NURS 480 Final Practice Exam | Medical-Surgical Nursing |
Verified Q&A Pack
Advanced Medical-Surgical Nursing Edition | Comprehensive Final
Assessment
SECTION 1: CARDIOVASCULAR NURSING
1. A nurse is assessing a client with heart failure. Which finding indicates left-sided heart failure?
A) Jugular venous distention
B) Peripheral edema
C) Crackles in the lungs
D) Hepatomegaly
Correct Answer: C) Crackles in the lungs
Rationale: Left-sided heart failure is characterized by pulmonary congestion, including crackles, dyspnea, orthopnea,
and pink frothy sputum. Right-sided heart failure is characterized by systemic congestion, including jugular venous
distention, peripheral edema, and hepatomegaly.
2. A nurse is caring for a client with atrial fibrillation. Which medication is used to prevent
thromboembolism?
A) Metoprolol
B) Warfarin
C) Digoxin
D) Amiodarone
Correct Answer: B) Warfarin
Rationale: Warfarin is an anticoagulant used to prevent thromboembolism in clients with atrial fibrillation. Metoprolol,
digoxin, and amiodarone are used for rate control but do not prevent clot formation.
3. A nurse is assessing a client with deep vein thrombosis (DVT). Which finding should the nurse expect?
A) Bilateral leg edema
B) Unilateral calf pain and swelling
C) Cool, pale extremity
D) Absent pedal pulses
Correct Answer: B) Unilateral calf pain and swelling
Rationale: DVT typically presents with unilateral calf pain, swelling, warmth, and redness. Bilateral edema is more
characteristic of heart failure or venous insufficiency. Cool, pale extremity and absent pedal pulses indicate arterial
insufficiency.
,4. A nurse is teaching a client about warfarin therapy. Which instruction should the nurse include?
A) "Maintain a consistent intake of green leafy vegetables."
B) "Increase your intake of green leafy vegetables."
C) "Avoid all green leafy vegetables."
D) "Take the medication on an empty stomach."
Correct Answer: A) "Maintain a consistent intake of green leafy vegetables."
Rationale: Clients taking warfarin should maintain a consistent intake of vitamin K-rich foods (green leafy vegetables)
to keep INR stable. Increasing or avoiding these foods can affect INR. Warfarin is taken at the same time daily,
typically in the evening.
5. A nurse is assessing a client with an abdominal aortic aneurysm. Which finding indicates impending
rupture?
A) Pulsatile mass in the abdomen
B) Severe back pain and hypotension
C) Bruit over the abdomen
D) Mild abdominal discomfort
Correct Answer: B) Severe back pain and hypotension
Rationale: Severe back pain and hypotension indicate impending or actual rupture of an abdominal aortic aneurysm,
a life-threatening emergency requiring immediate intervention. A pulsatile mass, bruit, and mild discomfort are
common findings in unruptured aneurysms.
6. A nurse is caring for a client with peripheral arterial disease (PAD). Which finding should the nurse
expect?
A) Warm, swollen extremity
B) Cool, pale extremity with decreased pulses
C) Red, warm extremity
D) Bilateral pitting edema
Correct Answer: B) Cool, pale extremity with decreased pulses
Rationale: PAD is characterized by decreased blood flow to the extremities, resulting in cool, pale skin, decreased or
absent pulses, and pain (intermittent claudication). Warm, swollen extremities and edema are seen in venous
insufficiency.
7. A nurse is assessing a client with peripheral venous disease (PVD). Which finding should the nurse
expect?
A) Cool, pale extremity
B) Intermittent claudication
,C) Warm, swollen extremity with edema
D) Decreased pedal pulses
Correct Answer: C) Warm, swollen extremity with edema
Rationale: PVD is characterized by venous congestion, resulting in warm, swollen extremities with edema, brownish
discoloration (hemosiderin staining), and ulcers. Cool, pale extremities, intermittent claudication, and decreased
pulses are seen in PAD.
8. A nurse is caring for a client with infective endocarditis. Which finding should the nurse expect?
A) Janeway lesions and Osler nodes
B) Bradycardia and hypotension
C) Clear lung sounds
D) Decreased white blood cell count
Correct Answer: A) Janeway lesions and Osler nodes
Rationale: Infective endocarditis is characterized by Janeway lesions (painless macules on palms and soles), Osler
nodes (painful nodules on fingertips), splinter hemorrhages, fever, and a new or changed murmur. Bradycardia,
hypotension, and decreased WBC count are not typical findings.
9. A nurse is assessing a client with cardiac tamponade. Which finding should the nurse expect?
A) Muffled heart sounds and hypotension
B) Clear heart sounds and hypertension
C) Bradycardia and hypertension
D) Tachycardia and hypertension
Correct Answer: A) Muffled heart sounds and hypotension
Rationale: Cardiac tamponade is characterized by Beck's triad: muffled heart sounds, hypotension, and jugular
venous distention. Tachycardia may also be present. This is a medical emergency requiring pericardiocentesis.
