NUR201 / NUR 201
Medical-Surgical Nursing I
Exam 2
Questions and Verified Answers
100% Correct | Grade A
Latest Update
Fortis College
100 Questions | Passing Score: 70%
30% Recall | 50% Application | 20% Analysis
1
, NUR201 Medical-Surgical Nursing I | Exam 2 | Fortis College | 2026/2027
Section 1: Cardiovascular System Disorders
Q1-Q20 | Hypertension, Heart Failure, CAD, MI, Valvular Disease
1. A nurse is assessing a client with hypertension. The client's blood pressure reading is 148/92 mmHg. According to
the 2026 ACC/AHA guidelines, how should this reading be classified?
A. Normal
B. Elevated
C. Stage 1 Hypertension [CORRECT]
D. Stage 2 Hypertension
Correct Answer: C
Rationale: Blood pressure of 148/92 mmHg meets criteria for Stage 1 Hypertension, defined as systolic 130-139 mmHg and/or
diastolic 80-89 mmHg. Elevated blood pressure is 120-129/<80 mmHg, while Stage 2 is 140/90 mmHg or higher. Accurate
classification guides treatment decisions including lifestyle modifications and pharmacological therapy per evidence-based guidelines.
2. A client with hypertension reports occasional headaches in the occipital area and episodes of epistaxis. The nurse
recognizes that hypertension is often referred to as the 'silent killer' because:
A. These symptoms are always present in hypertensive clients
B. The disease is often asymptomatic until target organ damage occurs [CORRECT]
C. Headaches and epistaxis are the most common presenting symptoms
D. Clients typically present with severe symptoms in the early stages
Correct Answer: B
Rationale: Hypertension is often asymptomatic for years, earning it the name 'silent killer.' Many clients are unaware of their condition
until they develop complications such as stroke, myocardial infarction, heart failure, or renal failure. While occipital headaches and
epistaxis can occur, they are not reliable indicators of disease severity. This underscores the importance of routine blood pressure
screening per the nursing process.
3. A nurse is providing discharge teaching to a client newly diagnosed with Stage 2 Hypertension (BP 152/96 mmHg).
Which lifestyle modification should the nurse prioritize as the most effective nonpharmacological intervention?
A. Reduce sodium intake to less than 2,300 mg per day
B. Engage in moderate aerobic exercise for at least 150 minutes per week
C. Follow the DASH diet emphasizing fruits, vegetables, and low-fat dairy [CORRECT]
D. Achieve and maintain a healthy body weight with BMI target of 18.5-24.9
Correct Answer: C
Rationale: The DASH (Dietary Approaches to Stop Hypertension) diet has the strongest evidence base for reducing blood pressure in
clients with hypertension. It emphasizes fruits, vegetables, whole grains, low-fat dairy, lean proteins, and reduced saturated fat. While
sodium restriction, exercise, and weight management are all important components, the DASH diet as a comprehensive dietary pattern
demonstrates the most significant and consistent BP reduction outcomes in clinical trials.
4. A client with hypertension is prescribed lisinopril (an ACE inhibitor). Which nursing intervention is most critical
for this medication?
A. Monitor for hyperkalemia and instruct the client to avoid potassium supplements [CORRECT]
B. Assess for reflex tachycardia and increased heart rate
C. Monitor for bradycardia and decreased cardiac output
D. Assess for hypoglycemia and changes in blood glucose levels
2
, NUR201 Medical-Surgical Nursing I | Exam 2 | Fortis College | 2026/2027
Correct Answer: A
Rationale: ACE inhibitors like lisinopril block the conversion of angiotensin I to angiotensin II, which decreases aldosterone secretion.
Reduced aldosterone leads to potassium retention, placing the client at risk for hyperkalemia. The nurse must monitor serum
potassium levels and instruct the client to avoid potassium salt substitutes and potassium supplements. This is a critical safety
consideration per nursing process and medication management competencies.
5. A client presents to the emergency department with a blood pressure of 186/118 mmHg, severe headache, blurred
vision, and confusion. The nurse should recognize this as which condition?
