, NUR 265 Exam 3 – Medical-Surgical Nursing –Actual
Questions & Answers (GCN) 100% Guarantee Pass
Question 1
A nurse is caring for a client with heart failure (HF). Which assessment finding requires
immediate intervention?
A) Weight gain of 2 pounds in 24 hours
B) Crackles in the lung bases
C) 2+ pitting edema in the lower extremities
D) Jugular vein distention when sitting upright
Answer: B
Rationale: Crackles in the lung bases indicate pulmonary congestion (fluid in the alveoli), a sign
of worsening heart failure that requires immediate intervention (e.g., diuretics, oxygen) to
prevent respiratory failure. Weight gain and edema are signs of fluid overload but are less
emergent than pulmonary congestion.
Question 2
A client with heart failure has a prescription for furosemide (Lasix). Which laboratory value
should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum glucose
Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia (low potassium). Potassium
levels should be monitored closely, especially in clients on digoxin, as hypokalemia increases the
risk of digoxin toxicity.
Question 3
A client with heart failure is on digoxin. Which finding indicates digoxin toxicity?
A) Heart rate of 68 bpm
B) Nausea, vomiting, and yellow-green halos around lights
,C) Serum digoxin level of 1.2 ng/mL (therapeutic range 0.8–2.0)
D) Constipation
Answer: B
Rationale: Signs of digoxin toxicity include: nausea, vomiting, anorexia, blurred or yellow-green
vision (halos), bradycardia, and cardiac dysrhythmias. A therapeutic digoxin level is 0.8–2.0
ng/mL. Levels above 2.0 indicate toxicity.
Question 4
A client with heart failure is on a fluid restriction of 1500 mL/day. Which statement indicates the
client understands the restriction?
A) "I can have 1500 mL of any liquid, including ice cream."
B) "I will measure all my liquids to stay within 1500 mL."
C) "I can have as much water as I want as long as I take my diuretic."
D) "I only need to count fluids at meals."
Answer: B
Rationale: Measuring all liquids helps the client adhere to the fluid restriction. Fluids include all
liquids and foods that melt at room temperature (ice cream, gelatin, soup).
Question 5
A client with heart failure is on a low-sodium diet. Which meal choice is most appropriate?
A) Grilled salmon with steamed asparagus
B) Ham and cheese sandwich
C) Canned tuna salad
D) Frozen lasagna
Answer: A
Rationale: Grilled salmon with steamed vegetables is a low-sodium choice. Ham, canned tuna,
and frozen entrees are high in sodium and should be avoided.
Question 6
The nurse is assessing a client with left-sided heart failure. Which finding is most indicative?
A) Jugular venous distention
B) Peripheral edema
, C) Crackles in the lung bases
D) Hepatomegaly
Answer: C
Rationale: Left-sided heart failure leads to pulmonary congestion, causing crackles, dyspnea,
and cough. The other findings are characteristic of right-sided heart failure.
Question 7
A client with chronic heart failure reports waking up at night with shortness of breath. The
nurse recognizes this as:
A) Orthopnea
B) Paroxysmal nocturnal dyspnea
C) Dyspnea on exertion
D) Hyperpnea
Answer: B
Rationale: Paroxysmal nocturnal dyspnea (PND) is awakening from sleep with shortness of
breath, often relieved by sitting up. Orthopnea is shortness of breath when lying flat. Dyspnea
on exertion occurs with activity.
Question 8
A client with heart failure is on continuous telemetry. Which rhythm should the nurse report
immediately?
A) Sinus tachycardia at 110 bpm
B) Atrial fibrillation
C) Ventricular tachycardia
D) Premature atrial complexes (PACs)
Answer: C
Rationale: Ventricular tachycardia is a life-threatening arrhythmia that requires immediate
intervention. Sinus tachycardia, atrial fibrillation, and PACs may be concerning but are not
immediately life-threatening.
