NUR 245 EXAMINATION
1. A client with heart failure has gained 1.5 kg (3.3 lb) in 24 hours. Which action
should the nurse take first?
A. Administer the next scheduled diuretic dose and reassess in one week
B. Encourage the client to increase oral fluid intake
C. Assess lung sounds, edema, and oxygen saturation, then notify the provider
D. Document the finding and continue routine care
Correct Answer: C. Assess lung sounds, edema, and oxygen saturation, then notify
the provider
Rationale: Rapid weight gain (about 1 kg/day or more) signals fluid retention and
worsening heart failure. The nurse assesses for pulmonary congestion, edema, and
hypoxia and reports findings so treatment can be adjusted.
2. Which finding is most characteristic of left-sided heart failure?
A. Crackles in the lungs and dyspnea
B. Jugular vein distention
C. Peripheral dependent edema
D. Hepatomegaly
Correct Answer: A. Crackles in the lungs and dyspnea
Rationale: Left ventricular failure causes blood to back up into the pulmonary
circulation, producing crackles, dyspnea, and cough. The other options are signs of
right-sided failure.
Page 1
,3. A client is prescribed digoxin. Which finding should the nurse report
immediately?
A. Nausea, yellow-green visual halos, and heart rate of 52 beats/min
B. Heart rate of 78 beats/min
C. Serum potassium of 4.2 mEq/L
D. Blood pressure of 128/82 mm Hg
Correct Answer: A. Nausea, yellow-green visual halos, and heart rate of 52
beats/min
Rationale: Nausea, visual disturbances (halos), and bradycardia indicate digoxin
toxicity. Hold the dose and notify the provider. Therapeutic level is about 0.5 to 2
ng/mL.
4. Which laboratory value increases the risk of digoxin toxicity?
A. Potassium 4.5 mEq/L
B. Potassium 3.0 mEq/L
C. Sodium 140 mEq/L
D. Calcium 9.0 mg/dL
Correct Answer: B. Potassium 3.0 mEq/L
Rationale: Hypokalemia enhances digoxin binding to the myocardium and
increases toxicity risk. Potassium is commonly low in clients also taking loop
diuretics.
5. A client with chest pain is diagnosed with unstable angina. Which statement
best distinguishes it from stable angina?
A. It occurs only with exertion and is relieved by rest
B. It is never associated with coronary artery disease
C. It causes permanent myocardial necrosis
D. It occurs at rest or with increasing frequency and is not reliably relieved by
rest
Correct Answer: D. It occurs at rest or with increasing frequency and is not reliably
relieved by rest
Rationale: Unstable angina is an acute coronary syndrome marked by pain at rest,
new-onset, or worsening pattern. Stable angina is predictable and relieved by rest or
nitroglycerin.
Page 2
,6. The nurse is caring for a client with suspected myocardial infarction. Which
is the priority intervention?
A. Provide a low-sodium diet tray
B. Obtain a 12-lead ECG and administer oxygen if saturation is low
C. Teach about cardiac rehabilitation
D. Schedule an echocardiogram for next week
Correct Answer: B. Obtain a 12-lead ECG and administer oxygen if saturation is
low
Rationale: Rapid ECG identifies ST-elevation MI so reperfusion can begin. Time is
myocardium, so immediate assessment and treatment take priority over teaching or
routine care.
7. Which laboratory marker is most specific for myocardial injury?
A. Myoglobin
B. Creatine kinase total
C. Troponin
D. Lactate dehydrogenase
Correct Answer: C. Troponin
Rationale: Troponin I and T are highly specific for cardiac muscle damage, rise
within 3 to 4 hours of injury, and stay elevated for 1 to 2 weeks.
8. A client takes nitroglycerin sublingually for chest pain that is not relieved
after one dose. What should the client be taught to do next?
A. Wait 30 minutes before taking another dose
B. Take a second tablet in 5 minutes and call 911 if pain persists
C. Swallow the tablet with water
D. Lie flat and rest without calling anyone
Correct Answer: B. Take a second tablet in 5 minutes and call 911 if pain persists
Rationale: If pain is not relieved 5 minutes after the first dose, emergency services
should be called and a second tablet taken. A maximum of three doses is used,
each 5 minutes apart.
Page 3
, 9. Which assessment finding indicates that a client with a new pacemaker may
have lead dislodgement?
A. Pulse rate of 72 beats/min
B. Warm and dry incision
C. Blood pressure of 120/80 mm Hg
D. Hiccups or twitching of abdominal muscles
Correct Answer: D. Hiccups or twitching of abdominal muscles
Rationale: Diaphragmatic or abdominal muscle stimulation (hiccups, twitching)
suggests lead displacement or perforation with stimulation of the diaphragm or
phrenic nerve.
10. A client has atrial fibrillation. Which complication is the nurse most
concerned about preventing?
A. Pulmonary fibrosis
B. Peptic ulcer disease
C. Renal calculi
D. Stroke from atrial thrombus formation
Correct Answer: D. Stroke from atrial thrombus formation
Rationale: Ineffective atrial contraction allows blood to pool and clot. Emboli can
travel to the brain, causing ischemic stroke, which is why anticoagulation is
commonly prescribed.
11. The nurse monitors a client on warfarin. Which laboratory value is used to
evaluate therapeutic effect?
A. aPTT
B. Platelet count
C. INR
D. Hemoglobin
Correct Answer: C. INR
Rationale: Warfarin is monitored with the INR. The usual therapeutic range is 2.0 to
3.0 for most indications. aPTT is used to monitor heparin.
