NUR 242 MEDICAL SURGICAL EXAM 3
1.A client with heart failure has tachypnea and bilateral crackles.
Which action is the priority?
A) Administer digoxin as prescribed
B) Place the client in a high-Fowler position
C) Notify the provider immediately
D) Apply oxygen at 2 L/min via nasal cannula
Correct Answer: Place the client in a high-Fowler position
Rationale: High-Fowler's position uses gravity to reduce venous return
(preload) and promotes lung expansion, immediately improving breathing.
This is the priority action for pulmonary congestion . Oxygen and
medications are important but should follow positioning.
2. Which assessment finding is characteristic of right-sided heart failure?
A) Crackles in lung bases
B) Paroxysmal nocturnal dyspnea
C) Dependent edema and swollen hands
D) Orthopnea
Correct Answer: Dependent edema and swollen hands
Rationale: Right-sided heart failure causes systemic venous congestion,
leading to dependent edema, swollen extremities, and hepatomegaly .
Crackles, PND, and orthopnea are signs of left-sided heart failure due to
pulmonary congestion.
3. A client takes furosemide and digoxin for heart failure. Why is orange
juice encouraged daily?
, A) To enhance digoxin absorption
B) To maintain potassium levels
C) To prevent constipation
D) To promote diuresis
Correct Answer: To maintain potassium levels
Rationale: Furosemide is a potassium-wasting diuretic. Hypokalemia
increases the risk of digoxin toxicity . Orange juice is a good potassium
source and helps maintain serum levels.
4. A client taking digoxin reports nausea and yellow vision. Which action
is appropriate?
A) Administer the medication as scheduled
B) Hold the digoxin and notify the provider
C) Increase the dose to improve effectiveness
D) Give the medication with food
Correct Answer: Hold the digoxin and notify the provider
Rationale: Nausea, vomiting, and yellow vision (xanthopsia) are classic signs
of digoxin toxicity . The medication should be held and the provider notified
immediately.
5. An infant with heart failure is prescribed furosemide. Which lab value
requires provider notification?
A) Sodium 140 mEq/L
B) Potassium 3.0 mEq/L
C) Calcium 9.5 mg/dL
D) Glucose 110 mg/dL
Correct Answer: Potassium 3.0 mEq/L
,Rationale: Potassium of 3.0 mEq/L indicates hypokalemia, a common side
effect of furosemide. This is especially concerning in infants and requires
provider notification . Normal potassium range is 3.5-5.0 mEq/L.
6. A client returns from an EGD with a blood pressure of 82/48 mmHg and
tachycardia. What is the priority action?
A) Offer ice chips for comfort
B) Notify the provider immediately
C) Administer antiemetic for nausea
D) Allow the client to rest
Correct Answer: Notify the provider immediately
Rationale: Post-EGD hypotension with tachycardia may indicate perforation
or internal bleeding, which can rapidly progress to shock . This requires
immediate provider notification.
7. Which intervention is the priority for a client with paroxysmal nocturnal
dyspnea (PND)?
A) Administer oxygen at 2 L/min
B) Assist the client to sit on the edge of the bed
C) Notify the provider immediately
D) Administer furosemide
Correct Answer: Assist the client to sit on the edge of the bed
Rationale: Sitting the client upright uses gravity to reduce venous return and
pulmonary congestion, relieving dyspnea . This is the immediate priority
before other interventions.
8. A client with heart failure reports a 9-pound weight gain in 2 weeks.
What is this most indicative of?
A) Improved nutritional status
, B) Fluid retention
C) Muscle gain from exercise
D) Expected weight fluctuation
Correct Answer: Fluid retention
Rationale: A 9-pound weight gain over 2 weeks indicates significant fluid
retention, a key sign of worsening heart failure. Daily weights are the most
sensitive indicator of fluid status .
9. Which statement indicates a client with GERD needs further teaching?
A) "I will avoid spicy and fatty foods."
B) "I will stop smoking and limit alcohol."
C) "I will keep my NG tube long-term to reduce reflux."
D) "I will work on losing weight if needed."
Correct Answer: "I will keep my NG tube long-term to reduce reflux."
Rationale: An NG tube actually increases reflux risk and is not a treatment
for GERD . The other statements reflect appropriate lifestyle modifications.
10. A client with a sliding hiatal hernia is most likely to report which
symptom?
A) Left lower quadrant pain after meals
B) Reflux and heartburn when lying down
C) Clay-colored stools
D) Foul-smelling breath and fever
Correct Answer: Reflux and heartburn when lying down
Rationale: Sliding hiatal hernias move into the thoracic cavity and commonly
cause reflux symptoms similar to GERD, especially when recumbent .