10. A nurse is caring for a client who has just undergone a cardiac catheterization. Which finding requires
immediate intervention?
A) Small bruise at the insertion site
B) Bleeding at the insertion site with hypotension
C) Mild discomfort at the insertion site
D) Palpable pedal pulse
Correct Answer: B) Bleeding at the insertion site with hypotension
Rationale: Bleeding at the insertion site with hypotension indicates possible hemorrhage or hematoma formation,
which requires immediate intervention. A small bruise, mild discomfort, and palpable pedal pulse are expected
findings.
, 11. A nurse is assessing a client with aortic stenosis. Which finding should the nurse expect?
A) Systolic murmur
B) Diastolic murmur
C) Continuous murmur
D) No murmur
Correct Answer: A) Systolic murmur
Rationale: Aortic stenosis produces a systolic murmur heard best at the right second intercostal space, radiating to
the neck. Aortic regurgitation produces a diastolic murmur. Mitral stenosis produces a diastolic murmur. Patent
ductus arteriosus produces a continuous murmur.
12. A nurse is assessing a client with mitral regurgitation. Which finding should the nurse expect?
A) Systolic murmur at the apex
B) Diastolic murmur at the apex
C) Continuous murmur
D) No murmur
Correct Answer: A) Systolic murmur at the apex
Rationale: Mitral regurgitation produces a systolic murmur heard best at the apex, radiating to the axilla. Mitral
stenosis produces a diastolic murmur at the apex. Aortic stenosis produces a systolic murmur at the right second
intercostal space.
13. A nurse is caring for a client with an artificial cardiac pacemaker. Which finding indicates malfunction?
A) Heart rate of 72 beats/min
B) Presence of a pacemaker spike before each QRS complex
C) Heart rate of 40 beats/min with dizziness
D) Blood pressure of 120/80 mm Hg
Correct Answer: C) Heart rate of 40 beats/min with dizziness
Rationale: A heart rate of 40 beats/min with dizziness indicates pacemaker malfunction (failure to capture or failure to
pace). A pacemaker spike before each QRS complex indicates proper functioning. Heart rate of 72 and blood
pressure of 120/80 are normal findings.
14. A nurse is teaching a client about a newly implanted pacemaker. Which instruction should the nurse
include?
A) "Avoid using a microwave oven."
B) "Carry a pacemaker identification card at all times."
C) "Avoid all physical activity."
D) "Sleep on your stomach."
Correct Answer: B) "Carry a pacemaker identification card at all times."
Verified Q&A Pack
Advanced Medical-Surgical Nursing Edition | Comprehensive Final
Assessment
SECTION 1: CARDIOVASCULAR NURSING
1. A nurse is assessing a client with heart failure. Which finding indicates left-sided heart failure?
A) Jugular venous distention
B) Peripheral edema
C) Crackles in the lungs
D) Hepatomegaly
Correct Answer: C) Crackles in the lungs
Rationale: Left-sided heart failure is characterized by pulmonary congestion, including crackles, dyspnea, orthopnea,
and pink frothy sputum. Right-sided heart failure is characterized by systemic congestion, including jugular venous
distention, peripheral edema, and hepatomegaly.
2. A nurse is caring for a client with atrial fibrillation. Which medication is used to prevent
thromboembolism?
A) Metoprolol
B) Warfarin
C) Digoxin
D) Amiodarone
Correct Answer: B) Warfarin
Rationale: Warfarin is an anticoagulant used to prevent thromboembolism in clients with atrial fibrillation. Metoprolol,
digoxin, and amiodarone are used for rate control but do not prevent clot formation.
3. A nurse is assessing a client with deep vein thrombosis (DVT). Which finding should the nurse expect?
A) Bilateral leg edema
B) Unilateral calf pain and swelling
C) Cool, pale extremity
D) Absent pedal pulses
Correct Answer: B) Unilateral calf pain and swelling
Rationale: DVT typically presents with unilateral calf pain, swelling, warmth, and redness. Bilateral edema is more
characteristic of heart failure or venous insufficiency. Cool, pale extremity and absent pedal pulses indicate arterial
insufficiency.
,4. A nurse is teaching a client about warfarin therapy. Which instruction should the nurse include?
A) "Maintain a consistent intake of green leafy vegetables."
B) "Increase your intake of green leafy vegetables."
C) "Avoid all green leafy vegetables."
D) "Take the medication on an empty stomach."
Correct Answer: A) "Maintain a consistent intake of green leafy vegetables."
Rationale: Clients taking warfarin should maintain a consistent intake of vitamin K-rich foods (green leafy vegetables)
to keep INR stable. Increasing or avoiding these foods can affect INR. Warfarin is taken at the same time daily,
typically in the evening.
5. A nurse is assessing a client with an abdominal aortic aneurysm. Which finding indicates impending
rupture?
