Exam 1: NUR209/ NUR 209 (2024/ 2025 Update) Medical Surgical Nursing II|
Questions and Verified Answers Plus Rationales| 100% Correct| Grade A – Fortis
Question 1
A nurse is assessing a client with left-sided heart failure. Which of the following findings should
the nurse expect?
A) Jugular venous distension
B) Dependent edema
C) Pulmonary crackles
D) Hepatic engorgement
E) Ascites
Correct Answer: C) Pulmonary crackles
Rationale: Left-sided heart failure results in inadequate output from the left ventricle,
causing blood to back up into the pulmonary veins and capillaries. This increased
hydrostatic pressure forces fluid into the alveoli, resulting in pulmonary edema and
crackles (rales) upon auscultation. Options A, B, D, and E are clinical manifestations of
right-sided heart failure, which results in systemic venous congestion and fluid volume
excess in the periphery.
Question 2
A nurse is caring for a client who is scheduled for a coronary angiogram. Which of the following
laboratory results is the priority for the nurse to review before the procedure?
A) Hemoglobin and hematocrit
B) Serum creatinine
C) Alkaline phosphatase
D) Serum albumin
E) Platelet count
Correct Answer: B) Serum creatinine
Rationale: Coronary angiography involves the use of iodine-based contrast dye, which is
nephrotoxic. The kidneys are responsible for excreting this dye; therefore, the nurse must
assess the client’s renal function (Creatinine and GFR) to determine the risk for contrast-
induced nephropathy. While other labs are important, the immediate safety concern
regarding the procedure’s medium is kidney function.
Question 3
A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which
of the following instructions should the nurse include?
A) "You may resume lifting heavy objects after 48 hours."
B) "Avoid standing near microwaves while they are in use."
C) "Do not use a cell phone on the side of your body where the pacemaker is located."
D) "Check your pulse for 15 seconds every morning."
E) "Notify the provider if your heart rate is 5 beats faster than the set rate."
, 2
Correct Answer: C) "Do not use a cell phone on the side of your body where the pacemaker
is located."
Rationale: To prevent electromagnetic interference (EMI) with the pacemaker's function,
clients are instructed to use their cell phone on the ear opposite the device and not to carry
the phone in a breast pocket directly over the generator. Heavy lifting is restricted for
several weeks to prevent lead displacement. Modern microwaves are safe. The pulse should
be checked for a full minute, and the provider should be notified if the rate is slower than
the set rate.
Question 4
A nurse is assessing a client who has pericarditis. Which of the following findings should the
nurse expect?
A) Pain that decreases when the client lies flat
B) Presence of a friction rub on auscultation
C) Widened pulse pressure
D) Bradycardia with ST-segment depression
E) Heart sounds that are loud and bounding
Correct Answer: B) Presence of a friction rub on auscultation
Rationale: Pericarditis is an inflammation of the pericardial sac. As the inflamed layers of
the pericardium rub against each other during the cardiac cycle, they produce a scratchy,
high-pitched sound known as a pericardial friction rub. Pain usually increases when lying
flat and decreases when leaning forward. Pericarditis typically shows ST-segment elevation
across most leads, not depression.
Question 5
A nurse is reviewing the EKG of a client who has a potassium level of 6.2 mEq/L. Which of the
following changes should the nurse expect?
A) Prominent U waves
B) Shortened PR interval
C) Tall, peaked T waves
D) ST-segment depression
E) Narrowed QRS complex
Correct Answer: C) Tall, peaked T waves
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) affects the repolarization phase of the
cardiac cycle, which is represented by the T wave. Tall, peaked T waves are one of the
earliest signs of hyperkalemia. As levels increase, the PR interval prolongs and the QRS
complex widens, eventually leading to cardiac arrest. U waves and ST depression are
associated with hypokalemia.
, 3
Question 6
A nurse is caring for a client who has an abdominal aortic aneurysm (AAA). Which of the
following findings indicates that the aneurysm is expanding or at risk of rupture?
A) Increased bowel sounds
B) Sudden, severe back or abdominal pain
C) Hypertension
D) Increased appetite
E) Warmth and redness in the extremities
Correct Answer: B) Sudden, severe back or abdominal pain
Rationale: As an abdominal aortic aneurysm expands, it may exert pressure on the
surrounding nerves and structures, causing constant or intermittent back or abdominal
pain. A sudden, sharp, and severe onset of pain often indicates that the aneurysm is
dissecting or has ruptured, which is a surgical emergency. Hypertension would worsen the
risk, but the pain is the hallmark sign of expansion/rupture.
