,NUR209Medical-Surgical Nursing II Exam 1
Study Guide & 150 Practice Questions Fortis
College 2026/2027
1. A 68-year-old client with a history of hypertension is admitted with acute decompensated
heart failure. The nurse notes jugular venous distention, bilateral crackles, and a weight gain of
3 kg in two days. The client reports orthopnea. Which nursing intervention should the nurse
implement first?
A. Administer the prescribed loop diuretic intravenously.
B. Encourage the client to ambulate in the hallway.
C. Provide a high-sodium diet to improve fluid balance.
D. Place the client in a supine position to promote venous return.
Correct Answer: A. Administer the prescribed loop diuretic intravenously.
Rationale: Intravenous loop diuretics rapidly reduce preload and fluid volume overload, which is
the priority in acute decompensated heart failure presenting with JVD, crackles, and rapid
weight gain. Ambulation and high-sodium intake would worsen fluid retention, and a supine
position increases venous return and pulmonary congestion.
2. A patient with right-sided heart failure would most likely exhibit which of the following
clinical manifestations?
,A. Orthopnea and paroxysmal nocturnal dyspnea.
B. Peripheral edema and jugular venous distention.
C. Crackles and cough.
D. Dyspnea on exertion.
Correct Answer: B. Peripheral edema and jugular venous distention.
Rationale: Right-sided heart failure causes systemic venous congestion, leading to peripheral
edema, jugular venous distention, hepatomegaly, and ascites. Orthopnea, crackles, and dyspnea
on exertion are signs of left-sided heart failure, which causes pulmonary congestion.
3. A client with chronic heart failure is prescribed digoxin and a potassium-sparing diuretic. The
nurse reviews the morning laboratory results: potassium 3.1 mEq/L, digoxin level 2.4 mg/mL,
and creatinine 1.8 mg/dL. Which finding requires the most immediate nursing action?
A. Mildly elevated creatinine alone.
B. Elevated digoxin level with concurrent hypokalemia.
C. Potassium level slightly below normal range.
, D. Combination of digoxin and potassium-sparing diuretic.
Correct Answer: B. Elevated digoxin level with concurrent hypokalemia.
Rationale: A digoxin level of 2.4 mg/mL is toxic and hypokalemia markedly increases the risk of
digoxin toxicity and life-threatening dysrhythmias. This combination demands immediate
intervention. Isolated mild creatinine elevation or a potassium-sparing diuretic alone do not
carry the same urgency.
4. A client who experienced an ST-elevation myocardial infarction two hours ago is receiving
continuous cardiac monitoring. The monitor shows frequent premature ventricular contractions
that progress to a short run of ventricular tachycardia. The client remains conscious and reports
mild chest discomfort. What is the nurse's priority action?
A. Prepare for immediate defibrillation at 200 joules.
B. Administer a fluid bolus of normal saline rapidly.
C. Assess the client's vital signs and notify the provider.
D. Instruct the client to perform Valsalva maneuver.
Correct Answer: C. Assess the client's vital signs and notify the provider.
Rationale: The client is hemodynamically stable with a short run of VT; therefore the priority is
to assess vital signs and notify the provider for possible antiarrhythmic therapy. Defibrillation is
Study Guide & 150 Practice Questions Fortis
College 2026/2027
1. A 68-year-old client with a history of hypertension is admitted with acute decompensated
heart failure. The nurse notes jugular venous distention, bilateral crackles, and a weight gain of
3 kg in two days. The client reports orthopnea. Which nursing intervention should the nurse
implement first?
A. Administer the prescribed loop diuretic intravenously.
B. Encourage the client to ambulate in the hallway.
C. Provide a high-sodium diet to improve fluid balance.
D. Place the client in a supine position to promote venous return.
Correct Answer: A. Administer the prescribed loop diuretic intravenously.
Rationale: Intravenous loop diuretics rapidly reduce preload and fluid volume overload, which is
the priority in acute decompensated heart failure presenting with JVD, crackles, and rapid
weight gain. Ambulation and high-sodium intake would worsen fluid retention, and a supine
position increases venous return and pulmonary congestion.
2. A patient with right-sided heart failure would most likely exhibit which of the following
clinical manifestations?
,A. Orthopnea and paroxysmal nocturnal dyspnea.
B. Peripheral edema and jugular venous distention.
C. Crackles and cough.
D. Dyspnea on exertion.
Correct Answer: B. Peripheral edema and jugular venous distention.
Rationale: Right-sided heart failure causes systemic venous congestion, leading to peripheral
edema, jugular venous distention, hepatomegaly, and ascites. Orthopnea, crackles, and dyspnea
on exertion are signs of left-sided heart failure, which causes pulmonary congestion.
3. A client with chronic heart failure is prescribed digoxin and a potassium-sparing diuretic. The
nurse reviews the morning laboratory results: potassium 3.1 mEq/L, digoxin level 2.4 mg/mL,
and creatinine 1.8 mg/dL. Which finding requires the most immediate nursing action?
A. Mildly elevated creatinine alone.
B. Elevated digoxin level with concurrent hypokalemia.
C. Potassium level slightly below normal range.
, D. Combination of digoxin and potassium-sparing diuretic.
Correct Answer: B. Elevated digoxin level with concurrent hypokalemia.
Rationale: A digoxin level of 2.4 mg/mL is toxic and hypokalemia markedly increases the risk of
digoxin toxicity and life-threatening dysrhythmias. This combination demands immediate
intervention. Isolated mild creatinine elevation or a potassium-sparing diuretic alone do not
carry the same urgency.
4. A client who experienced an ST-elevation myocardial infarction two hours ago is receiving
continuous cardiac monitoring. The monitor shows frequent premature ventricular contractions
that progress to a short run of ventricular tachycardia. The client remains conscious and reports
mild chest discomfort. What is the nurse's priority action?
A. Prepare for immediate defibrillation at 200 joules.
B. Administer a fluid bolus of normal saline rapidly.
C. Assess the client's vital signs and notify the provider.
D. Instruct the client to perform Valsalva maneuver.
Correct Answer: C. Assess the client's vital signs and notify the provider.
Rationale: The client is hemodynamically stable with a short run of VT; therefore the priority is
to assess vital signs and notify the provider for possible antiarrhythmic therapy. Defibrillation is
