NSG 233 Medical-Surgical Nursing II HESI – Higher
Education Nursing Curriculum
SECTION I: CARDIOVASCULAR DISORDERS
Questions 1–25
Question 1
A client with acute myocardial infarction reports chest pain unrelieved by
nitroglycerin. What is the priority nursing action?
A. Administer morphine sulfate IV
B. Obtain a 12-lead ECG
C. Start IV fluids
D. Provide oxygen via non-rebreather mask
Correct Answer: D
Rationale: Airway and oxygenation are the priority to limit myocardial
damage. Oxygen administration supports tissue perfusion and reduces ischemic
injury. While morphine, ECG, and IV fluids are important interventions,
establishing adequate oxygenation follows the ABC (Airway, Breathing,
Circulation) prioritization framework.
Question 2
A patient with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the medication and notify the
provider?
A. Blood pressure 110/70 mmHg
B. Serum potassium 3.2 mEq/L
C. Respiratory rate 18 breaths/min
D. Urine output 40 mL/hr
Correct Answer: B
, Rationale: Furosemide is a loop diuretic that causes potassium excretion,
increasing the risk for hypokalemia. A serum potassium of 3.2 mEq/L is below the
normal range (3.5–5.0 mEq/L) and requires intervention before administering
additional potassium-wasting diuretics to prevent cardiac dysrhythmias.
Question 3
A patient receiving intravenous vancomycin reports facial and neck flushing
during the infusion. What is the nurse's priority action?
A. Stop the infusion immediately
B. Slow the infusion rate
C. Administer diphenhydramine
D. Increase the infusion rate to complete it faster
Correct Answer: B
Rationale: Flushing of the face, neck, and torso during vancomycin infusion is
characteristic of "red man syndrome," typically caused by rapid infusion. Slowing
the rate usually resolves symptoms without needing to stop the drug. Increasing
the rate would worsen symptoms.
Question 4
A patient with atrial fibrillation is started on warfarin. Which laboratory value will
the nurse monitor to evaluate therapeutic effect?
A. Partial thromboplastin time (PTT)
B. International normalized ratio (INR)
C. Platelet count
D. Bleeding time
Correct Answer: B
Rationale: Warfarin's therapeutic effect is measured using the INR, which
standardizes prothrombin time results across laboratories. PTT monitors heparin
therapy, not warfarin. Platelet count and bleeding time do not reflect warfarin's
mechanism of action on vitamin K–dependent clotting factors.
,Question 5
A client with left-sided heart failure is exhibiting dyspnea, crackles in the lung
bases, and orthopnea. Which additional finding would the nurse expect?
A. Jugular venous distention
B. Peripheral edema
C. Hepatomegaly
D. Paroxysmal nocturnal dyspnea
Correct Answer: D
Rationale: Left-sided heart failure leads to pulmonary congestion, manifesting
as dyspnea, crackles, orthopnea, and paroxysmal nocturnal dyspnea. Jugular
venous distention, peripheral edema, and hepatomegaly are signs of right-sided
heart failure.
Question 6
A patient with a pulmonary embolism is receiving intravenous unfractionated
heparin. The aPTT is 120 seconds (therapeutic range 60–80 seconds). Which
complication is the patient at highest risk for, and what is the priority nursing
action?
A. Thrombosis; administer additional heparin bolus
B. Bleeding; hold the heparin infusion and notify the provider
C. Heparin-induced thrombocytopenia; check platelet count
D. Pulmonary infarction; prepare for thrombolytic therapy
Correct Answer: B
Rationale: An aPTT of 120 seconds is above the therapeutic range, indicating
an increased risk of bleeding. The nurse should hold the heparin infusion and
notify the provider for dose adjustment. Administering more heparin would
worsen bleeding.
, Question 7
A nurse is assessing a patient who has just been diagnosed with hypertension.
Which lifestyle modification should the nurse prioritize in patient teaching?
A. Increase sodium intake to 3,000 mg/day
B. Engage in moderate aerobic exercise 30 minutes most days
C. Limit alcohol consumption to 3 drinks per day
D. Reduce dietary potassium intake
Correct Answer: B
Rationale: Moderate aerobic exercise for 30 minutes most days of the week is
a first-line lifestyle modification for hypertension. Sodium should be reduced (not
increased) to less than 2,300 mg/day. Alcohol should be limited to 1–2 drinks per
day. Potassium intake should be increased, not reduced.
Question 8
A patient with stable angina is prescribed sublingual nitroglycerin. Which
instruction should the nurse include in the teaching?
A. "Take one tablet every 15 minutes for up to three doses"
B. "Take one tablet every 5 minutes for up to three doses"
C. "Call 911 after taking the first tablet"
D. "Chew the tablet for faster absorption"
Correct Answer: B
Rationale: The correct protocol for sublingual nitroglycerin is to take one
tablet every 5 minutes for up to three doses. If pain is unrelieved after the first
tablet, the patient should call 911 while continuing to take tablets. The tablet
should be placed under the tongue, not chewed.
Question 9
A client is admitted with chest pain, diaphoresis, and radiation of pain to the left
jaw and arm. ECG shows ST-segment elevation in leads II, III, and aVF. Which
coronary artery is most likely affected?