A. Stage 2 Hypertension requiring routine follow-up
B. Hypertensive urgency requiring BP reduction within 24 hours
C. Hypertensive emergency requiring immediate IV antihypertensive therapy [CORRECT]
D. Malignant hypertension with no target organ damage
Correct Answer: C
Rationale: A blood pressure reading of 186/118 mmHg exceeds 180/120 mmHg, meeting criteria for a hypertensive crisis. The
presence of neurologic symptoms (confusion, blurred vision) and severe headache indicates target organ damage, classifying this as a
hypertensive EMERGENCY rather than urgency. Hypertensive emergency requires immediate IV antihypertensive therapy in an
intensive care setting with continuous monitoring, not outpatient management.
6. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation is most consistent with this
condition?
A. Jugular venous distension (JVD)
B. Peripheral edema in the lower extremities
C. Bibasilar crackles and shortness of breath on exertion [CORRECT]
D. Hepatomegaly and ascites
Correct Answer: C
Rationale: Left-sided heart failure results in pulmonary congestion due to the left ventricle's inability to effectively pump blood
forward. This causes fluid backup into the lungs, leading to bibasilar crackles, dyspnea on exertion, orthopnea, paroxysmal nocturnal
dyspnea (PND), and potentially pink frothy sputum. JVD, peripheral edema, hepatomegaly, and ascites are manifestations of
RIGHT-sided heart failure, which results from systemic venous congestion.
7. A client with heart failure reports gaining 4 pounds over the past two days and has new-onset ankle edema. Which
nursing intervention should the nurse implement FIRST?
A. Assess for additional signs of fluid overload and notify the healthcare provider [CORRECT]
B. Restrict fluid intake to 1,500 mL per day
C. Administer the prescribed diuretic and recheck weight in 24 hours
D. Elevate the lower extremities and apply compression stockings
Correct Answer: A
Rationale: A weight gain of 4 pounds in 2 days (2 pounds per day) exceeds the expected limit of 2-3 pounds per 24 hours and indicates
significant fluid retention. The priority nursing action is a comprehensive assessment for additional fluid overload signs (crackles,
JVD, increased abdominal girth) and prompt notification of the healthcare provider. Fluid restriction and diuretic administration may
be warranted but require provider orders. Assessment and communication precede intervention per the nursing process.
8. A nurse is reviewing the laboratory results of a client with heart failure. The BNP (B-type natriuretic peptide) level
is 1,200 pg/mL. The nurse interprets this result as:
A. Normal finding, no heart failure present
B. Mild elevation suggesting early-stage heart failure
3
Medical-Surgical Nursing I
Exam 2
Questions and Verified Answers
100% Correct | Grade A
Latest Update
Fortis College
100 Questions | Passing Score: 70%
30% Recall | 50% Application | 20% Analysis
1
, NUR201 Medical-Surgical Nursing I | Exam 2 | Fortis College | 2026/2027
Section 1: Cardiovascular System Disorders
Q1-Q20 | Hypertension, Heart Failure, CAD, MI, Valvular Disease
1. A nurse is assessing a client with hypertension. The client's blood pressure reading is 148/92 mmHg. According to
the 2026 ACC/AHA guidelines, how should this reading be classified?
A. Normal
B. Elevated
C. Stage 1 Hypertension [CORRECT]
D. Stage 2 Hypertension
Correct Answer: C
Rationale: Blood pressure of 148/92 mmHg meets criteria for Stage 1 Hypertension, defined as systolic 130-139 mmHg and/or
diastolic 80-89 mmHg. Elevated blood pressure is 120-129/<80 mmHg, while Stage 2 is 140/90 mmHg or higher. Accurate
classification guides treatment decisions including lifestyle modifications and pharmacological therapy per evidence-based guidelines.
2. A client with hypertension reports occasional headaches in the occipital area and episodes of epistaxis. The nurse
recognizes that hypertension is often referred to as the 'silent killer' because:
A. These symptoms are always present in hypertensive clients
B. The disease is often asymptomatic until target organ damage occurs [CORRECT]
C. Headaches and epistaxis are the most common presenting symptoms
D. Clients typically present with severe symptoms in the early stages
Correct Answer: B
Rationale: Hypertension is often asymptomatic for years, earning it the name 'silent killer.' Many clients are unaware of their condition
until they develop complications such as stroke, myocardial infarction, heart failure, or renal failure. While occipital headaches and
epistaxis can occur, they are not reliable indicators of disease severity. This underscores the importance of routine blood pressure
screening per the nursing process.
3. A nurse is providing discharge teaching to a client newly diagnosed with Stage 2 Hypertension (BP 152/96 mmHg).
Which lifestyle modification should the nurse prioritize as the most effective nonpharmacological intervention?
