NUR 170 MED SURG EXAM 2 – VERSION 2 VERIFIED EXAM QUESTIONS AND
ANSWERS – LATEST VERSION 2026/2027
1. A client with heart failure gains 3 lbs overnight. What does this
finding most likely indicate?
A. Dietary protein increase
B. Increased muscle mass
C. Normal daily fluctuation
D. Fluid retention
D. Fluid retention — A rapid weight gain of 2-3 lbs in 24 hours in a
heart failure client typically reflects fluid retention and worsening
heart failure, requiring provider notification.
2. Which finding is most indicative of right-sided heart failure?
A. Frothy pink sputum
B. Orthopnea
C. Pulmonary crackles
D. Peripheral edema and hepatomegaly
D. Peripheral edema and hepatomegaly — Right-sided heart failure
causes systemic venous congestion, producing peripheral edema,
jugular vein distention, and hepatomegaly, distinct from the
pulmonary findings of left-sided failure.
3. A client taking digoxin reports nausea, visual halos, and anorexia.
What should the nurse suspect?
A. Allergic reaction
B. Hypoglycemia
C. Digoxin toxicity
D. Normal medication effect
C. Digoxin toxicity — Nausea, visual disturbances such as halos, and
anorexia are classic early signs of digoxin toxicity and warrant
holding the dose and checking a drug level.
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,4. A client presents with diaphoresis, nausea, and jaw pain but denies
chest pain. What is the nurse's priority action?
A. Obtain a 12-lead ECG
B. Offer an antiemetic and reassess later
C. Reassure the client that this is unlikely cardiac
D. Delay assessment until pain develops
A. Obtain a 12-lead ECG — Atypical presentations such as jaw pain,
nausea, and diaphoresis without chest pain can still indicate acute
coronary syndrome, especially in women and older adults; an ECG
should be obtained promptly.
5. A client newly prescribed an ACE inhibitor develops a persistent dry
cough. What should the nurse do?
A. Increase the dose to overcome the cough
B. Instruct the client to stop the medication immediately without
notifying the provider
C. Reassure the client this is unrelated to the medication
D. Notify the provider, as this is a known adverse effect
D. Notify the provider, as this is a known adverse effect — A
persistent dry cough is a known adverse effect of ACE inhibitors
caused by bradykinin accumulation; the provider should be notified
as an alternative agent may be needed.
6. A client on warfarin therapy reports a prothrombin time significantly
above the therapeutic range and gum bleeding. What is the priority
nursing action?
A. Hold the next dose and notify the provider
B. Disregard the bleeding as unrelated
C. Administer the next dose as scheduled
D. Increase the dose to correct the coagulation issue
A. Hold the next dose and notify the provider — An elevated PT/INR
with active bleeding signals excessive anticoagulation, requiring the
dose to be held and the provider notified for possible reversal agent
administration.
7. Which client statement indicates a need for further teaching about
managing hypertension through diet?
A. I will add extra salt to make my food taste better
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, B. I will increase my intake of fruits and vegetables
C. I will read nutrition labels for sodium content
D. I will limit processed and canned foods
A. I will add extra salt to make my food taste better — Adding extra
salt directly increases sodium intake, contradicting the goal of a low-
sodium diet for hypertension management, and indicates a need for
further teaching.
8. A client post-myocardial infarction reports new shortness of breath,
cough with pink frothy sputum, and crackles. The nurse recognizes this
as a sign of which complication?
A. Cardiac tamponade
B. Acute pulmonary edema
C. Deep vein thrombosis
D. Pericarditis
B. Acute pulmonary edema — Pink frothy sputum, crackles, and
dyspnea are classic findings of acute pulmonary edema resulting
from severe left ventricular failure after MI.
9. Which nursing intervention is appropriate for a client experiencing
acute pulmonary edema?
A. Position the client flat with legs elevated
B. Administer prescribed oxygen and position the client upright
C. Encourage oral fluid intake
D. Delay oxygen therapy until the provider arrives
B. Administer prescribed oxygen and position the client upright —
Upright positioning reduces venous return and eases breathing,
while supplemental oxygen addresses the hypoxemia associated
with pulmonary edema.
