, NUR 265 Exam 2 – Medical-Surgical Nursing Actual
Questions & Answers (GCN) 100% Guarantee Pass
1. A patient with heart failure is prescribed furosemide. Which laboratory value
should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium loss
(hypokalemia). Hypokalemia can lead to cardiac arrhythmias, especially in patients on
digoxin. The nurse should monitor serum potassium levels closely.
2. A patient with angina pectoris is prescribed sublingual nitroglycerin. Which
instruction should the nurse include in patient teaching?
A. "Take one tablet every 15 minutes for up to 3 doses."
B. "Swallow the tablet with a full glass of water."
C. "Take the tablet at the first sign of chest pain."
D. "Store the tablets in the refrigerator."
Correct Answer: C. "Take the tablet at the first sign of chest pain."
Rationale: Sublingual nitroglycerin should be taken at the first sign of chest pain. The
patient should take one tablet, and if pain is not relieved in 5 minutes, call 911 and take
a second tablet. It should be dissolved under the tongue, not swallowed. Tablets should
be kept in their original dark container, not refrigerated.
3. A patient with heart failure has an ejection fraction of 35%. This finding
indicates:
A. Normal cardiac function
B. Mildly reduced cardiac function
C. Moderately reduced cardiac function
D. Severely reduced cardiac function
Correct Answer: D. Severely reduced cardiac function
Rationale: A normal ejection fraction is 55-70%. An EF of 35% indicates severely
,reduced cardiac function (heart failure with reduced ejection fraction, HFrEF). This means
the left ventricle is not pumping effectively.
4. The nurse is caring for a patient with left-sided heart failure. Which assessment
finding is most consistent with this condition?
A. Jugular venous distention
B. Peripheral edema
C. Crackles in the lung bases
D. Hepatomegaly
Correct Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure leads to pulmonary congestion. Blood backs up into
the pulmonary circulation, causing fluid to leak into the alveoli, which presents as
crackles (rales) on lung auscultation. JVD, peripheral edema, and hepatomegaly are
signs of right-sided heart failure.
5. A patient is diagnosed with atrial fibrillation. Which medication is most
commonly prescribed to reduce the risk of stroke in this patient?
A. Aspirin
B. Clopidogrel
C. Warfarin
D. Heparin
Correct Answer: C. Warfarin
Rationale: Atrial fibrillation causes blood stasis in the atria, leading to clot formation
and a high risk of thromboembolic stroke. Warfarin (or a DOAC) is an anticoagulant
used to prevent clot formation. Aspirin is less effective for this indication.
6. A patient with hypertension is prescribed lisinopril. The nurse should monitor
for which common side effect?
A. Hyperkalemia
B. Hyponatremia
C. Hypokalemia
D. Hypercalcemia
Correct Answer: A. Hyperkalemia
Rationale: Lisinopril is an ACE inhibitor. ACE inhibitors can cause potassium retention,
leading to hyperkalemia. The nurse should monitor serum potassium levels, especially in
patients with renal impairment.
, 7. The nurse is assessing a patient with suspected peripheral arterial disease (PAD).
Which finding is most characteristic?
A. Bilateral leg edema
B. Intermittent claudication
C. Distended neck veins
D. Crackles in the lungs
Correct Answer: B. Intermittent claudication
Rationale: Intermittent claudication is pain (cramping) in the legs with exercise that is
relieved by rest. It is a classic symptom of PAD caused by insufficient blood flow to the
lower extremities.
8. A patient with chronic venous insufficiency has a venous stasis ulcer. The nurse
should expect this ulcer to be located:
A. On the toes
B. On the heel
C. On the medial malleolus (ankle)
D. On the plantar surface of the foot
Correct Answer: C. On the medial malleolus (ankle)
Rationale: Venous stasis ulcers typically occur on the medial malleolus (inner ankle) or
lower leg. Arterial ulcers are more common on the toes, heels, and other pressure
points.
9. A patient is receiving IV heparin for a pulmonary embolism. The nurse should
monitor which laboratory value to evaluate the effectiveness of therapy?
A. PT/INR
B. Platelet count
C. aPTT
D. Fibrinogen level
Correct Answer: C. aPTT
Rationale: Heparin is monitored by the activated partial thromboplastin time (aPTT).
The therapeutic goal is typically 1.5-2.5 times the normal control value. PT/INR is used to
monitor warfarin therapy.
