NSG 430 Adult Health Nursing II Exam 1 | Grand
Canyon University | Med-Surg Test Bank |
2026/2027 | Cardiovascular, Respiratory,
Neurological, GI, Renal & Endocrine | Q&A with
Rationales
SECTION I: CARDIOVASCULAR
1. A nurse is assessing a client with heart failure. Which finding indicates fluid
overload?
A. Flat neck veins
B. Weight loss of 2 kg in 24 hours
C. Bibasilar crackles and jugular venous distention
D. Blood pressure 90/60 mmHg
Answer: C
Rationale: Bibasilar crackles and JVD are classic signs of fluid volume excess (left
and right heart failure, respectively). Weight gain, not loss, would indicate fluid
retention. Flat neck veins and hypotension suggest fluid deficit.
2. A client is prescribed digoxin (Lanoxin). Which assessment finding requires
immediate intervention?
A. Heart rate 58 bpm
B. Serum potassium 3.2 mEq/L
C. Digoxin level 1.2 ng/mL
D. Nausea with visual disturbances
Answer: D
Rationale: Nausea and visual disturbances (yellow-green halos) are signs of
digoxin toxicity. While HR <60 and hypokalemia increase toxicity risk, the
presence of toxic symptoms requires immediate action. Therapeutic digoxin level
is 0.5–2.0 ng/mL.
,3. Which lab value is most concerning for a client on furosemide (Lasix)?
A. Sodium 140 mEq/L
B. Potassium 2.8 mEq/L
C. BUN 18 mg/dL
D. Glucose 110 mg/dL
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss. A potassium
of 2.8 mEq/L is dangerously low and can precipitate dysrhythmias, especially in
clients on digoxin.
4. A nurse is teaching a client about warfarin (Coumadin). Which statement
indicates understanding?
A. "I should increase my intake of green leafy vegetables."
B. "I will use a soft toothbrush and electric razor."
C. "I can take aspirin for headaches."
D. "I will stop taking it when my INR is 2.5."
Answer: B
Rationale: Warfarin increases bleeding risk; soft toothbrush and electric razor
reduce injury. Green leafy vegetables (vitamin K) should be kept consistent, not
increased. Aspirin increases bleeding risk. INR 2.0–3.0 is therapeutic, not a reason
to stop.
5. A client with an acute MI is prescribed morphine. What is the primary
rationale?
A. To prevent infection
B. To relieve pain and reduce myocardial oxygen demand
C. To increase heart rate
D. To promote diuresis
Answer: B
Rationale: Morphine relieves pain, reduces anxiety, and causes vasodilation,
which decreases preload and afterload—thereby reducing myocardial oxygen
demand.
,6. Which ECG finding indicates a STEMI?
A. ST elevation in contiguous leads
B. ST depression
C. T wave inversion
D. Prolonged QT interval
Answer: A
Rationale: ST elevation in contiguous leads is the hallmark of STEMI and indicates
myocardial injury requiring reperfusion. ST depression and T inversion suggest
ischemia or NSTEMI.
7. A nurse is caring for a client post-cardiac catheterization. Which finding
requires immediate notification of the provider?
A. Small bruise at the puncture site
B. Blood pressure 100/70 mmHg
C. Absent pedal pulse on the affected extremity
D. Mild discomfort at the site
Answer: C
Rationale: Absent pedal pulse indicates arterial occlusion or hematoma
formation—a vascular emergency. Bruising and mild discomfort are expected.
8. A client with atrial fibrillation is on heparin. Which lab value should the nurse
monitor?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin
Answer: B
Rationale: Unfractionated heparin is monitored with aPTT (therapeutic 1.5–2.5
times control). INR monitors warfarin. Platelets are monitored for HIT, but aPTT is
the primary heparin monitoring test.
, 9. Which client is at highest risk for infective endocarditis?
A. A client with a urinary tract infection
B. A client with a prosthetic heart valve
C. A client with asthma
D. A client with osteoarthritis
Answer: B
Rationale: Prosthetic heart valves are a major risk factor for infective
endocarditis. Other risks include IV drug use, rheumatic heart disease, and recent
dental procedures.
10. A nurse is assessing a client with peripheral arterial disease (PAD). Which
finding is expected?
A. Dependent rubor and cool extremities
B. Warm, edematous extremities
C. Pulse bounding
D. Brown discoloration of ankles
Answer: A
Rationale: PAD causes decreased arterial flow → cool extremities, dependent
rubor, diminished pulses, and intermittent claudication. Brown discoloration and
edema are seen in venous insufficiency.
11. A client on lisinopril (Prinivil) develops a persistent dry cough. What is the
nurse's best action?
