NUR209 Exam 1
Medical-Surgical Nursing II Questions with Answers— Fortis College| Pass
Guaranteed| Latest
1. A nurse is caring for a client with heart failure. Which assessment finding requires
immediate notification of the provider?
A) Bilateral 1+ pitting edema in the ankles
B) Weight gain of 3 lb (1.4 kg) in 24 hours
C) Crackles in the lower lung lobes bilaterally
D) Serum sodium of 138 mEq/L
Answer: B
Rationale: A rapid weight gain of 2-3 lb in 24 hours (or 5 lb in a week) indicates acute
fluid retention and worsening heart failure, requiring immediate provider notification.
Mild edema and crackles are expected findings in chronic HF that still warrant
monitoring, and a sodium of 138 mEq/L is within normal limits.
2. A client with hypertension is prescribed lisinopril. Which instruction should the
nurse include?
A) Avoid salt substitutes containing potassium
B) Take the medication with a high-sodium meal
C) Expect an increase in heart rate
D) Discontinue the drug if a mild headache occurs
Answer: A
Rationale: ACE inhibitors like lisinopril can cause hyperkalemia, so clients should avoid
potassium-containing salt substitutes. ACE inhibitors do not increase heart rate, high-
sodium intake worsens hypertension, and mild headache is a common transient side
effect, not a reason to stop the drug without provider guidance.
3. Which ECG finding is most consistent with an acute myocardial infarction?
A) Flattened T waves
B) ST-segment elevation
C) Shortened PR interval
D) Prolonged QT interval only
Answer: B
,Rationale: ST-segment elevation is the classic ECG hallmark of an acute (ST-elevation)
myocardial infarction reflecting transmural myocardial injury. Flattened T waves suggest
hypokalemia or ischemia in general, a shortened PR interval suggests pre-excitation
syndromes, and QT prolongation is associated with electrolyte imbalance or drug effects.
4. A nurse is teaching a client about nitroglycerin sublingual tablets for angina. Which
statement indicates correct understanding?
A) "I will take up to 3 tablets, 5 minutes apart, and call 911 if pain persists."
B) "I should swallow the tablet whole with water."
C) "I can drive myself to the hospital if the pain does not resolve."
D) "I should store the tablets in a warm, humid area for freshness."
Answer: A
Rationale: The client should take one sublingual nitroglycerin tablet every 5 minutes for
up to 3 doses, calling 911 if pain is unrelieved. The tablet must dissolve under the tongue,
not be swallowed; the client should never drive themselves during active chest pain; and
nitroglycerin must be stored in a cool, dark, dry place away from light and moisture.
5. A client with atrial fibrillation is started on warfarin. Which laboratory value does
the nurse monitor to evaluate therapeutic effect?
A) Partial thromboplastin time (PTT)
B) International normalized ratio (INR)
C) Platelet count
D) D-dimer
Answer: B
Rationale: Warfarin therapy is monitored using the INR, with a therapeutic range
typically 2.0-3.0 for atrial fibrillation. PTT monitors heparin therapy, platelet count
assesses clotting cell number rather than warfarin effect, and D-dimer assesses for active
clot formation/breakdown, not anticoagulation therapy level.
6. A client reports substernal chest pressure radiating to the left arm. What is the
nurse's priority action?
A) Obtain a 12-lead ECG and notify the provider
B) Administer an antacid
C) Ask the client to perform the Valsalva maneuver
D) Document the finding and reassess in 1 hour
Answer: A
,Rationale: Chest pain radiating to the arm is a classic presentation of myocardial
ischemia; the priority is a 12-lead ECG and provider notification to confirm and treat
quickly, since time is critical to preserve myocardium. Antacids and delayed
reassessment could dangerously delay treatment, and the Valsalva maneuver is not
indicated for suspected cardiac ischemia.
7. A client is receiving IV heparin for a deep vein thrombosis. Which finding indicates a
need to stop the infusion and notify the provider?
A) aPTT of 65 seconds (control 30 seconds)
B) Blood in the urine and gums bleeding
C) Mild bruising at the IV site
D) Heart rate of 82/min
Answer: B
Rationale: Hematuria and gum bleeding indicate excessive anticoagulation and active
bleeding, requiring the infusion to be stopped and the provider notified immediately. An
aPTT around 1.5-2.5 times control (45-70 seconds) is therapeutic, mild bruising is
common and expected, and a heart rate of 82 is within normal limits.