Question 9
A client with heart failure is on oxygen therapy. The nurse notes the client's oxygen saturation is
Questions & Answers (GCN) 100% Guarantee Pass
Question 1
A nurse is caring for a client with heart failure (HF). Which assessment finding requires
immediate intervention?
A) Weight gain of 2 pounds in 24 hours
B) Crackles in the lung bases
C) 2+ pitting edema in the lower extremities
D) Jugular vein distention when sitting upright
Answer: B
Rationale: Crackles in the lung bases indicate pulmonary congestion (fluid in the alveoli), a sign
of worsening heart failure that requires immediate intervention (e.g., diuretics, oxygen) to
prevent respiratory failure. Weight gain and edema are signs of fluid overload but are less
emergent than pulmonary congestion.
Question 2
A client with heart failure has a prescription for furosemide (Lasix). Which laboratory value
should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum glucose
Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia (low potassium). Potassium
levels should be monitored closely, especially in clients on digoxin, as hypokalemia increases the
risk of digoxin toxicity.
Question 3
A client with heart failure is on digoxin. Which finding indicates digoxin toxicity?
A) Heart rate of 68 bpm
B) Nausea, vomiting, and yellow-green halos around lights
,C) Serum digoxin level of 1.2 ng/mL (therapeutic range 0.8–2.0)
D) Constipation
Answer: B
Rationale: Signs of digoxin toxicity include: nausea, vomiting, anorexia, blurred or yellow-green
vision (halos), bradycardia, and cardiac dysrhythmias. A therapeutic digoxin level is 0.8–2.0
ng/mL. Levels above 2.0 indicate toxicity.
Question 4
A client with heart failure is on a fluid restriction of 1500 mL/day. Which statement indicates the
client understands the restriction?
A) "I can have 1500 mL of any liquid, including ice cream."
B) "I will measure all my liquids to stay within 1500 mL."
C) "I can have as much water as I want as long as I take my diuretic."
D) "I only need to count fluids at meals."
Answer: B
Rationale: Measuring all liquids helps the client adhere to the fluid restriction. Fluids include all
liquids and foods that melt at room temperature (ice cream, gelatin, soup).
Question 5
A client with heart failure is on a low-sodium diet. Which meal choice is most appropriate?
A) Grilled salmon with steamed asparagus
B) Ham and cheese sandwich
C) Canned tuna salad
D) Frozen lasagna
Answer: A
Rationale: Grilled salmon with steamed vegetables is a low-sodium choice. Ham, canned tuna,
and frozen entrees are high in sodium and should be avoided.
Question 6
The nurse is assessing a client with left-sided heart failure. Which finding is most indicative?
A) Jugular venous distention
B) Peripheral edema
, C) Crackles in the lung bases
D) Hepatomegaly
Answer: C
Rationale: Left-sided heart failure leads to pulmonary congestion, causing crackles, dyspnea,
and cough. The other findings are characteristic of right-sided heart failure.
Question 7
A client with chronic heart failure reports waking up at night with shortness of breath. The
nurse recognizes this as:
A) Orthopnea
B) Paroxysmal nocturnal dyspnea
C) Dyspnea on exertion
D) Hyperpnea
Answer: B
Rationale: Paroxysmal nocturnal dyspnea (PND) is awakening from sleep with shortness of
breath, often relieved by sitting up. Orthopnea is shortness of breath when lying flat. Dyspnea
on exertion occurs with activity.
Question 8
A client with heart failure is on continuous telemetry. Which rhythm should the nurse report
immediately?
A) Sinus tachycardia at 110 bpm
B) Atrial fibrillation
C) Ventricular tachycardia
D) Premature atrial complexes (PACs)
Answer: C
Rationale: Ventricular tachycardia is a life-threatening arrhythmia that requires immediate
intervention. Sinus tachycardia, atrial fibrillation, and PACs may be concerning but are not
immediately life-threatening.
Question 9
A client with heart failure is on oxygen therapy. The nurse notes the client's oxygen saturation is
