Adult Health Nursing II – Midterm Exam
Practice Questions & Answers
Question 1:
A client with chronic heart failure reports gaining 2.5 kg (5.5 lb) in 3 days. The
client also has increasing bilateral ankle edema and shortness of breath when lying
flat. Which action should the nurse take first?
A. Encourage increased oral fluid intake
B. Assess respiratory status and oxygen saturation
C. Encourage the client to walk in the hallway
D. Place the client in a supine position
Correct Answer: B. Assess respiratory status and oxygen saturation
Rationale: Rapid weight gain, edema, and orthopnea suggest worsening fluid
retention and possible acute heart failure. Respiratory assessment is the priority
because pulmonary edema can rapidly impair oxygenation. The nurse should assess
oxygen saturation, lung sounds, respiratory effort, and hemodynamic status.
Question 2:
A client with atrial fibrillation is prescribed apixaban. Which finding should the
nurse report immediately?
A. Mild fatigue
B. Occasional bruising on the arms
,C. Black, tarry stools
D. Heart rate of 82/min
Correct Answer: C. Black, tarry stools
Rationale: Black, tarry stools indicate possible gastrointestinal bleeding.
Anticoagulants increase bleeding risk, making melena a significant finding
requiring prompt evaluation. The nurse should assess for additional bleeding,
notify the provider, and follow the prescribed anticoagulation safety protocol.
Question 3:
A client with acute myocardial infarction reports persistent chest pain despite
receiving prescribed sublingual nitroglycerin. The blood pressure is 88/56 mm Hg.
Which action should the nurse take?
A. Administer another nitroglycerin dose
B. Place the client in high-Fowler position and notify the provider
C. Encourage the client to ambulate
D. Give a large glass of water
Correct Answer: B. Place the client in high-Fowler position and notify the
provider
Rationale: Persistent chest pain with hypotension indicates ongoing myocardial
ischemia and possible hemodynamic compromise. Additional nitroglycerin may
further lower blood pressure. The nurse should support oxygenation and
circulation, reassess the client, and obtain immediate medical assistance.
Question 4:
A client with a history of coronary artery disease suddenly develops severe chest
,pressure, diaphoresis, nausea, and dyspnea. Which diagnostic laboratory test is
most specific for myocardial injury?
A. Troponin
B. Sodium
C. Hemoglobin
D. Albumin
Correct Answer: A. Troponin
Rationale: Cardiac troponins are highly specific biomarkers of myocardial injury
and are central to evaluating suspected acute coronary syndrome. Serial
measurements are often obtained because levels change over time following
myocardial injury.
Question 5:
A client with heart failure receives IV furosemide. Four hours later, the client
reports muscle weakness and palpitations. Which laboratory value should the nurse
check first?
A. Sodium
B. Potassium
C. Hemoglobin
D. White blood cell count
Correct Answer: B. Potassium
Rationale: Furosemide promotes renal potassium loss. Hypokalemia can cause
muscle weakness and potentially life-threatening dysrhythmias. A client reporting
, weakness and palpitations after diuretic therapy requires prompt electrolyte and
cardiac assessment.
Question 6:
A client with severe aortic stenosis reports dizziness and syncope while walking.
Which finding requires the nurse's immediate attention?
A. Blood pressure of 118/70 mm Hg at rest
B. Syncope during exertion
C. Mild ankle edema at the end of the day
D. Heart rate of 78/min
Correct Answer: B. Syncope during exertion
Rationale: Exertional syncope is a concerning manifestation of severe aortic
stenosis because fixed obstruction to left ventricular outflow can prevent adequate
cardiac output during increased demand. It may indicate advanced disease and
requires prompt cardiovascular evaluation.
Question 7:
A client with peripheral arterial disease reports severe foot pain at rest that
improves when the leg is placed in a dependent position. Which explanation is
appropriate?