10. A client with peripheral arterial disease has thin, shiny skin and
diminished hair growth on the lower legs. What does this reflect?
A. Chronic decreased arterial blood flow
B. Chronic venous insufficiency
C. Normal age-related skin changes
D. Acute arterial occlusion
A. Chronic decreased arterial blood flow — Thin, shiny skin with
hair loss on the lower extremities reflects chronic tissue ischemia
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, from reduced arterial perfusion characteristic of peripheral arterial
disease.
11. Which finding in a client with peripheral arterial disease represents
an emergency requiring immediate provider notification?
A. Chronic intermittent claudication unchanged from baseline
B. Mild hair loss on the lower legs
C. Sudden onset of a cold, pale, pulseless extremity
D. Diminished but palpable pedal pulses
C. Sudden onset of a cold, pale, pulseless extremity — A sudden cold,
pale, pulseless extremity indicates acute arterial occlusion, a limb-
threatening emergency requiring immediate intervention to restore
blood flow.
12. A client is started on heparin for a deep vein thrombosis. Which
medication should be readily available in case of overdose?
A. Protamine sulfate
B. Vitamin K
C. Naloxone
D. Flumazenil
A. Protamine sulfate — Protamine sulfate is the specific reversal
agent for heparin, used to treat significant bleeding or overdose
related to heparin therapy.
13. Which client teaching is important to prevent recurrence of deep
vein thrombosis?
A. Wear tight, constrictive stockings
B. Perform ankle pumps and leg exercises during prolonged sitting
C. Cross the legs while sitting for extended periods
D. Remain immobile as much as possible
B. Perform ankle pumps and leg exercises during prolonged sitting
— Ankle pumps and leg exercises promote venous return and
reduce stasis during prolonged sitting, decreasing the risk of clot
recurrence.
14. A client presents with a severely elevated blood pressure of
220/130 mmHg and reports a headache and blurred vision. What is the
priority nursing action?
Page 4 of 38
ANSWERS – LATEST VERSION 2026/2027
1. A client with heart failure gains 3 lbs overnight. What does this
finding most likely indicate?
A. Dietary protein increase
B. Increased muscle mass
C. Normal daily fluctuation
D. Fluid retention
D. Fluid retention — A rapid weight gain of 2-3 lbs in 24 hours in a
heart failure client typically reflects fluid retention and worsening
heart failure, requiring provider notification.
2. Which finding is most indicative of right-sided heart failure?
A. Frothy pink sputum
B. Orthopnea
C. Pulmonary crackles
D. Peripheral edema and hepatomegaly
D. Peripheral edema and hepatomegaly — Right-sided heart failure
causes systemic venous congestion, producing peripheral edema,
jugular vein distention, and hepatomegaly, distinct from the
pulmonary findings of left-sided failure.
3. A client taking digoxin reports nausea, visual halos, and anorexia.
What should the nurse suspect?
A. Allergic reaction
B. Hypoglycemia
C. Digoxin toxicity
D. Normal medication effect
C. Digoxin toxicity — Nausea, visual disturbances such as halos, and
anorexia are classic early signs of digoxin toxicity and warrant
holding the dose and checking a drug level.
Page 1 of 38
,4. A client presents with diaphoresis, nausea, and jaw pain but denies
chest pain. What is the nurse's priority action?
A. Obtain a 12-lead ECG
B. Offer an antiemetic and reassess later
C. Reassure the client that this is unlikely cardiac
D. Delay assessment until pain develops
A. Obtain a 12-lead ECG — Atypical presentations such as jaw pain,
nausea, and diaphoresis without chest pain can still indicate acute
coronary syndrome, especially in women and older adults; an ECG
should be obtained promptly.
5. A client newly prescribed an ACE inhibitor develops a persistent dry
cough. What should the nurse do?
