,NUR 242 Exam 2 | Medical-Surgical Nursing Concepts
(2026/2027) PDF | Galen College
1. The nurse is monitoring a client with heart failure for fluid retention. Which
assessment finding provides the most accurate indication of fluid status?
A) Urine specific gravity
B) Skin turgor over the sternum
C) Daily weight obtained at the same time each morning
D) Intake and output totals for the last 24 hours
Correct Answer: Daily weight obtained at the same time each morning
Rationale: Daily weight is the most sensitive indicator of fluid gain or loss. Even
small changes reflect fluid shifts before they become clinically obvious.
Consistent weighing conditions are essential for accuracy.
2. A client’s serum potassium is 6.2 mEq/L. Which ECG change is most
characteristic?
A) Flattened T waves and prominent U waves
B) ST segment depression
C) Prolonged QT interval
D) Peaked T waves and widened QRS
Correct Answer: Peaked T waves and widened QRS
,Rationale: Hyperkalemia impairs cardiac repolarization, causing tall, tented T
waves. As levels rise, the QRS widens, and fatal arrhythmias such as ventricular
fibrillation can occur.
3. The nurse is reviewing the laboratory results of a client with end‑stage renal
disease. Which value is most concerning?
A) Calcium 8.0 mg/dL
B) Magnesium 2.0 mEq/L
C) Potassium 6.8 mEq/L
D) Sodium 138 mEq/L
Correct Answer: Potassium 6.8 mEq/L
Rationale: Severe hyperkalemia can cause life‑threatening cardiac arrhythmias.
Renal patients cannot excrete potassium efficiently, making this a priority. The
other values are outside normal but less immediately dangerous.
4. A client with cirrhosis develops ascites. The nurse understands that fluid
accumulation in the peritoneal cavity is primarily due to:
A) Increased capillary permeability
B) Portal hypertension and decreased plasma oncotic pressure
C) Lymphatic obstruction
D) Hyperaldosteronism
Correct Answer: Portal hypertension and decreased plasma oncotic pressure
, Rationale: Cirrhosis increases portal pressure and reduces albumin synthesis.
Low oncotic pressure combined with elevated hydrostatic pressure drives fluid
into the peritoneal space.
5. The nurse is teaching a client with atrial fibrillation about warfarin therapy.
Which statement by the client indicates a need for further teaching?
A) “I will have my INR checked regularly.”
B) “I need to use an electric razor for shaving.”
C) “I can take aspirin for headaches.”
D) “I will keep my intake of vitamin K consistent.”
Correct Answer: “I can take aspirin for headaches.”
Rationale: Aspirin inhibits platelets and increases the risk of bleeding when
combined with warfarin. Acetaminophen is a safer alternative for pain. The
other statements demonstrate correct understanding.
6. A client on a heparin infusion has an aPTT of 85 seconds. The nurse should:
A) Increase the infusion rate
B) Continue the current rate
C) Notify the provider and anticipate a rate reduction
D) Administer protamine sulfate immediately
Correct Answer: Notify the provider and anticipate a rate reduction
(2026/2027) PDF | Galen College
1. The nurse is monitoring a client with heart failure for fluid retention. Which
assessment finding provides the most accurate indication of fluid status?
A) Urine specific gravity
B) Skin turgor over the sternum
C) Daily weight obtained at the same time each morning
D) Intake and output totals for the last 24 hours
Correct Answer: Daily weight obtained at the same time each morning
Rationale: Daily weight is the most sensitive indicator of fluid gain or loss. Even
small changes reflect fluid shifts before they become clinically obvious.
Consistent weighing conditions are essential for accuracy.
2. A client’s serum potassium is 6.2 mEq/L. Which ECG change is most
characteristic?
A) Flattened T waves and prominent U waves
B) ST segment depression
C) Prolonged QT interval
D) Peaked T waves and widened QRS
Correct Answer: Peaked T waves and widened QRS
,Rationale: Hyperkalemia impairs cardiac repolarization, causing tall, tented T
waves. As levels rise, the QRS widens, and fatal arrhythmias such as ventricular
fibrillation can occur.
3. The nurse is reviewing the laboratory results of a client with end‑stage renal
disease. Which value is most concerning?
A) Calcium 8.0 mg/dL
B) Magnesium 2.0 mEq/L
C) Potassium 6.8 mEq/L
D) Sodium 138 mEq/L
Correct Answer: Potassium 6.8 mEq/L
Rationale: Severe hyperkalemia can cause life‑threatening cardiac arrhythmias.
Renal patients cannot excrete potassium efficiently, making this a priority. The
other values are outside normal but less immediately dangerous.
4. A client with cirrhosis develops ascites. The nurse understands that fluid
accumulation in the peritoneal cavity is primarily due to:
A) Increased capillary permeability
B) Portal hypertension and decreased plasma oncotic pressure
C) Lymphatic obstruction
D) Hyperaldosteronism
Correct Answer: Portal hypertension and decreased plasma oncotic pressure
, Rationale: Cirrhosis increases portal pressure and reduces albumin synthesis.
Low oncotic pressure combined with elevated hydrostatic pressure drives fluid
into the peritoneal space.
5. The nurse is teaching a client with atrial fibrillation about warfarin therapy.
Which statement by the client indicates a need for further teaching?
A) “I will have my INR checked regularly.”
B) “I need to use an electric razor for shaving.”
C) “I can take aspirin for headaches.”
D) “I will keep my intake of vitamin K consistent.”
Correct Answer: “I can take aspirin for headaches.”
Rationale: Aspirin inhibits platelets and increases the risk of bleeding when
combined with warfarin. Acetaminophen is a safer alternative for pain. The
other statements demonstrate correct understanding.
6. A client on a heparin infusion has an aPTT of 85 seconds. The nurse should:
A) Increase the infusion rate
B) Continue the current rate
C) Notify the provider and anticipate a rate reduction
D) Administer protamine sulfate immediately
Correct Answer: Notify the provider and anticipate a rate reduction