8. Which client is at greatest risk for developing infective endocarditis?
A) A client with a prosthetic heart valve
B) A client with well-controlled hypertension
C) A client recovering from a tonsillectomy 6 months ago
D) A client with seasonal allergies
Answer: A
Rationale: Prosthetic heart valves provide a surface for bacterial adherence and are a
major risk factor for infective endocarditis, requiring antibiotic prophylaxis before certain
procedures. Well-controlled hypertension, remote tonsillectomy, and allergies do not
carry the same structural risk for endocardial infection.
9. A client with peripheral arterial disease reports leg pain that occurs with walking
and is relieved by rest. The nurse recognizes this as:
A) Intermittent claudication
B) Venous stasis pain
C) Restless leg syndrome
D) Sciatica
Answer: A
, Rationale: Intermittent claudication is cramping leg pain caused by inadequate arterial
blood flow during activity; it is relieved by rest because oxygen demand decreases.
Venous stasis pain is typically a dull ache that worsens with standing and improves with
elevation, restless leg syndrome occurs at rest, and sciatica follows a nerve distribution
unrelated to exertion.
10. The nurse is teaching a client with peripheral arterial disease about foot care.
Which statement by the client requires further teaching?
A) "I will inspect my feet daily for cuts or sores."
B) "I will soak my feet in hot water every night."
C) "I will wear well-fitting, closed-toe shoes."
D) "I will avoid crossing my legs when sitting."
Answer: B
Rationale: Soaking feet in hot water can cause burns because arterial insufficiency
reduces sensation and healing capacity, so this statement indicates a need for further
teaching. Daily inspection, proper footwear, and avoiding leg crossing are all correct
measures to protect circulation and skin integrity in PAD.
11. A client has a blood pressure of 168/98 mmHg on three separate occasions. The
nurse understands this is classified as:
A) Normal blood pressure
B) Elevated blood pressure
C) Stage 1 hypertension
D) Stage 2 hypertension
Answer: D
Rationale: A systolic of 140 mmHg or higher, or diastolic 90 mmHg or higher, meets
criteria for Stage 2 hypertension per current guidelines. Normal is under 120/80,
elevated is 120-129/under 80, and Stage 1 is 130-139/80-89, all lower than this client's
reading.
12. A client with left-sided heart failure is most likely to exhibit which symptom?
A) Jugular vein distention
B) Dependent peripheral edema
C) Dyspnea and pulmonary crackles
D) Hepatomegaly
Answer: C
Medical-Surgical Nursing II Questions with Answers— Fortis College| Pass
Guaranteed| Latest
1. A nurse is caring for a client with heart failure. Which assessment finding requires
immediate notification of the provider?
A) Bilateral 1+ pitting edema in the ankles
B) Weight gain of 3 lb (1.4 kg) in 24 hours
C) Crackles in the lower lung lobes bilaterally
D) Serum sodium of 138 mEq/L
Answer: B
Rationale: A rapid weight gain of 2-3 lb in 24 hours (or 5 lb in a week) indicates acute
fluid retention and worsening heart failure, requiring immediate provider notification.
Mild edema and crackles are expected findings in chronic HF that still warrant
monitoring, and a sodium of 138 mEq/L is within normal limits.
2. A client with hypertension is prescribed lisinopril. Which instruction should the
nurse include?
A) Avoid salt substitutes containing potassium
B) Take the medication with a high-sodium meal
C) Expect an increase in heart rate
D) Discontinue the drug if a mild headache occurs
Answer: A
Rationale: ACE inhibitors like lisinopril can cause hyperkalemia, so clients should avoid
potassium-containing salt substitutes. ACE inhibitors do not increase heart rate, high-
sodium intake worsens hypertension, and mild headache is a common transient side
effect, not a reason to stop the drug without provider guidance.
3. Which ECG finding is most consistent with an acute myocardial infarction?
A) Flattened T waves
B) ST-segment elevation
C) Shortened PR interval
D) Prolonged QT interval only
Answer: B
,Rationale: ST-segment elevation is the classic ECG hallmark of an acute (ST-elevation)
myocardial infarction reflecting transmural myocardial injury. Flattened T waves suggest
hypokalemia or ischemia in general, a shortened PR interval suggests pre-excitation
syndromes, and QT prolongation is associated with electrolyte imbalance or drug effects.
4. A nurse is teaching a client about nitroglycerin sublingual tablets for angina. Which
statement indicates correct understanding?
A) "I will take up to 3 tablets, 5 minutes apart, and call 911 if pain persists."
B) "I should swallow the tablet whole with water."
C) "I can drive myself to the hospital if the pain does not resolve."
D) "I should store the tablets in a warm, humid area for freshness."
