a history of chronic sinusitis
D) A patient with a foreign body in the ear canal
Correct Answer: A patient who reports a sore throat and a muffled voice
Rationale: A muffled "hot potato" voice with sore throat is a hallmark of
peritonsillar abscess, which can rapidly progress to airway obstruction. This patient
