Herzing University NSG 223 Medical-Surgical Nursing
II 2026 | Nursing Interventions | Questions & Verified
Answers
1. Cardiovascular Nursing
Question: A patient with heart failure is prescribed furosemide. Which assessment finding
requires immediate intervention by the nurse?
A) Blood pressure of 110/70 mmHg
B) Serum potassium level of 3.0 mEq/L
C) Heart rate of 78 bpm
D) Urine output of 60 mL/hour
Answer:
B) Serum potassium level of 3.0 mEq/L ( THERAPEUTIC RANGE 3.5-5)
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. A potassium level of 3.0
mEq/L is low and increases the risk of cardiac dysrhythmias, requiring immediate intervention.
2. Respiratory Nursing
Question: A patient with COPD is experiencing shortness of breath. Which intervention should
the nurse implement first?
A) Place the patient in a high Fowler’s position
B) Administer prescribed bronchodilator
C) Encourage pursed-lip breathing
D) Assess oxygen saturation
Answer:
A) Place the patient in a high Fowler’s position
Rationale: Positioning the patient upright facilitates lung expansion and improves oxygenation,
making it the priority intervention.
3. Neurological Nursing
Question: A nurse is assessing a patient with a suspected stroke. Which finding requires
immediate action?
A) Slurred speech
B) Facial drooping
C) Sudden severe headache
D) Weakness in one arm
,Answer:
C) Sudden severe headache
Rationale: A sudden severe headache may indicate a hemorrhagic stroke, requiring immediate
intervention to prevent further complications.
4. Endocrine Nursing
Question: A patient with diabetes is experiencing confusion, tachycardia, and diaphoresis. What
is the priority nursing action?
A) Administer 10 units of insulin
B) Check the patient's blood glucose level
C) Give 4 oz of orange juice
D) Call the healthcare provider
Answer:
B) Check the patient's blood glucose level
Rationale: Symptoms suggest hypoglycemia, and confirming blood glucose levels before
treatment is crucial.
5. Renal Nursing
Question: A patient with acute kidney injury has a serum potassium level of 6.2 mEq/L. Which
medication should the nurse prepare to administer?
A) Kayexalate
B) Furosemide
C) Spironolactone
D) Lisinopril
Answer:
A) Kayexalate
Rationale: Kayexalate (sodium polystyrene sulfonate) removes excess potassium from the body
and is used for hyperkalemia management. *furosemide works slower to pull potassium
6. Gastrointestinal Nursing
Question: A patient with cirrhosis is at risk for hepatic encephalopathy. What dietary instruction
should the nurse provide?
A) Increase protein intake
B) Avoid high-fat foods
,C) Limit sodium intake
D) Reduce protein intake
Answer:
D) Reduce protein intake
Rationale: Excess protein can lead to increased ammonia levels, worsening hepatic
encephalopathy.
7. Hematology Nursing
Question: A patient receiving heparin therapy has an activated partial thromboplastin time
(aPTT) of 98 seconds. What should the nurse do first?
A) Continue the infusion
B) Increase the heparin dose
C) Stop the infusion and notify the provider
D) Prepare to administer vitamin K
Answer:
C) Stop the infusion and notify the provider
Rationale: An aPTT of 98 seconds is critically high, increasing the risk of bleeding. The
infusion should be stopped immediately. A typical aPTT value is 30-40 secs. If you get the test
because you're taking heparin, you'd want your PTT results to be more like 120-40 secs, + your
aPTT to be 60-80 secs. Partial thromboplastin time (PTT) and activated partial thromboplastin
time (aPTT) are used to test for the same functions; however, in aPTT, an activator is added that
speeds up the clotting time and results in a narrower reference range
8. Musculoskeletal Nursing
Question: A patient with a hip fracture is placed in Buck’s traction. Which finding requires
immediate intervention?
A) Capillary refill of 3 seconds in the affected foot
B) Pain relieved with analgesics
C) Reddened area on the coccyx
D) The patient’s foot is pale and cool to the touch
Answer:
D) The patient’s foot is pale and cool to the touch
Rationale: These findings suggest compromised circulation, which is an emergency.
9. Mental Health Nursing
, Question: A nurse is caring for a patient with major depressive disorder who states, “I have no
reason to go on living.” What is the nurse’s priority action?
A) Ask the patient why they feel this way
B) Notify the healthcare provider immediately
C) Assess for a specific suicide plan
D) Encourage the patient to express feelings
Answer:
C) Assess for a specific suicide plan
Rationale: Determining the presence of a plan helps assess the level of suicide risk and need for
immediate intervention.
10. Pharmacology Nursing
Question: A patient taking digoxin reports nausea, blurred vision, and dizziness. What is the
nurse’s next action?
A) Check the patient's apical pulse
B) Hold the digoxin dose and check digoxin levels
C) Administer an antiemetic
D) Encourage increased fluid intake
Answer:
B) Hold the digoxin dose and check digoxin levels
Rationale: Symptoms suggest digoxin toxicity, which requires withholding the medication and
assessing serum levels.
12. Respiratory Nursing
Question: A patient with pneumonia is receiving oxygen at 4 L/min via nasal cannula. Which
finding requires immediate action?
A) Oxygen saturation of 92%
B) Patient reports dyspnea
C) Respiratory rate of 8 breaths/min
D) The patient is in a high Fowler’s position
Answer:
C) Respiratory rate of 8 breaths/min
Rationale: A respiratory rate below 10 breaths/min may indicate respiratory depression,
requiring immediate intervention.
