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NUR 265 EXAMS 1–3 & FINAL WITH VERIFIED ANSWERS
DETAILED RATIONALES GRADED A+
NUR 265 Exams 1–3 & Final – Medical-Surgical Nursing
SECTION 1: CARDIOVASCULAR DISORDERS (Questions 1–40)
Question 1. A nurse is caring for a client with heart failure who has gained 2 kg (4.4 lb) over the
past 2 days and reports increased shortness of breath. Which action should the nurse take first?
A) Administer furosemide as ordered
B) Assess lung sounds and oxygen saturation
C) Place the client in a supine position
D) Restrict fluid intake
Answer: B
Rationale: The priority action is to assess lung sounds and oxygen saturation to determine the
severity of fluid overload. Weight gain and dyspnea indicate worsening heart failure.
Assessment precedes intervention. Placing the client supine would worsen breathing, and fluid
restriction is not first-line before assessment.
Question 2. A client with acute myocardial infarction is prescribed morphine sulfate. The nurse
understands this medication is given primarily to:
A) Relieve pain and reduce myocardial oxygen demand
B) Increase heart rate
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C) Prevent clot formation
D) Lower blood pressure only
Answer: A
Rationale: Morphine relieves pain and reduces preload and afterload, thereby decreasing
myocardial oxygen demand. It does not increase heart rate or prevent clot formation.
Question 3. A nurse is reviewing laboratory results for a client with heart failure. Which finding
requires immediate follow-up?
A) Potassium 4.0 mEq/L
B) Sodium 138 mEq/L
C) Potassium 2.8 mEq/L
D) BNP 150 pg/mL
Answer: C
Rationale: Hypokalemia (potassium <3.5 mEq/L) is dangerous in heart failure because it
increases the risk of dysrhythmias, especially in clients taking digoxin or diuretics. Potassium 2.8
mEq/L requires immediate intervention.
Question 4. A client with atrial fibrillation is prescribed warfarin. Which laboratory test should
the nurse monitor to evaluate therapeutic effectiveness?
A) aPTT
B) INR
C) Platelet count
D) Hemoglobin
Answer: B
Rationale: Warfarin therapy is monitored using the INR (international normalized ratio).
Therapeutic INR for atrial fibrillation is typically 2.0–3.0. aPTT monitors heparin therapy.
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Question 5. A nurse is teaching a client about digoxin therapy. Which statement by the client
indicates correct understanding?
A) "I should take my pulse before taking the medication."
B) "I should take the medication with an antacid."
C) "I should increase my potassium intake without consulting my provider."
D) "I should stop taking the medication if I feel better."
Answer: A
Rationale: Clients on digoxin should check their pulse before each dose and hold the
medication if the heart rate is below 60 bpm. Antacids decrease digoxin absorption. Potassium
should be monitored and supplemented only as prescribed.
Question 6. A client with peripheral arterial disease reports pain in the calf muscles that occurs
with walking and resolves with rest. This symptom is known as:
A) Rest pain
B) Intermittent claudication
C) Paresthesia
D) Pallor
Answer: B
Rationale: Intermittent claudication is reproducible muscle pain that occurs with exercise and
resolves with rest, caused by inadequate blood flow to the muscles. Rest pain occurs at rest and
indicates severe disease.
Question 7. A nurse is assessing a client with deep vein thrombosis. Which finding is most
concerning?
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A) Unilateral calf swelling and warmth
B) Bilateral pedal edema
C) Pink, warm extremities
D) Decreased pedal pulses bilaterally
Answer: A
Rationale: Unilateral calf swelling, warmth, and pain are classic signs of DVT, which can lead to
pulmonary embolism. Bilateral edema suggests heart failure or other systemic conditions.
Question 8. A client is prescribed lisinopril for hypertension. Which side effect should the nurse
monitor for?
A) Dry cough
B) Bradycardia
C) Hyperkalemia
D) Constipation
Answer: A
Rationale: ACE inhibitors like lisinopril commonly cause a persistent dry cough due to
bradykinin accumulation. Hyperkalemia can also occur but the dry cough is the most
characteristic side effect.
Question 9. A nurse is caring for a client who had a cardiac catheterization. Which finding
indicates a complication?
