GALEN NUR 242 EXAM 2 () | MED-
SURG NURSING | (A+ GUARANTEE) | PDF
Question 1
A nurse is assessing a client with left-sided heart failure. Which assessment finding requires
immediate intervention?
A. Bilateral ankle edema
B. Crackles in both lung bases
C. Jugular vein distention
D. Hepatomegaly
Answer: B. Crackles in both lung bases
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
producing pulmonary congestion and crackles. This finding indicates impaired gas exchange and
may progress to pulmonary edema if untreated. Peripheral edema, jugular vein distention, and
hepatomegaly are more commonly associated with right-sided heart failure.
Question 2
A client receiving IV insulin for diabetic ketoacidosis (DKA) is at greatest risk for developing
which electrolyte imbalance?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C. Hypokalemia
Rationale: Insulin drives potassium from the bloodstream into the cells. Although serum
potassium may initially be elevated in DKA, insulin therapy can rapidly decrease potassium
levels, placing the client at risk for life-threatening cardiac dysrhythmias. Potassium must be
monitored closely during treatment.
,Question 3
Which assessment finding is most concerning in a patient receiving a heparin infusion?
A. Platelet count of 240,000/mm³
B. aPTT of 70 seconds within the therapeutic range
C. Bleeding gums when brushing teeth
D. Blood pressure of 128/76 mm Hg
Answer: C. Bleeding gums when brushing teeth
Rationale: Bleeding is the most significant adverse effect of heparin therapy. Bleeding gums
may indicate excessive anticoagulation and require prompt assessment. Therapeutic aPTT values
and a normal platelet count are expected findings, while normal blood pressure is not concerning.
Question 4
A nurse is caring for a patient experiencing acute chest pain. Which action should be performed
first?
A. Administer prescribed morphine
B. Obtain a 12-lead ECG
C. Encourage the patient to rest
D. Notify dietary services
Answer: B. Obtain a 12-lead ECG
Rationale: Early electrocardiography is essential in evaluating suspected acute coronary
syndrome and should be performed within 10 minutes of arrival when possible. Identifying ST-
segment changes guides timely treatment and improves outcomes.
Question 5
A patient with COPD has an oxygen saturation of 89% while receiving 2 L/min of oxygen via
nasal cannula. What is the most appropriate nursing action?
A. Increase oxygen to 10 L/min by nonrebreather mask
B. Discontinue oxygen therapy
C. Continue monitoring because the saturation is within the target range
, D. Encourage hyperventilation
Answer: C. Continue monitoring because the saturation is within the target range
Rationale: For many patients with COPD and chronic CO₂ retention, the target oxygen
saturation is typically 88–92%. Increasing oxygen excessively may worsen hypercapnia in
susceptible patients.
Question 6
A nurse is caring for a client with hyperkalemia. Which assessment finding requires immediate
intervention?
A. Muscle cramps
B. Peaked T waves on the ECG
C. Mild nausea
D. Constipation
Answer: B. Peaked T waves on the ECG
Rationale: Hyperkalemia can cause dangerous cardiac conduction abnormalities. Peaked T
waves are an early ECG sign of hyperkalemia and may progress to widened QRS complexes,
ventricular dysrhythmias, or cardiac arrest. Cardiac monitoring and rapid treatment are priorities.
Question 7
A client with chronic kidney disease has a serum creatinine of 4.2 mg/dL. Which prescribed
medication should the nurse question?
A. Calcium carbonate
B. Erythropoietin
C. Ibuprofen
D. Vitamin D
Answer: C. Ibuprofen
Rationale: NSAIDs reduce renal blood flow and can worsen kidney function. Patients with
chronic kidney disease should generally avoid nephrotoxic medications unless specifically
directed by the provider.
Question 8
SURG NURSING | (A+ GUARANTEE) | PDF
Question 1
A nurse is assessing a client with left-sided heart failure. Which assessment finding requires
immediate intervention?
A. Bilateral ankle edema
B. Crackles in both lung bases
C. Jugular vein distention
D. Hepatomegaly
Answer: B. Crackles in both lung bases
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
producing pulmonary congestion and crackles. This finding indicates impaired gas exchange and
may progress to pulmonary edema if untreated. Peripheral edema, jugular vein distention, and
hepatomegaly are more commonly associated with right-sided heart failure.
Question 2
A client receiving IV insulin for diabetic ketoacidosis (DKA) is at greatest risk for developing
which electrolyte imbalance?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C. Hypokalemia
Rationale: Insulin drives potassium from the bloodstream into the cells. Although serum
potassium may initially be elevated in DKA, insulin therapy can rapidly decrease potassium
levels, placing the client at risk for life-threatening cardiac dysrhythmias. Potassium must be
monitored closely during treatment.
,Question 3
Which assessment finding is most concerning in a patient receiving a heparin infusion?
A. Platelet count of 240,000/mm³
B. aPTT of 70 seconds within the therapeutic range
C. Bleeding gums when brushing teeth
D. Blood pressure of 128/76 mm Hg
Answer: C. Bleeding gums when brushing teeth
Rationale: Bleeding is the most significant adverse effect of heparin therapy. Bleeding gums
may indicate excessive anticoagulation and require prompt assessment. Therapeutic aPTT values
and a normal platelet count are expected findings, while normal blood pressure is not concerning.
Question 4
A nurse is caring for a patient experiencing acute chest pain. Which action should be performed
first?
A. Administer prescribed morphine
B. Obtain a 12-lead ECG
C. Encourage the patient to rest
D. Notify dietary services
Answer: B. Obtain a 12-lead ECG
Rationale: Early electrocardiography is essential in evaluating suspected acute coronary
syndrome and should be performed within 10 minutes of arrival when possible. Identifying ST-
segment changes guides timely treatment and improves outcomes.
Question 5
A patient with COPD has an oxygen saturation of 89% while receiving 2 L/min of oxygen via
nasal cannula. What is the most appropriate nursing action?
A. Increase oxygen to 10 L/min by nonrebreather mask
B. Discontinue oxygen therapy
C. Continue monitoring because the saturation is within the target range
, D. Encourage hyperventilation
Answer: C. Continue monitoring because the saturation is within the target range
Rationale: For many patients with COPD and chronic CO₂ retention, the target oxygen
saturation is typically 88–92%. Increasing oxygen excessively may worsen hypercapnia in
susceptible patients.
Question 6
A nurse is caring for a client with hyperkalemia. Which assessment finding requires immediate
intervention?
A. Muscle cramps
B. Peaked T waves on the ECG
C. Mild nausea
D. Constipation
Answer: B. Peaked T waves on the ECG
Rationale: Hyperkalemia can cause dangerous cardiac conduction abnormalities. Peaked T
waves are an early ECG sign of hyperkalemia and may progress to widened QRS complexes,
ventricular dysrhythmias, or cardiac arrest. Cardiac monitoring and rapid treatment are priorities.
Question 7
A client with chronic kidney disease has a serum creatinine of 4.2 mg/dL. Which prescribed
medication should the nurse question?
A. Calcium carbonate
B. Erythropoietin
C. Ibuprofen
D. Vitamin D
Answer: C. Ibuprofen
Rationale: NSAIDs reduce renal blood flow and can worsen kidney function. Patients with
chronic kidney disease should generally avoid nephrotoxic medications unless specifically
directed by the provider.
Question 8