A. Increase the dose to overcome the cough
B. Instruct the client to stop the medication immediately without
notifying the provider
C. Reassure the client this is unrelated to the medication
D. Notify the provider, as this is a known adverse effect
D. Notify the provider, as this is a known adverse effect — A
persistent dry cough is a known adverse effect of ACE inhibitors
caused by bradykinin accumulation; the provider should be notified
as an alternative agent may be needed.
6. A client on warfarin therapy reports a prothrombin time significantly
above the therapeutic range and gum bleeding. What is the priority
nursing action?
A. Hold the next dose and notify the provider
B. Disregard the bleeding as unrelated
C. Administer the next dose as scheduled
D. Increase the dose to correct the coagulation issue
A. Hold the next dose and notify the provider — An elevated PT/INR
with active bleeding signals excessive anticoagulation, requiring the
dose to be held and the provider notified for possible reversal agent
administration.
7. Which client statement indicates a need for further teaching about
managing hypertension through diet?
A. I will add extra salt to make my food taste better
Page 2 of 38
, B. I will increase my intake of fruits and vegetables
C. I will read nutrition labels for sodium content
D. I will limit processed and canned foods
A. I will add extra salt to make my food taste better — Adding extra
salt directly increases sodium intake, contradicting the goal of a low-
sodium diet for hypertension management, and indicates a need for
further teaching.
8. A client post-myocardial infarction reports new shortness of breath,
cough with pink frothy sputum, and crackles. The nurse recognizes this
as a sign of which complication?
A. Cardiac tamponade
B. Acute pulmonary edema
C. Deep vein thrombosis
D. Pericarditis
B. Acute pulmonary edema — Pink frothy sputum, crackles, and
dyspnea are classic findings of acute pulmonary edema resulting
from severe left ventricular failure after MI.
9. Which nursing intervention is appropriate for a client experiencing
acute pulmonary edema?
A. Position the client flat with legs elevated
B. Administer prescribed oxygen and position the client upright
C. Encourage oral fluid intake
D. Delay oxygen therapy until the provider arrives
B. Administer prescribed oxygen and position the client upright —
Upright positioning reduces venous return and eases breathing,
while supplemental oxygen addresses the hypoxemia associated
with pulmonary edema.
10. A client with peripheral arterial disease has thin, shiny skin and
diminished hair growth on the lower legs. What does this reflect?
A. Chronic decreased arterial blood flow
B. Chronic venous insufficiency
C. Normal age-related skin changes
D. Acute arterial occlusion
A. Chronic decreased arterial blood flow — Thin, shiny skin with
hair loss on the lower extremities reflects chronic tissue ischemia
Page 3 of 38
, from reduced arterial perfusion characteristic of peripheral arterial
disease.
11. Which finding in a client with peripheral arterial disease represents
an emergency requiring immediate provider notification?
A. Chronic intermittent claudication unchanged from baseline
B. Mild hair loss on the lower legs
C. Sudden onset of a cold, pale, pulseless extremity
D. Diminished but palpable pedal pulses
C. Sudden onset of a cold, pale, pulseless extremity — A sudden cold,
pale, pulseless extremity indicates acute arterial occlusion, a limb-
threatening emergency requiring immediate intervention to restore
blood flow.
12. A client is started on heparin for a deep vein thrombosis. Which
medication should be readily available in case of overdose?
A. Protamine sulfate
B. Vitamin K
C. Naloxone
D. Flumazenil
A. Protamine sulfate — Protamine sulfate is the specific reversal
agent for heparin, used to treat significant bleeding or overdose
related to heparin therapy.
13. Which client teaching is important to prevent recurrence of deep
vein thrombosis?
A. Wear tight, constrictive stockings
B. Perform ankle pumps and leg exercises during prolonged sitting
C. Cross the legs while sitting for extended periods
D. Remain immobile as much as possible
B. Perform ankle pumps and leg exercises during prolonged sitting
— Ankle pumps and leg exercises promote venous return and
reduce stasis during prolonged sitting, decreasing the risk of clot
recurrence.
14. A client presents with a severely elevated blood pressure of
220/130 mmHg and reports a headache and blurred vision. What is the
priority nursing action?
Page 4 of 38