1.A client with heart failure has tachypnea and bilateral crackles.
Which action is the priority?
A) Administer digoxin as prescribed
B) Place the client in a high-Fowler position
C) Notify the provider immediately
D) Apply oxygen at 2 L/min via nasal cannula
Correct Answer: Place the client in a high-Fowler position
Rationale: High-Fowler's position uses gravity to reduce venous return
(preload) and promotes lung expansion, immediately improving breathing.
This is the priority action for pulmonary congestion . Oxygen and
medications are important but should follow positioning.
2. Which assessment finding is characteristic of right-sided heart failure?
A) Crackles in lung bases
B) Paroxysmal nocturnal dyspnea
C) Dependent edema and swollen hands
D) Orthopnea
Correct Answer: Dependent edema and swollen hands
Rationale: Right-sided heart failure causes systemic venous congestion,
leading to dependent edema, swollen extremities, and hepatomegaly .
Crackles, PND, and orthopnea are signs of left-sided heart failure due to
pulmonary congestion.
3. A client takes furosemide and digoxin for heart failure. Why is orange
juice encouraged daily?
, A) To enhance digoxin absorption
B) To maintain potassium levels
C) To prevent constipation
D) To promote diuresis
Correct Answer: To maintain potassium levels
Rationale: Furosemide is a potassium-wasting diuretic. Hypokalemia
increases the risk of digoxin toxicity . Orange juice is a good potassium
source and helps maintain serum levels.
4. A client taking digoxin reports nausea and yellow vision. Which action
is appropriate?
A) Administer the medication as scheduled
B) Hold the digoxin and notify the provider
C) Increase the dose to improve effectiveness
D) Give the medication with food
Correct Answer: Hold the digoxin and notify the provider
Rationale: Nausea, vomiting, and yellow vision (xanthopsia) are classic signs
of digoxin toxicity . The medication should be held and the provider notified
immediately.
5. An infant with heart failure is prescribed furosemide. Which lab value
requires provider notification?
A) Sodium 140 mEq/L
B) Potassium 3.0 mEq/L
C) Calcium 9.5 mg/dL
D) Glucose 110 mg/dL
Correct Answer: Potassium 3.0 mEq/L
,Rationale: Potassium of 3.0 mEq/L indicates hypokalemia, a common side
effect of furosemide. This is especially concerning in infants and requires
provider notification . Normal potassium range is 3.5-5.0 mEq/L.
6. A client returns from an EGD with a blood pressure of 82/48 mmHg and
tachycardia. What is the priority action?
A) Offer ice chips for comfort
B) Notify the provider immediately
C) Administer antiemetic for nausea
D) Allow the client to rest
Correct Answer: Notify the provider immediately
Rationale: Post-EGD hypotension with tachycardia may indicate perforation
or internal bleeding, which can rapidly progress to shock . This requires
immediate provider notification.
7. Which intervention is the priority for a client with paroxysmal nocturnal
dyspnea (PND)?
A) Administer oxygen at 2 L/min
B) Assist the client to sit on the edge of the bed
C) Notify the provider immediately
D) Administer furosemide
Correct Answer: Assist the client to sit on the edge of the bed
Rationale: Sitting the client upright uses gravity to reduce venous return and
pulmonary congestion, relieving dyspnea . This is the immediate priority
before other interventions.
8. A client with heart failure reports a 9-pound weight gain in 2 weeks.
What is this most indicative of?
A) Improved nutritional status
, B) Fluid retention
C) Muscle gain from exercise
D) Expected weight fluctuation
Correct Answer: Fluid retention
Rationale: A 9-pound weight gain over 2 weeks indicates significant fluid
retention, a key sign of worsening heart failure. Daily weights are the most
sensitive indicator of fluid status .
9. Which statement indicates a client with GERD needs further teaching?
A) "I will avoid spicy and fatty foods."
B) "I will stop smoking and limit alcohol."
C) "I will keep my NG tube long-term to reduce reflux."
D) "I will work on losing weight if needed."
Correct Answer: "I will keep my NG tube long-term to reduce reflux."
Rationale: An NG tube actually increases reflux risk and is not a treatment
for GERD . The other statements reflect appropriate lifestyle modifications.
10. A client with a sliding hiatal hernia is most likely to report which
symptom?
A) Left lower quadrant pain after meals
B) Reflux and heartburn when lying down
C) Clay-colored stools
D) Foul-smelling breath and fever
Correct Answer: Reflux and heartburn when lying down
Rationale: Sliding hiatal hernias move into the thoracic cavity and commonly
cause reflux symptoms similar to GERD, especially when recumbent .