A. Encourage cough suppressants
B. Notify the provider; this is a common ACE inhibitor side effect
C. Hold the medication and give a beta-blocker
D. Reassure the client it will resolve in 48 hours
Answer: B
Rationale: ACE inhibitors cause a dry cough due to bradykinin accumulation. The
Canyon University | Med-Surg Test Bank |
2026/2027 | Cardiovascular, Respiratory,
Neurological, GI, Renal & Endocrine | Q&A with
Rationales
SECTION I: CARDIOVASCULAR
1. A nurse is assessing a client with heart failure. Which finding indicates fluid
overload?
A. Flat neck veins
B. Weight loss of 2 kg in 24 hours
C. Bibasilar crackles and jugular venous distention
D. Blood pressure 90/60 mmHg
Answer: C
Rationale: Bibasilar crackles and JVD are classic signs of fluid volume excess (left
and right heart failure, respectively). Weight gain, not loss, would indicate fluid
retention. Flat neck veins and hypotension suggest fluid deficit.
2. A client is prescribed digoxin (Lanoxin). Which assessment finding requires
immediate intervention?
A. Heart rate 58 bpm
B. Serum potassium 3.2 mEq/L
C. Digoxin level 1.2 ng/mL
D. Nausea with visual disturbances
Answer: D
Rationale: Nausea and visual disturbances (yellow-green halos) are signs of
digoxin toxicity. While HR <60 and hypokalemia increase toxicity risk, the
presence of toxic symptoms requires immediate action. Therapeutic digoxin level
is 0.5–2.0 ng/mL.
,3. Which lab value is most concerning for a client on furosemide (Lasix)?
A. Sodium 140 mEq/L
B. Potassium 2.8 mEq/L
C. BUN 18 mg/dL
D. Glucose 110 mg/dL
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss. A potassium
of 2.8 mEq/L is dangerously low and can precipitate dysrhythmias, especially in
clients on digoxin.
4. A nurse is teaching a client about warfarin (Coumadin). Which statement
indicates understanding?
A. "I should increase my intake of green leafy vegetables."
B. "I will use a soft toothbrush and electric razor."
C. "I can take aspirin for headaches."
D. "I will stop taking it when my INR is 2.5."
Answer: B
Rationale: Warfarin increases bleeding risk; soft toothbrush and electric razor
reduce injury. Green leafy vegetables (vitamin K) should be kept consistent, not
increased. Aspirin increases bleeding risk. INR 2.0–3.0 is therapeutic, not a reason
to stop.
5. A client with an acute MI is prescribed morphine. What is the primary
rationale?
A. To prevent infection
B. To relieve pain and reduce myocardial oxygen demand
C. To increase heart rate
D. To promote diuresis
Answer: B
Rationale: Morphine relieves pain, reduces anxiety, and causes vasodilation,
which decreases preload and afterload—thereby reducing myocardial oxygen
demand.
,6. Which ECG finding indicates a STEMI?
A. ST elevation in contiguous leads
B. ST depression
C. T wave inversion
D. Prolonged QT interval
Answer: A
Rationale: ST elevation in contiguous leads is the hallmark of STEMI and indicates
myocardial injury requiring reperfusion. ST depression and T inversion suggest
ischemia or NSTEMI.
7. A nurse is caring for a client post-cardiac catheterization. Which finding
requires immediate notification of the provider?
A. Small bruise at the puncture site
B. Blood pressure 100/70 mmHg
C. Absent pedal pulse on the affected extremity
D. Mild discomfort at the site
Answer: C
Rationale: Absent pedal pulse indicates arterial occlusion or hematoma
formation—a vascular emergency. Bruising and mild discomfort are expected.
8. A client with atrial fibrillation is on heparin. Which lab value should the nurse
monitor?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin
Answer: B
Rationale: Unfractionated heparin is monitored with aPTT (therapeutic 1.5–2.5
times control). INR monitors warfarin. Platelets are monitored for HIT, but aPTT is
the primary heparin monitoring test.
, 9. Which client is at highest risk for infective endocarditis?
A. A client with a urinary tract infection
B. A client with a prosthetic heart valve
C. A client with asthma
D. A client with osteoarthritis
Answer: B
Rationale: Prosthetic heart valves are a major risk factor for infective
endocarditis. Other risks include IV drug use, rheumatic heart disease, and recent
dental procedures.
10. A nurse is assessing a client with peripheral arterial disease (PAD). Which
finding is expected?
A. Dependent rubor and cool extremities
B. Warm, edematous extremities
C. Pulse bounding
D. Brown discoloration of ankles
Answer: A
Rationale: PAD causes decreased arterial flow → cool extremities, dependent
rubor, diminished pulses, and intermittent claudication. Brown discoloration and
edema are seen in venous insufficiency.
11. A client on lisinopril (Prinivil) develops a persistent dry cough. What is the
nurse's best action?
A. Encourage cough suppressants
B. Notify the provider; this is a common ACE inhibitor side effect
C. Hold the medication and give a beta-blocker
D. Reassure the client it will resolve in 48 hours
Answer: B
Rationale: ACE inhibitors cause a dry cough due to bradykinin accumulation. The
