,NUR 209 Exam 2 | Medical - Surgical Nursing II (2026) Actual
Q&A PDF | Fortis College
1. A nurse is caring for a patient with heart failure who reports increased shortness
of breath. Which assessment finding is the most reliable early indicator of
worsening left - sided heart failure?
A) Peripheral edema
B) Jugular venous distention
C) Crackles heard in the lung bases
D) Weight gain of 2 pounds in 24 hours
Correct Answer: Crackles heard in the lung bases
Rationale: Left - sided heart failure leads to pulmonary congestion, and crackles in
the lung bases are an early sign of fluid accumulation in the lungs. Peripheral
edema and jugular venous distention are more consistent with right - sided heart
failure. Weight gain is important but occurs later and is not specific to left - sided
failure.
2. Which statement by a patient with newly diagnosed heart failure indicates that
teaching about daily weight monitoring was effective?
A) "I will weigh myself every morning after breakfast."
B) "I will call the clinic if my weight goes up 3 pounds in a week."
C) "I will weigh myself only when I feel short of breath."
D) "I will use a different scale each time I weigh myself."
Correct Answer: "I will call the clinic if my weight goes up 3 pounds in a week."
,Rationale: A weight gain of 3 pounds in a week or 2 pounds in 24 hours indicates
fluid retention and should be reported promptly. Weighing after breakfast may be
inaccurate; it should be done in the morning before eating, after voiding, using the
same scale. Weighin g only when symptomatic delays early detection.
3. A nurse is teaching a patient about a low - sodium diet for hypertension. Which
food should the nurse instruct the patient to avoid?
A) Fresh apples
B) Canned soup
C) Grilled chicken breast
D) Steamed broccoli
Correct Answer: Canned soup
Rationale: Canned soups are typically high in sodium due to added salt as a
preservative and flavor enhancer. Fresh fruits, plain grilled chicken, and steamed
vegetables are naturally low in sodium. Processed and canned foods should be
limited in a low - sodium diet.
4. A patient with atrial fibrillation is prescribed warfarin. Which laboratory value
should the nurse monitor to evaluate therapeutic effectiveness?
A) Platelet count
B) INR
C) aPTT
D) Hemoglobin
Correct Answer: INR
, Rationale: Warfarin therapy is monitored using the INR, with a therapeutic range
typically between 2.0 and 3.0 for atrial fibrillation. Platelet count assesses clotting
ability but not warfarin effectiveness. aPTT monitors heparin therapy, and
hemoglobin assesses ox ygen - carrying capacity.
5. Which finding in a patient receiving heparin therapy requires immediate
intervention?
A) INR of 2.5
B) Platelet count of 150,000/mm³
C) Sudden onset of back pain and hypotension
D) Bruise at the injection site
Correct Answer: Sudden onset of back pain and hypotension
Rationale: Sudden back pain and hypotension may indicate retroperitoneal
bleeding, a serious complication of heparin therapy. An INR of 2.5 is therapeutic for
warfarin, not heparin. A platelet count of 150,000/mm³ is within normal limits, and a
bruise at the injecti on site is expected.
6. A patient with a history of venous thromboembolism is prescribed enoxaparin.
Which instruction should the nurse include?
A) Take the medication with food to reduce nausea.
B) Inject into the abdomen, rotating sites.
C) Massage the injection site after administration.
D) Take aspirin concurrently for added protection.
Correct Answer: Inject into the abdomen, rotating sites.
Q&A PDF | Fortis College
1. A nurse is caring for a patient with heart failure who reports increased shortness
of breath. Which assessment finding is the most reliable early indicator of
worsening left - sided heart failure?
A) Peripheral edema
B) Jugular venous distention
C) Crackles heard in the lung bases
D) Weight gain of 2 pounds in 24 hours
Correct Answer: Crackles heard in the lung bases
Rationale: Left - sided heart failure leads to pulmonary congestion, and crackles in
the lung bases are an early sign of fluid accumulation in the lungs. Peripheral
edema and jugular venous distention are more consistent with right - sided heart
failure. Weight gain is important but occurs later and is not specific to left - sided
failure.
2. Which statement by a patient with newly diagnosed heart failure indicates that
teaching about daily weight monitoring was effective?
A) "I will weigh myself every morning after breakfast."
B) "I will call the clinic if my weight goes up 3 pounds in a week."
C) "I will weigh myself only when I feel short of breath."
D) "I will use a different scale each time I weigh myself."
Correct Answer: "I will call the clinic if my weight goes up 3 pounds in a week."
,Rationale: A weight gain of 3 pounds in a week or 2 pounds in 24 hours indicates
fluid retention and should be reported promptly. Weighing after breakfast may be
inaccurate; it should be done in the morning before eating, after voiding, using the
same scale. Weighin g only when symptomatic delays early detection.
3. A nurse is teaching a patient about a low - sodium diet for hypertension. Which
food should the nurse instruct the patient to avoid?
A) Fresh apples
B) Canned soup
C) Grilled chicken breast
D) Steamed broccoli
Correct Answer: Canned soup
Rationale: Canned soups are typically high in sodium due to added salt as a
preservative and flavor enhancer. Fresh fruits, plain grilled chicken, and steamed
vegetables are naturally low in sodium. Processed and canned foods should be
limited in a low - sodium diet.
4. A patient with atrial fibrillation is prescribed warfarin. Which laboratory value
should the nurse monitor to evaluate therapeutic effectiveness?
A) Platelet count
B) INR
C) aPTT
D) Hemoglobin
Correct Answer: INR
, Rationale: Warfarin therapy is monitored using the INR, with a therapeutic range
typically between 2.0 and 3.0 for atrial fibrillation. Platelet count assesses clotting
ability but not warfarin effectiveness. aPTT monitors heparin therapy, and
hemoglobin assesses ox ygen - carrying capacity.
5. Which finding in a patient receiving heparin therapy requires immediate
intervention?
A) INR of 2.5
B) Platelet count of 150,000/mm³
C) Sudden onset of back pain and hypotension
D) Bruise at the injection site
Correct Answer: Sudden onset of back pain and hypotension
Rationale: Sudden back pain and hypotension may indicate retroperitoneal
bleeding, a serious complication of heparin therapy. An INR of 2.5 is therapeutic for
warfarin, not heparin. A platelet count of 150,000/mm³ is within normal limits, and a
bruise at the injecti on site is expected.
6. A patient with a history of venous thromboembolism is prescribed enoxaparin.
Which instruction should the nurse include?
A) Take the medication with food to reduce nausea.
B) Inject into the abdomen, rotating sites.
C) Massage the injection site after administration.
D) Take aspirin concurrently for added protection.
Correct Answer: Inject into the abdomen, rotating sites.