Education Nursing Curriculum
SECTION I: CARDIOVASCULAR DISORDERS
Questions 1–25
Question 1
A client with acute myocardial infarction reports chest pain unrelieved by
nitroglycerin. What is the priority nursing action?
A. Administer morphine sulfate IV
B. Obtain a 12-lead ECG
C. Start IV fluids
D. Provide oxygen via non-rebreather mask
Correct Answer: D
Rationale: Airway and oxygenation are the priority to limit myocardial
damage. Oxygen administration supports tissue perfusion and reduces ischemic
injury. While morphine, ECG, and IV fluids are important interventions,
establishing adequate oxygenation follows the ABC (Airway, Breathing,
Circulation) prioritization framework.
Question 2
A patient with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the medication and notify the
provider?
A. Blood pressure 110/70 mmHg
B. Serum potassium 3.2 mEq/L
C. Respiratory rate 18 breaths/min
D. Urine output 40 mL/hr
Correct Answer: B
, Rationale: Furosemide is a loop diuretic that causes potassium excretion,
increasing the risk for hypokalemia. A serum potassium of 3.2 mEq/L is below the
normal range (3.5–5.0 mEq/L) and requires intervention before administering
additional potassium-wasting diuretics to prevent cardiac dysrhythmias.
Question 3
A patient receiving intravenous vancomycin reports facial and neck flushing
during the infusion. What is the nurse's priority action?
A. Stop the infusion immediately
B. Slow the infusion rate
C. Administer diphenhydramine
D. Increase the infusion rate to complete it faster
Correct Answer: B
Rationale: Flushing of the face, neck, and torso during vancomycin infusion is
characteristic of "red man syndrome," typically caused by rapid infusion. Slowing
the rate usually resolves symptoms without needing to stop the drug. Increasing
the rate would worsen symptoms.
Question 4
A patient with atrial fibrillation is started on warfarin. Which laboratory value will
the nurse monitor to evaluate therapeutic effect?
A. Partial thromboplastin time (PTT)
B. International normalized ratio (INR)
C. Platelet count
D. Bleeding time
Correct Answer: B
Rationale: Warfarin's therapeutic effect is measured using the INR, which
standardizes prothrombin time results across laboratories. PTT monitors heparin
therapy, not warfarin. Platelet count and bleeding time do not reflect warfarin's
mechanism of action on vitamin K–dependent clotting factors.
,Question 5
A client with left-sided heart failure is exhibiting dyspnea, crackles in the lung
bases, and orthopnea. Which additional finding would the nurse expect?
A. Jugular venous distention
B. Peripheral edema
C. Hepatomegaly
D. Paroxysmal nocturnal dyspnea
Correct Answer: D
Rationale: Left-sided heart failure leads to pulmonary congestion, manifesting
as dyspnea, crackles, orthopnea, and paroxysmal nocturnal dyspnea. Jugular
venous distention, peripheral edema, and hepatomegaly are signs of right-sided
heart failure.
Question 6
A patient with a pulmonary embolism is receiving intravenous unfractionated
heparin. The aPTT is 120 seconds (therapeutic range 60–80 seconds). Which
complication is the patient at highest risk for, and what is the priority nursing
action?
A. Thrombosis; administer additional heparin bolus
B. Bleeding; hold the heparin infusion and notify the provider
C. Heparin-induced thrombocytopenia; check platelet count
D. Pulmonary infarction; prepare for thrombolytic therapy
Correct Answer: B
Rationale: An aPTT of 120 seconds is above the therapeutic range, indicating
an increased risk of bleeding. The nurse should hold the heparin infusion and
notify the provider for dose adjustment. Administering more heparin would
worsen bleeding.
, Question 7
A nurse is assessing a patient who has just been diagnosed with hypertension.
Which lifestyle modification should the nurse prioritize in patient teaching?
A. Increase sodium intake to 3,000 mg/day
B. Engage in moderate aerobic exercise 30 minutes most days
C. Limit alcohol consumption to 3 drinks per day
D. Reduce dietary potassium intake
Correct Answer: B
Rationale: Moderate aerobic exercise for 30 minutes most days of the week is
a first-line lifestyle modification for hypertension. Sodium should be reduced (not
increased) to less than 2,300 mg/day. Alcohol should be limited to 1–2 drinks per
day. Potassium intake should be increased, not reduced.
Question 8
A patient with stable angina is prescribed sublingual nitroglycerin. Which
instruction should the nurse include in the teaching?
A. "Take one tablet every 15 minutes for up to three doses"
B. "Take one tablet every 5 minutes for up to three doses"
C. "Call 911 after taking the first tablet"
D. "Chew the tablet for faster absorption"
Correct Answer: B
Rationale: The correct protocol for sublingual nitroglycerin is to take one
tablet every 5 minutes for up to three doses. If pain is unrelieved after the first
tablet, the patient should call 911 while continuing to take tablets. The tablet
should be placed under the tongue, not chewed.
Question 9
A client is admitted with chest pain, diaphoresis, and radiation of pain to the left
jaw and arm. ECG shows ST-segment elevation in leads II, III, and aVF. Which
coronary artery is most likely affected?
