Medical-Surgical Nursing
8th Edition
• Author(s)Adrianne Dill Linton;
Mary Ann Matteson
• Print ISBN: 9780323826716
TEST BANK
QUESTION 1 — MCQ
Clinical Scenario
A 72-year-old patient with a history of heart failure is admitted
with worsening dyspnea, bilateral crackles, and 3+ pitting
edema. The patient is receiving IV furosemide.
,Question Stem
Which assessment finding indicates the IV furosemide is having
the desired therapeutic effect?
Answer Options
A. Blood pressure decreases from 168/92 mm Hg to 160/88 mm
Hg
B. Urine output increases to 150 mL/hr
C. Heart rate increases from 84 to 110 beats/min
D. Oxygen saturation decreases from 95% to 91%
Correct Answer
B. Urine output increases to 150 mL/hr
Detailed Rationale
Furosemide is a loop diuretic used to reduce fluid overload in
heart failure. Increased urine output demonstrates effective
diuresis and reduction of excess intravascular volume. This
helps decrease pulmonary congestion and peripheral edema.
Loop diuretics inhibit sodium and chloride reabsorption in the
ascending loop of Henle, promoting rapid fluid removal.
Monitoring urine output is a direct indicator of effectiveness.
,Incorrect Option Analysis
A. Blood pressure decreases slightly
• Why Incorrect: Mild BP reduction alone does not confirm
adequate fluid removal.
• Common Misconception: Assuming any BP decrease
means improvement.
• Safety Risk: Overlooking persistent pulmonary edema.
C. Increased heart rate
• Why Incorrect: Tachycardia may indicate hypovolemia or
worsening cardiac stress.
• Misconception: Believing compensatory changes are
therapeutic.
• Safety Risk: Missing early instability.
D. Decreased oxygen saturation
• Why Incorrect: Lower oxygen saturation suggests
worsening pulmonary congestion.
• Safety Risk: Delayed respiratory intervention.
Nursing Process Linkage
Evaluation
, NCJMM Competencies
• Recognize Cues
• Evaluate Outcomes
Difficulty
Easy
Bloom’s Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Evaluate effectiveness of diuretic therapy in heart failure using
assessment findings.
QUESTION 2 — SATA
Clinical Scenario
A patient with diabetic ketoacidosis (DKA) is admitted to the
ICU.
Question Stem
8th Edition
• Author(s)Adrianne Dill Linton;
Mary Ann Matteson
• Print ISBN: 9780323826716
TEST BANK
QUESTION 1 — MCQ
Clinical Scenario
A 72-year-old patient with a history of heart failure is admitted
with worsening dyspnea, bilateral crackles, and 3+ pitting
edema. The patient is receiving IV furosemide.
,Question Stem
Which assessment finding indicates the IV furosemide is having
the desired therapeutic effect?
Answer Options
A. Blood pressure decreases from 168/92 mm Hg to 160/88 mm
Hg
B. Urine output increases to 150 mL/hr
C. Heart rate increases from 84 to 110 beats/min
D. Oxygen saturation decreases from 95% to 91%
Correct Answer
B. Urine output increases to 150 mL/hr
Detailed Rationale
Furosemide is a loop diuretic used to reduce fluid overload in
heart failure. Increased urine output demonstrates effective
diuresis and reduction of excess intravascular volume. This
helps decrease pulmonary congestion and peripheral edema.
Loop diuretics inhibit sodium and chloride reabsorption in the
ascending loop of Henle, promoting rapid fluid removal.
Monitoring urine output is a direct indicator of effectiveness.
,Incorrect Option Analysis
A. Blood pressure decreases slightly
• Why Incorrect: Mild BP reduction alone does not confirm
adequate fluid removal.
• Common Misconception: Assuming any BP decrease
means improvement.
• Safety Risk: Overlooking persistent pulmonary edema.
C. Increased heart rate
• Why Incorrect: Tachycardia may indicate hypovolemia or
worsening cardiac stress.
• Misconception: Believing compensatory changes are
therapeutic.
• Safety Risk: Missing early instability.
D. Decreased oxygen saturation
• Why Incorrect: Lower oxygen saturation suggests
worsening pulmonary congestion.
• Safety Risk: Delayed respiratory intervention.
Nursing Process Linkage
Evaluation
, NCJMM Competencies
• Recognize Cues
• Evaluate Outcomes
Difficulty
Easy
Bloom’s Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Evaluate effectiveness of diuretic therapy in heart failure using
assessment findings.
QUESTION 2 — SATA
Clinical Scenario
A patient with diabetic ketoacidosis (DKA) is admitted to the
ICU.
Question Stem
