NUR 170 MED SURG EXAM 2 - VERSION 1 | TOP RATED QUESTIONS AND
ANSWERS | 100% ACCURATE | NEWEST EDITION FOR EXAM SUCCESS
1. A client with heart failure has a new order for furosemide. Which
assessment finding requires the nurse to notify the provider before
administering the dose?
A. Urine output of 45 mL/hr
B. Weight loss of 1 lb since yesterday
C. Blood pressure of 128/78 mmHg
D. Serum potassium of 2.9 mEq/L
D. Serum potassium of 2.9 mEq/L — Furosemide is a loop diuretic
that causes potassium loss; a level below 3.5 mEq/L increases risk
for dysrhythmias and should be corrected before the next dose.
2. Which finding is most indicative of left-sided heart failure?
A. Jugular vein distention
B. Peripheral pitting edema
C. Crackles in the lung bases
D. Hepatomegaly
C. Crackles in the lung bases — Left-sided failure causes blood to
back up into the pulmonary circulation, producing crackles and
dyspnea; the other findings reflect right-sided (systemic) failure.
3. A client is prescribed digoxin for heart failure. Which finding should
prompt the nurse to hold the dose and notify the provider?
A. Apical pulse of 52 beats/min
Page 1 of 36
, B. Blood pressure of 122/76 mmHg
C. Respiratory rate of 18/min
D. Serum potassium of 4.2 mEq/L
A. Apical pulse of 52 beats/min — Digoxin slows AV conduction; a
heart rate below 60 beats/min in an adult indicates possible toxicity
or excessive effect and warrants holding the dose.
4. A client reports crushing substernal chest pain radiating to the left
arm. What is the nurse's priority action?
A. Start a peripheral IV
B. Obtain a 12-lead ECG
C. Administer sublingual nitroglycerin
D. Notify the healthcare provider
B. Obtain a 12-lead ECG — A 12-lead ECG should be obtained within
10 minutes of chest pain onset to identify ST-segment changes and
guide emergent treatment decisions.
5. Which teaching point is appropriate for a client newly prescribed a
beta-blocker for hypertension?
A. Discontinue if mild fatigue occurs
B. Do not stop the medication abruptly
C. Expect an increase in heart rate initially
D. Take the medication on an empty stomach only
B. Do not stop the medication abruptly — Abrupt discontinuation of
beta-blockers can cause rebound hypertension and tachycardia; the
medication should be tapered under provider guidance.
6. A client with atrial fibrillation is started on warfarin. Which
laboratory value does the nurse monitor to evaluate therapeutic effect?
A. Hematocrit
B. INR
C. aPTT
D. Platelet count
B. INR — Warfarin therapy is monitored using the International
Normalized Ratio (INR), with a therapeutic range typically 2.0-3.0 for
atrial fibrillation.
Page 2 of 36
,7. Which client statement indicates a need for further teaching about a
low-sodium diet for hypertension management?
A. I will read food labels for sodium content
B. I can eat canned soup as long as I add extra pepper
C. I can season food with fresh herbs instead of salt
D. I should avoid processed lunch meats
B. I can eat canned soup as long as I add extra pepper — Canned
soups are typically very high in sodium regardless of added
seasonings; the client needs further teaching about hidden sodium
sources.
8. A client post-myocardial infarction develops new-onset crackles,
jugular vein distention, and dyspnea. The nurse suspects which
complication?
A. Pulmonary embolism
B. Cardiac tamponade
C. Heart failure
D. Pericarditis
C. Heart failure — These findings together reflect fluid overload and
impaired pumping ability consistent with heart failure following MI-
related myocardial damage.
9. Which position is best for a client experiencing acute pulmonary
edema?
A. High Fowler's with legs dependent
B. Trendelenburg
C. Left lateral recumbent
D. Supine with legs elevated
A. High Fowler's with legs dependent — High Fowler's position with
legs dependent reduces venous return to the heart and improves
lung expansion, easing the work of breathing.
10. A client with peripheral arterial disease reports leg pain that
resolves with rest. The nurse recognizes this as which symptom?
A. Intermittent claudication
B. Raynaud's phenomenon
C. Compartment syndrome
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, D. Venous stasis
A. Intermittent claudication — Intermittent claudication is exercise-
induced ischemic muscle pain relieved by rest, a hallmark symptom
of peripheral arterial disease.
11. Which finding in a client with peripheral arterial disease requires
immediate provider notification?
A. Diminished pedal pulses bilaterally
B. A cool, pulseless, mottled foot
C. Hair loss on the lower legs
D. Thin, shiny skin on the calves
B. A cool, pulseless, mottled foot — A cool, pulseless, mottled
extremity suggests acute arterial occlusion, a limb-threatening
emergency requiring immediate intervention.
12. A client with deep vein thrombosis is started on heparin. Which lab
value does the nurse monitor for therapeutic effect?
A. Platelet count only
B. Fibrinogen
C. INR
D. aPTT
D. aPTT — Unfractionated heparin therapy is monitored using
activated partial thromboplastin time (aPTT), typically maintained
at 1.5-2.5 times control.
13. Which instruction should the nurse give a client recovering from a
deep vein thrombosis?
A. Apply a heating pad to the leg
B. Wear tight, restrictive clothing
C. Avoid prolonged sitting or standing
D. Massage the affected leg daily
C. Avoid prolonged sitting or standing — Prolonged immobility
promotes venous stasis and clot formation; frequent position
changes and ambulation reduce recurrence risk.
14. A client is diagnosed with hypertensive crisis. Which medication
class is used for rapid blood pressure reduction?
