nurse 242 med surge review exam 4
Actual Answers @2026!!!!
the nurse is completing ana assessment on a heart failure pt which of the following findings should
receive the highest priority
a) bp 100/62 hr 92 with a fib and bibasilar crackles
b) confusion, wet cough, orthopnea
c) 02 sat 92% on 2l, rr 22 , +1 le edema
d) weight gain of 1kg in 3 days. bp 150/80 - ANSWERS💫✔️-B
the nurse notices that the clients HR dropped from 63 to 50 in the two hours since their initial
assessment. the nurse should first
a) administer atropine per standing order
b) notify the md
c) review the clients medication record
d) take the clients BP - ANSWERS💫✔️-D
captopril, furosemide, and metoprolol are all rx for a pt with HF the clients BP is 1636/82 HR 65 prior to
0900 medications the nurse reviews the clients most recent labs sodium 146, pot 5.8 bun 18 creatinine
1.0 which should the nurse do first
a) administer the medication as ordered
b) call the healthcare provider
c) withhold captopril
d) withhold furosemide - ANSWERS💫✔️-c
which rhythms should be defibrillated - ANSWERS💫✔️-ventricular fibulation
and pulseless vtach
the nurse suspects arterial insuff in the 50 year old pt when the feet and legs exhibit
a) equal warmth
, b) shiny hairless skin
c) brown discoloration
d) pedal edema - ANSWERS💫✔️-B , hair follicles need oxygenated blood
a nurse asses a pt with AFIB which manifestation requires immediate f/u by the nurse
a) sinus tachycardia
b) speech alterations
c) fatigue
d) dyspnea with activity - ANSWERS💫✔️-B
a nurse is assessing a client admitted to the cardiac unit which statement by the client alerts the nurse
to the possibility of RT sided heart failure
a) " i sleep with four pillows at night"
b) my shoes fit really tight
c) i wake up coughing every night
d) i have trouble catching my breath - ANSWERS💫✔️-B
a nurse is teaching a client with HF who has been rx enalapril. which statement should the nurse include
in this clients teaching
a) avoid using salt substitutes
b) take your medication with food
c) avoid using aspirin containing products
d) check your pulse daily - ANSWERS💫✔️-A
s nurse is assessing an obese client in the clinic for a f/u after an episode of DVT the client lost 20
pounds since last visit what action is most important
a) ask if weight loss was intended
b) encourage high protein, high fiber
c) measure for new compression socks
Actual Answers @2026!!!!
the nurse is completing ana assessment on a heart failure pt which of the following findings should
receive the highest priority
a) bp 100/62 hr 92 with a fib and bibasilar crackles
b) confusion, wet cough, orthopnea
c) 02 sat 92% on 2l, rr 22 , +1 le edema
d) weight gain of 1kg in 3 days. bp 150/80 - ANSWERS💫✔️-B
the nurse notices that the clients HR dropped from 63 to 50 in the two hours since their initial
assessment. the nurse should first
a) administer atropine per standing order
b) notify the md
c) review the clients medication record
d) take the clients BP - ANSWERS💫✔️-D
captopril, furosemide, and metoprolol are all rx for a pt with HF the clients BP is 1636/82 HR 65 prior to
0900 medications the nurse reviews the clients most recent labs sodium 146, pot 5.8 bun 18 creatinine
1.0 which should the nurse do first
a) administer the medication as ordered
b) call the healthcare provider
c) withhold captopril
d) withhold furosemide - ANSWERS💫✔️-c
which rhythms should be defibrillated - ANSWERS💫✔️-ventricular fibulation
and pulseless vtach
the nurse suspects arterial insuff in the 50 year old pt when the feet and legs exhibit
a) equal warmth
, b) shiny hairless skin
c) brown discoloration
d) pedal edema - ANSWERS💫✔️-B , hair follicles need oxygenated blood
a nurse asses a pt with AFIB which manifestation requires immediate f/u by the nurse
a) sinus tachycardia
b) speech alterations
c) fatigue
d) dyspnea with activity - ANSWERS💫✔️-B
a nurse is assessing a client admitted to the cardiac unit which statement by the client alerts the nurse
to the possibility of RT sided heart failure
a) " i sleep with four pillows at night"
b) my shoes fit really tight
c) i wake up coughing every night
d) i have trouble catching my breath - ANSWERS💫✔️-B
a nurse is teaching a client with HF who has been rx enalapril. which statement should the nurse include
in this clients teaching
a) avoid using salt substitutes
b) take your medication with food
c) avoid using aspirin containing products
d) check your pulse daily - ANSWERS💫✔️-A
s nurse is assessing an obese client in the clinic for a f/u after an episode of DVT the client lost 20
pounds since last visit what action is most important
a) ask if weight loss was intended
b) encourage high protein, high fiber
c) measure for new compression socks