A) Pulsatile mass in the abdomen
B) Severe back pain and hypotension
C) Bruit over the abdomen
D) Mild abdominal discomfort
Correct Answer: B) Severe back pain and hypotension
Rationale: Severe back pain and hypotension indicate impending or actual rupture of an abdominal aortic aneurysm,
a life-threatening emergency requiring immediate intervention. A pulsatile mass, bruit, and mild discomfort are
common findings in unruptured aneurysms.
6. A nurse is caring for a client with peripheral arterial disease (PAD). Which finding should the nurse
expect?
A) Warm, swollen extremity
B) Cool, pale extremity with decreased pulses
C) Red, warm extremity
D) Bilateral pitting edema
Correct Answer: B) Cool, pale extremity with decreased pulses
Rationale: PAD is characterized by decreased blood flow to the extremities, resulting in cool, pale skin, decreased or
absent pulses, and pain (intermittent claudication). Warm, swollen extremities and edema are seen in venous
insufficiency.
7. A nurse is assessing a client with peripheral venous disease (PVD). Which finding should the nurse
expect?
A) Cool, pale extremity
B) Intermittent claudication
,C) Warm, swollen extremity with edema
D) Decreased pedal pulses
Correct Answer: C) Warm, swollen extremity with edema
Rationale: PVD is characterized by venous congestion, resulting in warm, swollen extremities with edema, brownish
discoloration (hemosiderin staining), and ulcers. Cool, pale extremities, intermittent claudication, and decreased
pulses are seen in PAD.
8. A nurse is caring for a client with infective endocarditis. Which finding should the nurse expect?
A) Janeway lesions and Osler nodes
B) Bradycardia and hypotension
C) Clear lung sounds
D) Decreased white blood cell count
Correct Answer: A) Janeway lesions and Osler nodes
Rationale: Infective endocarditis is characterized by Janeway lesions (painless macules on palms and soles), Osler
nodes (painful nodules on fingertips), splinter hemorrhages, fever, and a new or changed murmur. Bradycardia,
hypotension, and decreased WBC count are not typical findings.
9. A nurse is assessing a client with cardiac tamponade. Which finding should the nurse expect?
A) Muffled heart sounds and hypotension
B) Clear heart sounds and hypertension
C) Bradycardia and hypertension
D) Tachycardia and hypertension
Correct Answer: A) Muffled heart sounds and hypotension
Rationale: Cardiac tamponade is characterized by Beck's triad: muffled heart sounds, hypotension, and jugular
venous distention. Tachycardia may also be present. This is a medical emergency requiring pericardiocentesis.
10. A nurse is caring for a client who has just undergone a cardiac catheterization. Which finding requires
immediate intervention?
A) Small bruise at the insertion site
B) Bleeding at the insertion site with hypotension
C) Mild discomfort at the insertion site
D) Palpable pedal pulse
Correct Answer: B) Bleeding at the insertion site with hypotension
Rationale: Bleeding at the insertion site with hypotension indicates possible hemorrhage or hematoma formation,
which requires immediate intervention. A small bruise, mild discomfort, and palpable pedal pulse are expected
findings.
, 11. A nurse is assessing a client with aortic stenosis. Which finding should the nurse expect?
A) Systolic murmur
B) Diastolic murmur
C) Continuous murmur
D) No murmur
Correct Answer: A) Systolic murmur
Rationale: Aortic stenosis produces a systolic murmur heard best at the right second intercostal space, radiating to
the neck. Aortic regurgitation produces a diastolic murmur. Mitral stenosis produces a diastolic murmur. Patent
ductus arteriosus produces a continuous murmur.
12. A nurse is assessing a client with mitral regurgitation. Which finding should the nurse expect?
A) Systolic murmur at the apex
B) Diastolic murmur at the apex
C) Continuous murmur
D) No murmur
Correct Answer: A) Systolic murmur at the apex
Rationale: Mitral regurgitation produces a systolic murmur heard best at the apex, radiating to the axilla. Mitral
stenosis produces a diastolic murmur at the apex. Aortic stenosis produces a systolic murmur at the right second
intercostal space.
13. A nurse is caring for a client with an artificial cardiac pacemaker. Which finding indicates malfunction?
A) Heart rate of 72 beats/min
B) Presence of a pacemaker spike before each QRS complex
C) Heart rate of 40 beats/min with dizziness
D) Blood pressure of 120/80 mm Hg
Correct Answer: C) Heart rate of 40 beats/min with dizziness
Rationale: A heart rate of 40 beats/min with dizziness indicates pacemaker malfunction (failure to capture or failure to
pace). A pacemaker spike before each QRS complex indicates proper functioning. Heart rate of 72 and blood
pressure of 120/80 are normal findings.
14. A nurse is teaching a client about a newly implanted pacemaker. Which instruction should the nurse
include?
A) "Avoid using a microwave oven."
B) "Carry a pacemaker identification card at all times."
C) "Avoid all physical activity."
D) "Sleep on your stomach."
Correct Answer: B) "Carry a pacemaker identification card at all times."