A. Loop diuretics
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ANSWERS | 100% ACCURATE | NEWEST EDITION FOR EXAM SUCCESS
1. A client with heart failure has a new order for furosemide. Which
assessment finding requires the nurse to notify the provider before
administering the dose?
A. Urine output of 45 mL/hr
B. Weight loss of 1 lb since yesterday
C. Blood pressure of 128/78 mmHg
D. Serum potassium of 2.9 mEq/L
D. Serum potassium of 2.9 mEq/L — Furosemide is a loop diuretic
that causes potassium loss; a level below 3.5 mEq/L increases risk
for dysrhythmias and should be corrected before the next dose.
2. Which finding is most indicative of left-sided heart failure?
A. Jugular vein distention
B. Peripheral pitting edema
C. Crackles in the lung bases
D. Hepatomegaly
C. Crackles in the lung bases — Left-sided failure causes blood to
back up into the pulmonary circulation, producing crackles and
dyspnea; the other findings reflect right-sided (systemic) failure.
3. A client is prescribed digoxin for heart failure. Which finding should
prompt the nurse to hold the dose and notify the provider?
A. Apical pulse of 52 beats/min
Page 1 of 36
, B. Blood pressure of 122/76 mmHg
C. Respiratory rate of 18/min
D. Serum potassium of 4.2 mEq/L
A. Apical pulse of 52 beats/min — Digoxin slows AV conduction; a
heart rate below 60 beats/min in an adult indicates possible toxicity
or excessive effect and warrants holding the dose.
4. A client reports crushing substernal chest pain radiating to the left
arm. What is the nurse's priority action?
A. Start a peripheral IV
B. Obtain a 12-lead ECG
C. Administer sublingual nitroglycerin
D. Notify the healthcare provider
B. Obtain a 12-lead ECG — A 12-lead ECG should be obtained within
10 minutes of chest pain onset to identify ST-segment changes and
guide emergent treatment decisions.
5. Which teaching point is appropriate for a client newly prescribed a
beta-blocker for hypertension?
A. Discontinue if mild fatigue occurs
B. Do not stop the medication abruptly
C. Expect an increase in heart rate initially
D. Take the medication on an empty stomach only
B. Do not stop the medication abruptly — Abrupt discontinuation of
beta-blockers can cause rebound hypertension and tachycardia; the
medication should be tapered under provider guidance.
6. A client with atrial fibrillation is started on warfarin. Which
laboratory value does the nurse monitor to evaluate therapeutic effect?
A. Hematocrit
B. INR
C. aPTT
D. Platelet count
B. INR — Warfarin therapy is monitored using the International
Normalized Ratio (INR), with a therapeutic range typically 2.0-3.0 for
atrial fibrillation.
Page 2 of 36
,7. Which client statement indicates a need for further teaching about a
low-sodium diet for hypertension management?
A. I will read food labels for sodium content
B. I can eat canned soup as long as I add extra pepper
C. I can season food with fresh herbs instead of salt
D. I should avoid processed lunch meats
B. I can eat canned soup as long as I add extra pepper — Canned
soups are typically very high in sodium regardless of added
seasonings; the client needs further teaching about hidden sodium
sources.
8. A client post-myocardial infarction develops new-onset crackles,
jugular vein distention, and dyspnea. The nurse suspects which
complication?
A. Pulmonary embolism
B. Cardiac tamponade
C. Heart failure
D. Pericarditis
C. Heart failure — These findings together reflect fluid overload and
impaired pumping ability consistent with heart failure following MI-
related myocardial damage.
9. Which position is best for a client experiencing acute pulmonary
edema?
A. High Fowler's with legs dependent
B. Trendelenburg
C. Left lateral recumbent
D. Supine with legs elevated
A. High Fowler's with legs dependent — High Fowler's position with
legs dependent reduces venous return to the heart and improves
lung expansion, easing the work of breathing.
10. A client with peripheral arterial disease reports leg pain that
resolves with rest. The nurse recognizes this as which symptom?
A. Intermittent claudication
B. Raynaud's phenomenon
C. Compartment syndrome
Page 3 of 36
, D. Venous stasis
A. Intermittent claudication — Intermittent claudication is exercise-
induced ischemic muscle pain relieved by rest, a hallmark symptom
of peripheral arterial disease.
11. Which finding in a client with peripheral arterial disease requires
immediate provider notification?
A. Diminished pedal pulses bilaterally
B. A cool, pulseless, mottled foot
C. Hair loss on the lower legs
D. Thin, shiny skin on the calves
B. A cool, pulseless, mottled foot — A cool, pulseless, mottled
extremity suggests acute arterial occlusion, a limb-threatening
emergency requiring immediate intervention.
12. A client with deep vein thrombosis is started on heparin. Which lab
value does the nurse monitor for therapeutic effect?
A. Platelet count only
B. Fibrinogen
C. INR
D. aPTT
D. aPTT — Unfractionated heparin therapy is monitored using
activated partial thromboplastin time (aPTT), typically maintained
at 1.5-2.5 times control.
13. Which instruction should the nurse give a client recovering from a
deep vein thrombosis?
A. Apply a heating pad to the leg
B. Wear tight, restrictive clothing
C. Avoid prolonged sitting or standing
D. Massage the affected leg daily
C. Avoid prolonged sitting or standing — Prolonged immobility
promotes venous stasis and clot formation; frequent position
changes and ambulation reduce recurrence risk.
14. A client is diagnosed with hypertensive crisis. Which medication
class is used for rapid blood pressure reduction?
A. Loop diuretics
Page 4 of 36
