,NUR 242 Exam 3 – Medical-Surgical Nursing
–Actual Questions & Answers (GCN) 100%
Guarantee Pass
1. The clinic nurse is teaching a group of clients with heart failure (HF) about dietary
interventions to prevent fluid overload. Which topic should be included?
A) Use of canned vegetables for convenience
B) Use of fresh or frozen vegetables instead of canned ones
C) Limiting fluid intake to 1 liter per day
D) Increasing salt intake to maintain blood pressure
Correct Answer: B
Rationale: Clients with heart failure should follow a low-sodium diet to prevent fluid overload.
Fresh or frozen vegetables are lower in sodium than canned vegetables, which often contain
added salt for preservation. Sodium restriction (typically 2 grams per day) is the most important
dietary intervention for heart failure to prevent fluid retention .
2. A client with heart failure has an episode of paroxysmal nocturnal dyspnea (PND). Which
action should the nurse take first?
A) Administer oxygen via nasal cannula
B) Assist the client to sit on the edge of the bed
C) Notify the healthcare provider
D) Administer furosemide IV push
Correct Answer: B
Rationale: PND occurs when fluid shifts from the legs to the lungs during sleep, causing sudden
shortness of breath. The priority action is to assist the client to sit upright (on the edge of the
bed) to use gravity to reduce venous return and improve oxygenation. Oxygen may be needed
next, and then the provider should be notified .
3. When caring for a client with right ventricular heart failure, which assessment findings
would the nurse expect? (Select all that apply)
A) Dependent edema
B) Swollen hands and fingers
C) Right upper quadrant discomfort
,D) Crackles in the lung bases
E) Jugular venous distention
Correct Answer: A, B, C, E
Rationale: Right-sided heart failure results in systemic venous congestion. Findings include
dependent edema, swollen hands and fingers, right upper quadrant discomfort (hepatic
congestion), and jugular venous distention. Crackles in the lung bases are characteristic of left-
sided (pulmonary) heart failure .
4. A client with heart failure is prescribed furosemide. Which electrolyte imbalance should the
nurse monitor for?
A) Hyperkalemia
B) Hypokalemia
C) Hypernatremia
D) Hypermagnesemia
Correct Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia (low potassium) by
increasing potassium excretion in the urine. Hypokalemia can increase the risk of digoxin
toxicity if the client is also taking digoxin. The nurse should monitor serum potassium levels and
encourage potassium-rich foods .
5. A client with heart failure is prescribed digoxin. Which finding indicates digoxin toxicity?
A) Heart rate 72 bpm
B) Yellow-green halos around lights
C) Blood pressure 130/80 mmHg
D) Serum potassium 4.2 mEq/L
Correct Answer: B
Rationale: Visual disturbances, including yellow-green halos around lights (xanthopsia), are
classic signs of digoxin toxicity. Other signs include nausea, vomiting, anorexia, and cardiac
arrhythmias. Hypokalemia increases the risk of digoxin toxicity .
6. A client with left-sided heart failure is experiencing dyspnea and orthopnea. Which
pathophysiologic mechanism is the primary cause of these symptoms?
A) Decreased cardiac output to the systemic circulation
B) Fluid backup into the pulmonary circulation
, C) Decreased renal perfusion
D) Increased venous return to the heart
Correct Answer: B
Rationale: Left-sided heart failure causes fluid to back up into the pulmonary circulation
because the left ventricle cannot pump blood forward effectively. This leads to pulmonary
congestion, which manifests as dyspnea, orthopnea, and crackles .
7. Which medication is commonly prescribed for heart failure to reduce preload and
afterload?
A) Digoxin
B) Furosemide
C) Lisinopril (ACE inhibitor)
D) Metoprolol
Correct Answer: C
Rationale: ACE inhibitors (e.g., lisinopril) reduce preload and afterload by vasodilation and are
first-line medications for heart failure. They also have renal-protective effects. Digoxin increases
cardiac contractility, furosemide reduces fluid volume, and metoprolol is a beta-blocker used for
rate control .
8. A client with heart failure has a weight gain of 3 pounds in 24 hours. What is the priority
nursing action?
A) Notify the healthcare provider
B) Restrict fluid intake
C) Administer furosemide
D) Assess for peripheral edema
Correct Answer: D
Rationale: Rapid weight gain indicates fluid retention. The nurse should first assess for
peripheral edema and other signs of fluid overload before implementing interventions or
notifying the provider. Assessment is always the first step .
9. A client with heart failure is receiving IV furosemide. Which assessment finding indicates
the medication is effective?