A. Dependency can improve arterial blood flow to the foot
B. Dependency increases venous return
C. The symptom indicates normal circulation
D. Elevation always improves arterial perfusion
Correct Answer: A. Dependency can improve arterial blood flow to the foot
Practice Questions & Answers
Question 1:
A client with chronic heart failure reports gaining 2.5 kg (5.5 lb) in 3 days. The
client also has increasing bilateral ankle edema and shortness of breath when lying
flat. Which action should the nurse take first?
A. Encourage increased oral fluid intake
B. Assess respiratory status and oxygen saturation
C. Encourage the client to walk in the hallway
D. Place the client in a supine position
Correct Answer: B. Assess respiratory status and oxygen saturation
Rationale: Rapid weight gain, edema, and orthopnea suggest worsening fluid
retention and possible acute heart failure. Respiratory assessment is the priority
because pulmonary edema can rapidly impair oxygenation. The nurse should assess
oxygen saturation, lung sounds, respiratory effort, and hemodynamic status.
Question 2:
A client with atrial fibrillation is prescribed apixaban. Which finding should the
nurse report immediately?
A. Mild fatigue
B. Occasional bruising on the arms
,C. Black, tarry stools
D. Heart rate of 82/min
Correct Answer: C. Black, tarry stools
Rationale: Black, tarry stools indicate possible gastrointestinal bleeding.
Anticoagulants increase bleeding risk, making melena a significant finding
requiring prompt evaluation. The nurse should assess for additional bleeding,
notify the provider, and follow the prescribed anticoagulation safety protocol.
Question 3:
A client with acute myocardial infarction reports persistent chest pain despite
receiving prescribed sublingual nitroglycerin. The blood pressure is 88/56 mm Hg.
Which action should the nurse take?
A. Administer another nitroglycerin dose
B. Place the client in high-Fowler position and notify the provider
C. Encourage the client to ambulate
D. Give a large glass of water
Correct Answer: B. Place the client in high-Fowler position and notify the
provider
Rationale: Persistent chest pain with hypotension indicates ongoing myocardial
ischemia and possible hemodynamic compromise. Additional nitroglycerin may
further lower blood pressure. The nurse should support oxygenation and
circulation, reassess the client, and obtain immediate medical assistance.
Question 4:
A client with a history of coronary artery disease suddenly develops severe chest
,pressure, diaphoresis, nausea, and dyspnea. Which diagnostic laboratory test is
most specific for myocardial injury?
A. Troponin
B. Sodium
C. Hemoglobin
D. Albumin
Correct Answer: A. Troponin
Rationale: Cardiac troponins are highly specific biomarkers of myocardial injury
and are central to evaluating suspected acute coronary syndrome. Serial
measurements are often obtained because levels change over time following
myocardial injury.
Question 5:
A client with heart failure receives IV furosemide. Four hours later, the client
reports muscle weakness and palpitations. Which laboratory value should the nurse
check first?
A. Sodium
B. Potassium
C. Hemoglobin
D. White blood cell count
Correct Answer: B. Potassium
Rationale: Furosemide promotes renal potassium loss. Hypokalemia can cause
muscle weakness and potentially life-threatening dysrhythmias. A client reporting
, weakness and palpitations after diuretic therapy requires prompt electrolyte and
cardiac assessment.
Question 6:
A client with severe aortic stenosis reports dizziness and syncope while walking.
Which finding requires the nurse's immediate attention?
A. Blood pressure of 118/70 mm Hg at rest
B. Syncope during exertion
C. Mild ankle edema at the end of the day
D. Heart rate of 78/min
Correct Answer: B. Syncope during exertion
Rationale: Exertional syncope is a concerning manifestation of severe aortic
stenosis because fixed obstruction to left ventricular outflow can prevent adequate
cardiac output during increased demand. It may indicate advanced disease and
requires prompt cardiovascular evaluation.
Question 7:
A client with peripheral arterial disease reports severe foot pain at rest that
improves when the leg is placed in a dependent position. Which explanation is
appropriate?
A. Dependency can improve arterial blood flow to the foot
B. Dependency increases venous return
C. The symptom indicates normal circulation
D. Elevation always improves arterial perfusion
Correct Answer: A. Dependency can improve arterial blood flow to the foot