A. Reduce sodium intake to less than 2,300 mg per day
B. Engage in moderate aerobic exercise for at least 150 minutes per week
C. Follow the DASH diet emphasizing fruits, vegetables, and low-fat dairy [CORRECT]
D. Achieve and maintain a healthy body weight with BMI target of 18.5-24.9
Correct Answer: C
Rationale: The DASH (Dietary Approaches to Stop Hypertension) diet has the strongest evidence base for reducing blood pressure in
clients with hypertension. It emphasizes fruits, vegetables, whole grains, low-fat dairy, lean proteins, and reduced saturated fat. While
sodium restriction, exercise, and weight management are all important components, the DASH diet as a comprehensive dietary pattern
demonstrates the most significant and consistent BP reduction outcomes in clinical trials.
4. A client with hypertension is prescribed lisinopril (an ACE inhibitor). Which nursing intervention is most critical
for this medication?
A. Monitor for hyperkalemia and instruct the client to avoid potassium supplements [CORRECT]
B. Assess for reflex tachycardia and increased heart rate
C. Monitor for bradycardia and decreased cardiac output
D. Assess for hypoglycemia and changes in blood glucose levels
2
, NUR201 Medical-Surgical Nursing I | Exam 2 | Fortis College | 2026/2027
Correct Answer: A
Rationale: ACE inhibitors like lisinopril block the conversion of angiotensin I to angiotensin II, which decreases aldosterone secretion.
Reduced aldosterone leads to potassium retention, placing the client at risk for hyperkalemia. The nurse must monitor serum
potassium levels and instruct the client to avoid potassium salt substitutes and potassium supplements. This is a critical safety
consideration per nursing process and medication management competencies.
5. A client presents to the emergency department with a blood pressure of 186/118 mmHg, severe headache, blurred
vision, and confusion. The nurse should recognize this as which condition?
A. Stage 2 Hypertension requiring routine follow-up
B. Hypertensive urgency requiring BP reduction within 24 hours
C. Hypertensive emergency requiring immediate IV antihypertensive therapy [CORRECT]
D. Malignant hypertension with no target organ damage
Correct Answer: C
Rationale: A blood pressure reading of 186/118 mmHg exceeds 180/120 mmHg, meeting criteria for a hypertensive crisis. The
presence of neurologic symptoms (confusion, blurred vision) and severe headache indicates target organ damage, classifying this as a
hypertensive EMERGENCY rather than urgency. Hypertensive emergency requires immediate IV antihypertensive therapy in an
intensive care setting with continuous monitoring, not outpatient management.
6. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation is most consistent with this
condition?
A. Jugular venous distension (JVD)
B. Peripheral edema in the lower extremities
C. Bibasilar crackles and shortness of breath on exertion [CORRECT]
D. Hepatomegaly and ascites
Correct Answer: C
Rationale: Left-sided heart failure results in pulmonary congestion due to the left ventricle's inability to effectively pump blood
forward. This causes fluid backup into the lungs, leading to bibasilar crackles, dyspnea on exertion, orthopnea, paroxysmal nocturnal
dyspnea (PND), and potentially pink frothy sputum. JVD, peripheral edema, hepatomegaly, and ascites are manifestations of
RIGHT-sided heart failure, which results from systemic venous congestion.
7. A client with heart failure reports gaining 4 pounds over the past two days and has new-onset ankle edema. Which
nursing intervention should the nurse implement FIRST?
A. Assess for additional signs of fluid overload and notify the healthcare provider [CORRECT]
B. Restrict fluid intake to 1,500 mL per day
C. Administer the prescribed diuretic and recheck weight in 24 hours
D. Elevate the lower extremities and apply compression stockings
Correct Answer: A
Rationale: A weight gain of 4 pounds in 2 days (2 pounds per day) exceeds the expected limit of 2-3 pounds per 24 hours and indicates
significant fluid retention. The priority nursing action is a comprehensive assessment for additional fluid overload signs (crackles,
JVD, increased abdominal girth) and prompt notification of the healthcare provider. Fluid restriction and diuretic administration may
be warranted but require provider orders. Assessment and communication precede intervention per the nursing process.
8. A nurse is reviewing the laboratory results of a client with heart failure. The BNP (B-type natriuretic peptide) level
is 1,200 pg/mL. The nurse interprets this result as:
A. Normal finding, no heart failure present
B. Mild elevation suggesting early-stage heart failure
3