II 2026 | Nursing Interventions | Questions & Verified
Answers
1. Cardiovascular Nursing
Question: A patient with heart failure is prescribed furosemide. Which assessment finding
requires immediate intervention by the nurse?
A) Blood pressure of 110/70 mmHg
B) Serum potassium level of 3.0 mEq/L
C) Heart rate of 78 bpm
D) Urine output of 60 mL/hour
Answer:
B) Serum potassium level of 3.0 mEq/L ( THERAPEUTIC RANGE 3.5-5)
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. A potassium level of 3.0
mEq/L is low and increases the risk of cardiac dysrhythmias, requiring immediate intervention.
2. Respiratory Nursing
Question: A patient with COPD is experiencing shortness of breath. Which intervention should
the nurse implement first?
A) Place the patient in a high Fowler’s position
B) Administer prescribed bronchodilator
C) Encourage pursed-lip breathing
D) Assess oxygen saturation
Answer:
A) Place the patient in a high Fowler’s position
Rationale: Positioning the patient upright facilitates lung expansion and improves oxygenation,
making it the priority intervention.
3. Neurological Nursing
Question: A nurse is assessing a patient with a suspected stroke. Which finding requires
immediate action?
A) Slurred speech
B) Facial drooping
C) Sudden severe headache
D) Weakness in one arm
,Answer:
C) Sudden severe headache
Rationale: A sudden severe headache may indicate a hemorrhagic stroke, requiring immediate
intervention to prevent further complications.
4. Endocrine Nursing
Question: A patient with diabetes is experiencing confusion, tachycardia, and diaphoresis. What
is the priority nursing action?
A) Administer 10 units of insulin
B) Check the patient's blood glucose level
C) Give 4 oz of orange juice
D) Call the healthcare provider
Answer:
B) Check the patient's blood glucose level
Rationale: Symptoms suggest hypoglycemia, and confirming blood glucose levels before
treatment is crucial.
5. Renal Nursing
Question: A patient with acute kidney injury has a serum potassium level of 6.2 mEq/L. Which
medication should the nurse prepare to administer?
A) Kayexalate
B) Furosemide
C) Spironolactone
D) Lisinopril
Answer:
A) Kayexalate
Rationale: Kayexalate (sodium polystyrene sulfonate) removes excess potassium from the body
and is used for hyperkalemia management. *furosemide works slower to pull potassium
6. Gastrointestinal Nursing
Question: A patient with cirrhosis is at risk for hepatic encephalopathy. What dietary instruction
should the nurse provide?
A) Increase protein intake
B) Avoid high-fat foods
,C) Limit sodium intake
D) Reduce protein intake
Answer:
D) Reduce protein intake
Rationale: Excess protein can lead to increased ammonia levels, worsening hepatic
encephalopathy.
7. Hematology Nursing
Question: A patient receiving heparin therapy has an activated partial thromboplastin time
(aPTT) of 98 seconds. What should the nurse do first?
A) Continue the infusion
B) Increase the heparin dose
C) Stop the infusion and notify the provider
D) Prepare to administer vitamin K
Answer:
C) Stop the infusion and notify the provider
Rationale: An aPTT of 98 seconds is critically high, increasing the risk of bleeding. The
infusion should be stopped immediately. A typical aPTT value is 30-40 secs. If you get the test
because you're taking heparin, you'd want your PTT results to be more like 120-40 secs, + your
aPTT to be 60-80 secs. Partial thromboplastin time (PTT) and activated partial thromboplastin
time (aPTT) are used to test for the same functions; however, in aPTT, an activator is added that
speeds up the clotting time and results in a narrower reference range
8. Musculoskeletal Nursing
Question: A patient with a hip fracture is placed in Buck’s traction. Which finding requires
immediate intervention?
A) Capillary refill of 3 seconds in the affected foot
B) Pain relieved with analgesics
C) Reddened area on the coccyx
D) The patient’s foot is pale and cool to the touch
Answer:
D) The patient’s foot is pale and cool to the touch
Rationale: These findings suggest compromised circulation, which is an emergency.
9. Mental Health Nursing
, Question: A nurse is caring for a patient with major depressive disorder who states, “I have no
reason to go on living.” What is the nurse’s priority action?
A) Ask the patient why they feel this way
B) Notify the healthcare provider immediately
C) Assess for a specific suicide plan
D) Encourage the patient to express feelings
Answer:
C) Assess for a specific suicide plan
Rationale: Determining the presence of a plan helps assess the level of suicide risk and need for
immediate intervention.
10. Pharmacology Nursing
Question: A patient taking digoxin reports nausea, blurred vision, and dizziness. What is the
nurse’s next action?
A) Check the patient's apical pulse
B) Hold the digoxin dose and check digoxin levels
C) Administer an antiemetic
D) Encourage increased fluid intake
Answer:
B) Hold the digoxin dose and check digoxin levels
Rationale: Symptoms suggest digoxin toxicity, which requires withholding the medication and
assessing serum levels.
12. Respiratory Nursing
Question: A patient with pneumonia is receiving oxygen at 4 L/min via nasal cannula. Which
finding requires immediate action?
A) Oxygen saturation of 92%
B) Patient reports dyspnea
C) Respiratory rate of 8 breaths/min
D) The patient is in a high Fowler’s position
Answer:
C) Respiratory rate of 8 breaths/min
Rationale: A respiratory rate below 10 breaths/min may indicate respiratory depression,
requiring immediate intervention.