A) Increased urine output
B) Decreased blood pressure
–Actual Questions & Answers (GCN) 100%
Guarantee Pass
1. The clinic nurse is teaching a group of clients with heart failure (HF) about dietary
interventions to prevent fluid overload. Which topic should be included?
A) Use of canned vegetables for convenience
B) Use of fresh or frozen vegetables instead of canned ones
C) Limiting fluid intake to 1 liter per day
D) Increasing salt intake to maintain blood pressure
Correct Answer: B
Rationale: Clients with heart failure should follow a low-sodium diet to prevent fluid overload.
Fresh or frozen vegetables are lower in sodium than canned vegetables, which often contain
added salt for preservation. Sodium restriction (typically 2 grams per day) is the most important
dietary intervention for heart failure to prevent fluid retention .
2. A client with heart failure has an episode of paroxysmal nocturnal dyspnea (PND). Which
action should the nurse take first?
A) Administer oxygen via nasal cannula
B) Assist the client to sit on the edge of the bed
C) Notify the healthcare provider
D) Administer furosemide IV push
Correct Answer: B
Rationale: PND occurs when fluid shifts from the legs to the lungs during sleep, causing sudden
shortness of breath. The priority action is to assist the client to sit upright (on the edge of the
bed) to use gravity to reduce venous return and improve oxygenation. Oxygen may be needed
next, and then the provider should be notified .
3. When caring for a client with right ventricular heart failure, which assessment findings
would the nurse expect? (Select all that apply)
A) Dependent edema
B) Swollen hands and fingers
C) Right upper quadrant discomfort
,D) Crackles in the lung bases
E) Jugular venous distention
Correct Answer: A, B, C, E
Rationale: Right-sided heart failure results in systemic venous congestion. Findings include
dependent edema, swollen hands and fingers, right upper quadrant discomfort (hepatic
congestion), and jugular venous distention. Crackles in the lung bases are characteristic of left-
sided (pulmonary) heart failure .
4. A client with heart failure is prescribed furosemide. Which electrolyte imbalance should the
nurse monitor for?
A) Hyperkalemia
B) Hypokalemia
C) Hypernatremia
D) Hypermagnesemia
Correct Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia (low potassium) by
increasing potassium excretion in the urine. Hypokalemia can increase the risk of digoxin
toxicity if the client is also taking digoxin. The nurse should monitor serum potassium levels and
encourage potassium-rich foods .
5. A client with heart failure is prescribed digoxin. Which finding indicates digoxin toxicity?
A) Heart rate 72 bpm
B) Yellow-green halos around lights
C) Blood pressure 130/80 mmHg
D) Serum potassium 4.2 mEq/L
Correct Answer: B
Rationale: Visual disturbances, including yellow-green halos around lights (xanthopsia), are
classic signs of digoxin toxicity. Other signs include nausea, vomiting, anorexia, and cardiac
arrhythmias. Hypokalemia increases the risk of digoxin toxicity .
6. A client with left-sided heart failure is experiencing dyspnea and orthopnea. Which
pathophysiologic mechanism is the primary cause of these symptoms?
A) Decreased cardiac output to the systemic circulation
B) Fluid backup into the pulmonary circulation
, C) Decreased renal perfusion
D) Increased venous return to the heart
Correct Answer: B
Rationale: Left-sided heart failure causes fluid to back up into the pulmonary circulation
because the left ventricle cannot pump blood forward effectively. This leads to pulmonary
congestion, which manifests as dyspnea, orthopnea, and crackles .
7. Which medication is commonly prescribed for heart failure to reduce preload and
afterload?
A) Digoxin
B) Furosemide
C) Lisinopril (ACE inhibitor)
D) Metoprolol
Correct Answer: C
Rationale: ACE inhibitors (e.g., lisinopril) reduce preload and afterload by vasodilation and are
first-line medications for heart failure. They also have renal-protective effects. Digoxin increases
cardiac contractility, furosemide reduces fluid volume, and metoprolol is a beta-blocker used for
rate control .
8. A client with heart failure has a weight gain of 3 pounds in 24 hours. What is the priority
nursing action?
A) Notify the healthcare provider
B) Restrict fluid intake
C) Administer furosemide
D) Assess for peripheral edema
Correct Answer: D
Rationale: Rapid weight gain indicates fluid retention. The nurse should first assess for
peripheral edema and other signs of fluid overload before implementing interventions or
notifying the provider. Assessment is always the first step .
9. A client with heart failure is receiving IV furosemide. Which assessment finding indicates
the medication is effective?
A) Increased urine output
B) Decreased blood pressure