10. A patient with heart failure is prescribed digoxin. The nurse should monitor for
signs of digoxin toxicity, which include:
A. Bradycardia and visual disturbances
Questions & Answers (GCN) 100% Guarantee Pass
1. A patient with heart failure is prescribed furosemide. Which laboratory value
should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium loss
(hypokalemia). Hypokalemia can lead to cardiac arrhythmias, especially in patients on
digoxin. The nurse should monitor serum potassium levels closely.
2. A patient with angina pectoris is prescribed sublingual nitroglycerin. Which
instruction should the nurse include in patient teaching?
A. "Take one tablet every 15 minutes for up to 3 doses."
B. "Swallow the tablet with a full glass of water."
C. "Take the tablet at the first sign of chest pain."
D. "Store the tablets in the refrigerator."
Correct Answer: C. "Take the tablet at the first sign of chest pain."
Rationale: Sublingual nitroglycerin should be taken at the first sign of chest pain. The
patient should take one tablet, and if pain is not relieved in 5 minutes, call 911 and take
a second tablet. It should be dissolved under the tongue, not swallowed. Tablets should
be kept in their original dark container, not refrigerated.
3. A patient with heart failure has an ejection fraction of 35%. This finding
indicates:
A. Normal cardiac function
B. Mildly reduced cardiac function
C. Moderately reduced cardiac function
D. Severely reduced cardiac function
Correct Answer: D. Severely reduced cardiac function
Rationale: A normal ejection fraction is 55-70%. An EF of 35% indicates severely
,reduced cardiac function (heart failure with reduced ejection fraction, HFrEF). This means
the left ventricle is not pumping effectively.
4. The nurse is caring for a patient with left-sided heart failure. Which assessment
finding is most consistent with this condition?
A. Jugular venous distention
B. Peripheral edema
C. Crackles in the lung bases
D. Hepatomegaly
Correct Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure leads to pulmonary congestion. Blood backs up into
the pulmonary circulation, causing fluid to leak into the alveoli, which presents as
crackles (rales) on lung auscultation. JVD, peripheral edema, and hepatomegaly are
signs of right-sided heart failure.
5. A patient is diagnosed with atrial fibrillation. Which medication is most
commonly prescribed to reduce the risk of stroke in this patient?
A. Aspirin
B. Clopidogrel
C. Warfarin
D. Heparin
Correct Answer: C. Warfarin
Rationale: Atrial fibrillation causes blood stasis in the atria, leading to clot formation
and a high risk of thromboembolic stroke. Warfarin (or a DOAC) is an anticoagulant
used to prevent clot formation. Aspirin is less effective for this indication.
6. A patient with hypertension is prescribed lisinopril. The nurse should monitor
for which common side effect?
A. Hyperkalemia
B. Hyponatremia
C. Hypokalemia
D. Hypercalcemia
Correct Answer: A. Hyperkalemia
Rationale: Lisinopril is an ACE inhibitor. ACE inhibitors can cause potassium retention,
leading to hyperkalemia. The nurse should monitor serum potassium levels, especially in
patients with renal impairment.
, 7. The nurse is assessing a patient with suspected peripheral arterial disease (PAD).
Which finding is most characteristic?
A. Bilateral leg edema
B. Intermittent claudication
C. Distended neck veins
D. Crackles in the lungs
Correct Answer: B. Intermittent claudication
Rationale: Intermittent claudication is pain (cramping) in the legs with exercise that is
relieved by rest. It is a classic symptom of PAD caused by insufficient blood flow to the
lower extremities.
8. A patient with chronic venous insufficiency has a venous stasis ulcer. The nurse
should expect this ulcer to be located:
A. On the toes
B. On the heel
C. On the medial malleolus (ankle)
D. On the plantar surface of the foot
Correct Answer: C. On the medial malleolus (ankle)
Rationale: Venous stasis ulcers typically occur on the medial malleolus (inner ankle) or
lower leg. Arterial ulcers are more common on the toes, heels, and other pressure
points.
9. A patient is receiving IV heparin for a pulmonary embolism. The nurse should
monitor which laboratory value to evaluate the effectiveness of therapy?
A. PT/INR
B. Platelet count
C. aPTT
D. Fibrinogen level
Correct Answer: C. aPTT
Rationale: Heparin is monitored by the activated partial thromboplastin time (aPTT).
The therapeutic goal is typically 1.5-2.5 times the normal control value. PT/INR is used to
monitor warfarin therapy.
10. A patient with heart failure is prescribed digoxin. The nurse should monitor for
signs of digoxin toxicity, which include:
A. Bradycardia and visual disturbances