Page 4
1. A client with heart failure has gained 1.5 kg (3.3 lb) in 24 hours. Which action
should the nurse take first?
A. Administer the next scheduled diuretic dose and reassess in one week
B. Encourage the client to increase oral fluid intake
C. Assess lung sounds, edema, and oxygen saturation, then notify the provider
D. Document the finding and continue routine care
Correct Answer: C. Assess lung sounds, edema, and oxygen saturation, then notify
the provider
Rationale: Rapid weight gain (about 1 kg/day or more) signals fluid retention and
worsening heart failure. The nurse assesses for pulmonary congestion, edema, and
hypoxia and reports findings so treatment can be adjusted.
2. Which finding is most characteristic of left-sided heart failure?
A. Crackles in the lungs and dyspnea
B. Jugular vein distention
C. Peripheral dependent edema
D. Hepatomegaly
Correct Answer: A. Crackles in the lungs and dyspnea
Rationale: Left ventricular failure causes blood to back up into the pulmonary
circulation, producing crackles, dyspnea, and cough. The other options are signs of
right-sided failure.
Page 1
,3. A client is prescribed digoxin. Which finding should the nurse report
immediately?
A. Nausea, yellow-green visual halos, and heart rate of 52 beats/min
B. Heart rate of 78 beats/min
C. Serum potassium of 4.2 mEq/L
D. Blood pressure of 128/82 mm Hg
Correct Answer: A. Nausea, yellow-green visual halos, and heart rate of 52
beats/min
Rationale: Nausea, visual disturbances (halos), and bradycardia indicate digoxin
toxicity. Hold the dose and notify the provider. Therapeutic level is about 0.5 to 2
ng/mL.
4. Which laboratory value increases the risk of digoxin toxicity?
A. Potassium 4.5 mEq/L
B. Potassium 3.0 mEq/L
C. Sodium 140 mEq/L
D. Calcium 9.0 mg/dL
Correct Answer: B. Potassium 3.0 mEq/L
Rationale: Hypokalemia enhances digoxin binding to the myocardium and
increases toxicity risk. Potassium is commonly low in clients also taking loop
diuretics.
5. A client with chest pain is diagnosed with unstable angina. Which statement
best distinguishes it from stable angina?
A. It occurs only with exertion and is relieved by rest
B. It is never associated with coronary artery disease
C. It causes permanent myocardial necrosis
D. It occurs at rest or with increasing frequency and is not reliably relieved by
rest
Correct Answer: D. It occurs at rest or with increasing frequency and is not reliably
relieved by rest
Rationale: Unstable angina is an acute coronary syndrome marked by pain at rest,
new-onset, or worsening pattern. Stable angina is predictable and relieved by rest or
nitroglycerin.
Page 2
,6. The nurse is caring for a client with suspected myocardial infarction. Which
is the priority intervention?
A. Provide a low-sodium diet tray
B. Obtain a 12-lead ECG and administer oxygen if saturation is low
C. Teach about cardiac rehabilitation
D. Schedule an echocardiogram for next week
Correct Answer: B. Obtain a 12-lead ECG and administer oxygen if saturation is
low
Rationale: Rapid ECG identifies ST-elevation MI so reperfusion can begin. Time is
myocardium, so immediate assessment and treatment take priority over teaching or
routine care.
7. Which laboratory marker is most specific for myocardial injury?
A. Myoglobin
B. Creatine kinase total
C. Troponin
D. Lactate dehydrogenase
Correct Answer: C. Troponin
Rationale: Troponin I and T are highly specific for cardiac muscle damage, rise
within 3 to 4 hours of injury, and stay elevated for 1 to 2 weeks.
8. A client takes nitroglycerin sublingually for chest pain that is not relieved
after one dose. What should the client be taught to do next?
A. Wait 30 minutes before taking another dose
B. Take a second tablet in 5 minutes and call 911 if pain persists
C. Swallow the tablet with water
D. Lie flat and rest without calling anyone
Correct Answer: B. Take a second tablet in 5 minutes and call 911 if pain persists
Rationale: If pain is not relieved 5 minutes after the first dose, emergency services
should be called and a second tablet taken. A maximum of three doses is used,
each 5 minutes apart.
Page 3
, 9. Which assessment finding indicates that a client with a new pacemaker may
have lead dislodgement?
A. Pulse rate of 72 beats/min
B. Warm and dry incision
C. Blood pressure of 120/80 mm Hg
D. Hiccups or twitching of abdominal muscles
Correct Answer: D. Hiccups or twitching of abdominal muscles
Rationale: Diaphragmatic or abdominal muscle stimulation (hiccups, twitching)
suggests lead displacement or perforation with stimulation of the diaphragm or
phrenic nerve.
10. A client has atrial fibrillation. Which complication is the nurse most
concerned about preventing?
A. Pulmonary fibrosis
B. Peptic ulcer disease
C. Renal calculi
D. Stroke from atrial thrombus formation
Correct Answer: D. Stroke from atrial thrombus formation
Rationale: Ineffective atrial contraction allows blood to pool and clot. Emboli can
travel to the brain, causing ischemic stroke, which is why anticoagulation is
commonly prescribed.
11. The nurse monitors a client on warfarin. Which laboratory value is used to
evaluate therapeutic effect?
A. aPTT
B. Platelet count
C. INR
D. Hemoglobin
Correct Answer: C. INR
Rationale: Warfarin is monitored with the INR. The usual therapeutic range is 2.0 to
3.0 for most indications. aPTT is used to monitor heparin.
Page 4