Answer: A
Rationale: The client should take one sublingual nitroglycerin tablet every 5 minutes for
up to 3 doses, calling 911 if pain is unrelieved. The tablet must dissolve under the tongue,
not be swallowed; the client should never drive themselves during active chest pain; and
nitroglycerin must be stored in a cool, dark, dry place away from light and moisture.
5. A client with atrial fibrillation is started on warfarin. Which laboratory value does
the nurse monitor to evaluate therapeutic effect?
A) Partial thromboplastin time (PTT)
B) International normalized ratio (INR)
C) Platelet count
D) D-dimer
Answer: B
Rationale: Warfarin therapy is monitored using the INR, with a therapeutic range
typically 2.0-3.0 for atrial fibrillation. PTT monitors heparin therapy, platelet count
assesses clotting cell number rather than warfarin effect, and D-dimer assesses for active
clot formation/breakdown, not anticoagulation therapy level.
6. A client reports substernal chest pressure radiating to the left arm. What is the
nurse's priority action?
A) Obtain a 12-lead ECG and notify the provider
B) Administer an antacid
C) Ask the client to perform the Valsalva maneuver
D) Document the finding and reassess in 1 hour
Answer: A
,Rationale: Chest pain radiating to the arm is a classic presentation of myocardial
ischemia; the priority is a 12-lead ECG and provider notification to confirm and treat
quickly, since time is critical to preserve myocardium. Antacids and delayed
reassessment could dangerously delay treatment, and the Valsalva maneuver is not
indicated for suspected cardiac ischemia.
7. A client is receiving IV heparin for a deep vein thrombosis. Which finding indicates a
need to stop the infusion and notify the provider?
A) aPTT of 65 seconds (control 30 seconds)
B) Blood in the urine and gums bleeding
C) Mild bruising at the IV site
D) Heart rate of 82/min
Answer: B
Rationale: Hematuria and gum bleeding indicate excessive anticoagulation and active
bleeding, requiring the infusion to be stopped and the provider notified immediately. An
aPTT around 1.5-2.5 times control (45-70 seconds) is therapeutic, mild bruising is
common and expected, and a heart rate of 82 is within normal limits.
8. Which client is at greatest risk for developing infective endocarditis?
A) A client with a prosthetic heart valve
B) A client with well-controlled hypertension
C) A client recovering from a tonsillectomy 6 months ago
D) A client with seasonal allergies
Answer: A
Rationale: Prosthetic heart valves provide a surface for bacterial adherence and are a
major risk factor for infective endocarditis, requiring antibiotic prophylaxis before certain
procedures. Well-controlled hypertension, remote tonsillectomy, and allergies do not
carry the same structural risk for endocardial infection.
9. A client with peripheral arterial disease reports leg pain that occurs with walking
and is relieved by rest. The nurse recognizes this as:
A) Intermittent claudication
B) Venous stasis pain
C) Restless leg syndrome
D) Sciatica
Answer: A
, Rationale: Intermittent claudication is cramping leg pain caused by inadequate arterial
blood flow during activity; it is relieved by rest because oxygen demand decreases.
Venous stasis pain is typically a dull ache that worsens with standing and improves with
elevation, restless leg syndrome occurs at rest, and sciatica follows a nerve distribution
unrelated to exertion.
10. The nurse is teaching a client with peripheral arterial disease about foot care.
Which statement by the client requires further teaching?
A) "I will inspect my feet daily for cuts or sores."
B) "I will soak my feet in hot water every night."
C) "I will wear well-fitting, closed-toe shoes."
D) "I will avoid crossing my legs when sitting."
Answer: B
Rationale: Soaking feet in hot water can cause burns because arterial insufficiency
reduces sensation and healing capacity, so this statement indicates a need for further
teaching. Daily inspection, proper footwear, and avoiding leg crossing are all correct
measures to protect circulation and skin integrity in PAD.
11. A client has a blood pressure of 168/98 mmHg on three separate occasions. The
nurse understands this is classified as:
A) Normal blood pressure
B) Elevated blood pressure
C) Stage 1 hypertension
D) Stage 2 hypertension
Answer: D
Rationale: A systolic of 140 mmHg or higher, or diastolic 90 mmHg or higher, meets
criteria for Stage 2 hypertension per current guidelines. Normal is under 120/80,
elevated is 120-129/under 80, and Stage 1 is 130-139/80-89, all lower than this client's
reading.
12. A client with left-sided heart failure is most likely to exhibit which symptom?
A) Jugular vein distention
B) Dependent peripheral edema
C) Dyspnea and pulmonary crackles
D) Hepatomegaly
Answer: C
