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NUR209 MEDICAL-SURGICAL NURSING II
EXAM QUESTIONS WITH VERIFIED
SOLUTIONS
1. A 68-year-old patient admitted with acute decompensated heart failure reports
new dyspnea and anxiety. Vital signs are BP 168/96, HR 112, RR 32, SpO₂ 88% on
room air. Which initial action by the nurse is most appropriate?
A. Restrict all oral intake and place supine
B. Place the patient in high Fowler's position and apply supplemental oxygen
C. Reposition to left lateral Trendelenburg
D. Administer a scheduled beta-blocker immediately
Correct Answer: B
Rationale: Positioning in high Fowler's decreases venous return and reduces
preload, while supplemental oxygen addresses hypoxemia. This is the fastest first
action; medications follow provider orders after assessment .
2. A patient with a STEMI is receiving a continuous heparin infusion. The aPTT is
120 sec (control 30 sec). The patient has new melena. Which order should the
nurse anticipate first?
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A. Increase the heparin rate
B. Stop the heparin infusion and notify the provider; prepare protamine sulfate
C. Give aspirin 325 mg orally
D. Administer vitamin K intravenously
Correct Answer: B
Rationale: An aPTT approximately 4 × control with active bleeding indicates
heparin toxicity. The nurse should stop the infusion, notify the provider, and
prepare to administer protamine sulfate, the specific heparin reversal agent.
Vitamin K reverses warfarin, not heparin .
3. A 74-year-old patient with COPD is receiving 4 L/min oxygen via nasal cannula.
The patient becomes lethargic and the SpO₂ is 92%. ABG shows pH 7.28, PaCO₂
78, HCO₃ 32. Which interpretation is most accurate?
A. Respiratory alkalosis with renal compensation
B. Metabolic alkalosis with hypoventilation
C. Respiratory acidosis with partial metabolic compensation, likely oxygen-
induced hypoventilation
D. Metabolic acidosis with respiratory compensation
Correct Answer: C
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Rationale: In COPD patients dependent on hypoxic drive, excess oxygen can
suppress ventilation, causing CO₂ retention and respiratory acidosis. The pH is
low, PaCO₂ is markedly elevated, and HCO₃ is elevated indicating chronic renal
compensation. Reduce oxygen cautiously while monitoring ABGs .
4. Which laboratory value should the nurse closely monitor in a client taking
digoxin?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
Correct Answer: B
Rationale: Low potassium levels increase the risk of digoxin toxicity. Hypokalemia
enhances digoxin's effects on the heart, leading to dysrhythmias. Monitoring
potassium is essential .
5. A client with chronic kidney disease asks why phosphate binders are
prescribed. What is the nurse's best explanation?
NUR209 MEDICAL-SURGICAL NURSING II
EXAM QUESTIONS WITH VERIFIED
SOLUTIONS
1. A 68-year-old patient admitted with acute decompensated heart failure reports
new dyspnea and anxiety. Vital signs are BP 168/96, HR 112, RR 32, SpO₂ 88% on
room air. Which initial action by the nurse is most appropriate?
A. Restrict all oral intake and place supine
B. Place the patient in high Fowler's position and apply supplemental oxygen
C. Reposition to left lateral Trendelenburg
D. Administer a scheduled beta-blocker immediately
Correct Answer: B
Rationale: Positioning in high Fowler's decreases venous return and reduces
preload, while supplemental oxygen addresses hypoxemia. This is the fastest first
action; medications follow provider orders after assessment .
2. A patient with a STEMI is receiving a continuous heparin infusion. The aPTT is
120 sec (control 30 sec). The patient has new melena. Which order should the
nurse anticipate first?
,2|Page
A. Increase the heparin rate
B. Stop the heparin infusion and notify the provider; prepare protamine sulfate
C. Give aspirin 325 mg orally
D. Administer vitamin K intravenously
Correct Answer: B
Rationale: An aPTT approximately 4 × control with active bleeding indicates
heparin toxicity. The nurse should stop the infusion, notify the provider, and
prepare to administer protamine sulfate, the specific heparin reversal agent.
Vitamin K reverses warfarin, not heparin .
3. A 74-year-old patient with COPD is receiving 4 L/min oxygen via nasal cannula.
The patient becomes lethargic and the SpO₂ is 92%. ABG shows pH 7.28, PaCO₂
78, HCO₃ 32. Which interpretation is most accurate?
A. Respiratory alkalosis with renal compensation
B. Metabolic alkalosis with hypoventilation
C. Respiratory acidosis with partial metabolic compensation, likely oxygen-
induced hypoventilation
D. Metabolic acidosis with respiratory compensation
Correct Answer: C
, 3|Page
Rationale: In COPD patients dependent on hypoxic drive, excess oxygen can
suppress ventilation, causing CO₂ retention and respiratory acidosis. The pH is
low, PaCO₂ is markedly elevated, and HCO₃ is elevated indicating chronic renal
compensation. Reduce oxygen cautiously while monitoring ABGs .
4. Which laboratory value should the nurse closely monitor in a client taking
digoxin?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
Correct Answer: B
Rationale: Low potassium levels increase the risk of digoxin toxicity. Hypokalemia
enhances digoxin's effects on the heart, leading to dysrhythmias. Monitoring
potassium is essential .
5. A client with chronic kidney disease asks why phosphate binders are
prescribed. What is the nurse's best explanation?
