PNR 201/PNR201 Exam 2 V3 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient diagnosed with Chronic Obstructive Pulmonary Disease
(COPD) who is receiving oxygen via nasal cannula at 2 L/min. The patient’s SpO2 is 89%. What
is the most appropriate nursing action?
A. Increase the oxygen flow to 6 L/min immediately.
B. Continue to monitor the patient as this is an expected finding for COPD.
C. Switch the delivery device to a non-rebreather mask.
D. Prepare for immediate intubation and mechanical ventilation.
Correct Answer: B
Explanation: Patients with COPD often have a lower baseline oxygen saturation, typically
ranging between 88% and 92%. Providing too much oxygen can suppress the hypoxic
drive, which is the primary stimulus for breathing in these patients. The nurse should
recognize that 89% is within the acceptable target range for this specific chronic condition.
2. The nurse is assessing a patient for suspected right-sided heart failure. Which clinical
manifestation is most indicative of this condition?
A. Crackles heard in the lung bases.
B. Peripheral edema and jugular venous distension.
C. Dyspnea on exertion and orthopnea.
,D. Pink, frothy sputum production.
Correct Answer: B
Explanation: Right-sided heart failure leads to systemic venous congestion because the
right ventricle is unable to pump blood effectively into the pulmonary circulation. This
causes fluid to back up into the systemic veins, resulting in peripheral edema,
hepatomegaly, and jugular venous distension (JVD). Crackles and dyspnea are classic signs
of left-sided heart failure where fluid backs up into the lungs.
3. A patient with deep vein thrombosis (DVT) is prescribed Heparin via continuous
intravenous infusion. Which laboratory value must the nurse monitor to evaluate the
effectiveness and safety of this therapy?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Correct Answer: C
Explanation: The aPTT is the standard laboratory test used to monitor the therapeutic
effect of unfractionated heparin. PT and INR are used primarily to monitor the
effectiveness of Warfarin (Coumadin) therapy. While platelet counts are monitored to
check for heparin-induced thrombocytopenia (HIT), the aPTT is the specific indicator for
dosage adjustment.
, 4. During a respiratory assessment, the nurse notes the patient has a ‘barrel chest’
appearance. The nurse understands this is a characteristic sign of which condition?
A. Acute Bronchitis
B. Emphysema
C. Pulmonary Embolism
D. Pneumonia
Correct Answer: B
Explanation: A barrel chest is caused by chronic air trapping and hyperinflation of the
lungs, which is a hallmark of emphysema. Over time, the increased workload of breathing
and the expansion of the rib cage change the anterior-posterior diameter of the chest. This
physical finding is less common in acute conditions like pneumonia or bronchitis.
5. A patient is admitted with a diagnosis of Pernicious Anemia. The nurse should anticipate
administering which of the following medications long-term?
A. Oral Iron supplements
B. Vitamin B12 injections
C. Folic acid tablets
D. Erythropoietin injections
Correct Answer: B
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient diagnosed with Chronic Obstructive Pulmonary Disease
(COPD) who is receiving oxygen via nasal cannula at 2 L/min. The patient’s SpO2 is 89%. What
is the most appropriate nursing action?
A. Increase the oxygen flow to 6 L/min immediately.
B. Continue to monitor the patient as this is an expected finding for COPD.
C. Switch the delivery device to a non-rebreather mask.
D. Prepare for immediate intubation and mechanical ventilation.
Correct Answer: B
Explanation: Patients with COPD often have a lower baseline oxygen saturation, typically
ranging between 88% and 92%. Providing too much oxygen can suppress the hypoxic
drive, which is the primary stimulus for breathing in these patients. The nurse should
recognize that 89% is within the acceptable target range for this specific chronic condition.
2. The nurse is assessing a patient for suspected right-sided heart failure. Which clinical
manifestation is most indicative of this condition?
A. Crackles heard in the lung bases.
B. Peripheral edema and jugular venous distension.
C. Dyspnea on exertion and orthopnea.
,D. Pink, frothy sputum production.
Correct Answer: B
Explanation: Right-sided heart failure leads to systemic venous congestion because the
right ventricle is unable to pump blood effectively into the pulmonary circulation. This
causes fluid to back up into the systemic veins, resulting in peripheral edema,
hepatomegaly, and jugular venous distension (JVD). Crackles and dyspnea are classic signs
of left-sided heart failure where fluid backs up into the lungs.
3. A patient with deep vein thrombosis (DVT) is prescribed Heparin via continuous
intravenous infusion. Which laboratory value must the nurse monitor to evaluate the
effectiveness and safety of this therapy?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Correct Answer: C
Explanation: The aPTT is the standard laboratory test used to monitor the therapeutic
effect of unfractionated heparin. PT and INR are used primarily to monitor the
effectiveness of Warfarin (Coumadin) therapy. While platelet counts are monitored to
check for heparin-induced thrombocytopenia (HIT), the aPTT is the specific indicator for
dosage adjustment.
, 4. During a respiratory assessment, the nurse notes the patient has a ‘barrel chest’
appearance. The nurse understands this is a characteristic sign of which condition?
A. Acute Bronchitis
B. Emphysema
C. Pulmonary Embolism
D. Pneumonia
Correct Answer: B
Explanation: A barrel chest is caused by chronic air trapping and hyperinflation of the
lungs, which is a hallmark of emphysema. Over time, the increased workload of breathing
and the expansion of the rib cage change the anterior-posterior diameter of the chest. This
physical finding is less common in acute conditions like pneumonia or bronchitis.
5. A patient is admitted with a diagnosis of Pernicious Anemia. The nurse should anticipate
administering which of the following medications long-term?
A. Oral Iron supplements
B. Vitamin B12 injections
C. Folic acid tablets
D. Erythropoietin injections
Correct Answer: B