A) Small bruise at the insertion site
B) Bleeding at the insertion site with hypotension
C) Mild discomfort at the site
D) Pedal pulses equal bilaterally
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NUR 265 EXAMS 1–3 & FINAL WITH VERIFIED ANSWERS
DETAILED RATIONALES GRADED A+
NUR 265 Exams 1–3 & Final – Medical-Surgical Nursing
SECTION 1: CARDIOVASCULAR DISORDERS (Questions 1–40)
Question 1. A nurse is caring for a client with heart failure who has gained 2 kg (4.4 lb) over the
past 2 days and reports increased shortness of breath. Which action should the nurse take first?
A) Administer furosemide as ordered
B) Assess lung sounds and oxygen saturation
C) Place the client in a supine position
D) Restrict fluid intake
Answer: B
Rationale: The priority action is to assess lung sounds and oxygen saturation to determine the
severity of fluid overload. Weight gain and dyspnea indicate worsening heart failure.
Assessment precedes intervention. Placing the client supine would worsen breathing, and fluid
restriction is not first-line before assessment.
Question 2. A client with acute myocardial infarction is prescribed morphine sulfate. The nurse
understands this medication is given primarily to:
A) Relieve pain and reduce myocardial oxygen demand
B) Increase heart rate
1|Page
,Page 2 of 118
C) Prevent clot formation
D) Lower blood pressure only
Answer: A
Rationale: Morphine relieves pain and reduces preload and afterload, thereby decreasing
myocardial oxygen demand. It does not increase heart rate or prevent clot formation.
Question 3. A nurse is reviewing laboratory results for a client with heart failure. Which finding
requires immediate follow-up?
A) Potassium 4.0 mEq/L
B) Sodium 138 mEq/L
C) Potassium 2.8 mEq/L
D) BNP 150 pg/mL
Answer: C
Rationale: Hypokalemia (potassium <3.5 mEq/L) is dangerous in heart failure because it
increases the risk of dysrhythmias, especially in clients taking digoxin or diuretics. Potassium 2.8
mEq/L requires immediate intervention.
Question 4. A client with atrial fibrillation is prescribed warfarin. Which laboratory test should
the nurse monitor to evaluate therapeutic effectiveness?
A) aPTT
B) INR
C) Platelet count
D) Hemoglobin
Answer: B
Rationale: Warfarin therapy is monitored using the INR (international normalized ratio).
Therapeutic INR for atrial fibrillation is typically 2.0–3.0. aPTT monitors heparin therapy.
2|Page
,Page 3 of 118
Question 5. A nurse is teaching a client about digoxin therapy. Which statement by the client
indicates correct understanding?
A) "I should take my pulse before taking the medication."
B) "I should take the medication with an antacid."
C) "I should increase my potassium intake without consulting my provider."
D) "I should stop taking the medication if I feel better."
Answer: A
Rationale: Clients on digoxin should check their pulse before each dose and hold the
medication if the heart rate is below 60 bpm. Antacids decrease digoxin absorption. Potassium
should be monitored and supplemented only as prescribed.
Question 6. A client with peripheral arterial disease reports pain in the calf muscles that occurs
with walking and resolves with rest. This symptom is known as:
A) Rest pain
B) Intermittent claudication
C) Paresthesia
D) Pallor
Answer: B
Rationale: Intermittent claudication is reproducible muscle pain that occurs with exercise and
resolves with rest, caused by inadequate blood flow to the muscles. Rest pain occurs at rest and
indicates severe disease.
Question 7. A nurse is assessing a client with deep vein thrombosis. Which finding is most
concerning?
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A) Unilateral calf swelling and warmth
B) Bilateral pedal edema
C) Pink, warm extremities
D) Decreased pedal pulses bilaterally
Answer: A
Rationale: Unilateral calf swelling, warmth, and pain are classic signs of DVT, which can lead to
pulmonary embolism. Bilateral edema suggests heart failure or other systemic conditions.
Question 8. A client is prescribed lisinopril for hypertension. Which side effect should the nurse
monitor for?
A) Dry cough
B) Bradycardia
C) Hyperkalemia
D) Constipation
Answer: A
Rationale: ACE inhibitors like lisinopril commonly cause a persistent dry cough due to
bradykinin accumulation. Hyperkalemia can also occur but the dry cough is the most
characteristic side effect.
Question 9. A nurse is caring for a client who had a cardiac catheterization. Which finding
indicates a complication?
A) Small bruise at the insertion site
B) Bleeding at the insertion site with hypotension
C) Mild discomfort at the site
D) Pedal pulses equal bilaterally
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