Question 7
A nurse is preparing to administer digoxin to a client with heart failure. Which of the following
findings should the nurse identify as a manifestation of digoxin toxicity?
A) Tachycardia
B) Hypertension
C) Vision changes, such as yellow halos
D) Increased urinary output
E) Constipation
Correct Answer: C) Vision changes, such as yellow halos
Rationale: Digoxin toxicity is characterized by gastrointestinal distress (nausea, vomiting,
anorexia) and neurological/visual disturbances. Clients often report seeing yellow, green, or
white halos around objects. Dysrhythmias, especially bradycardia, are also common.
Digoxin does not cause hypertension or constipation; rather, it increases the force of
contraction (positive inotrope) and slows the heart rate (negative chronotrope).
Question 8
A nurse is teaching a client about the prevention of infective endocarditis. Which of the
following statements by the client indicates an understanding of the teaching?
A) "I will take antibiotics before I have any dental work done."
B) "I should use a firm toothbrush to keep my gums clean."
C) "I will limit my fluid intake to 1 liter per day."
D) "I don't need to worry about skin cuts as long as they aren't on my chest."
E) "I will stop my heart medications if I get a fever."
, 4
Correct Answer: A) "I will take antibiotics before I have any dental work done."
Rationale: Infective endocarditis involves bacteria entering the bloodstream and attaching
to heart valves. High-risk clients (those with prosthetic valves or a history of endocarditis)
require prophylactic antibiotic therapy before invasive procedures, including dental work,
to prevent bacteremia. Firm toothbrushes should be avoided as they can cause gum
bleeding, providing an entry point for bacteria.
Question 9
A nurse is caring for a client who is 4 hours postoperative following a carotid endarterectomy.
Which of the following is the priority assessment?
A) Bowel sounds
B) Urinary output
C) Respiratory status and airway patency
D) Pedal pulses
E) Incisional pain level
Correct Answer: C) Respiratory status and airway patency
Rationale: A carotid endarterectomy involves an incision in the neck. Postoperative
complications include hematoma formation, which can rapidly compress the trachea and
obstruct the airway. The nurse must prioritize monitoring for respiratory distress, tracheal
deviation, and neck swelling (ABC priority). While pain and output are important, airway
stability is life-critical.
Question 10
A nurse is assessing a client for manifestations of Buerger's disease (thromboangiitis obliterans).
Which of the following questions should the nurse ask?
A) "Do you have a history of high blood pressure?"
B) "Do you currently use tobacco products?"
C) "Do you have a family history of diabetes?"
D) "Are you allergic to shellfish or iodine?"
E) "How much alcohol do you consume daily?"
Correct Answer: B) "Do you currently use tobacco products?"
Rationale: Buerger's disease is an inflammatory disease of the small and medium-sized
arteries and veins. It is most common in young men and is strongly associated with tobacco
use (smoking or chewing). The primary treatment is the complete cessation of tobacco;
without it, the disease progresses to gangrene and amputation. Hypertension and diabetes
are risk factors for general atherosclerosis, but not specific to Buerger's.
Question 11
A nurse is providing teaching to a client with Raynaud's phenomenon. Which of the following
interventions should the nurse recommend?
Questions and Verified Answers Plus Rationales| 100% Correct| Grade A – Fortis
Question 1
A nurse is assessing a client with left-sided heart failure. Which of the following findings should
the nurse expect?
A) Jugular venous distension
B) Dependent edema
C) Pulmonary crackles
D) Hepatic engorgement
E) Ascites
Correct Answer: C) Pulmonary crackles
Rationale: Left-sided heart failure results in inadequate output from the left ventricle,
causing blood to back up into the pulmonary veins and capillaries. This increased
hydrostatic pressure forces fluid into the alveoli, resulting in pulmonary edema and
crackles (rales) upon auscultation. Options A, B, D, and E are clinical manifestations of
right-sided heart failure, which results in systemic venous congestion and fluid volume
excess in the periphery.
Question 2
A nurse is caring for a client who is scheduled for a coronary angiogram. Which of the following
laboratory results is the priority for the nurse to review before the procedure?
A) Hemoglobin and hematocrit
B) Serum creatinine
C) Alkaline phosphatase
D) Serum albumin
E) Platelet count
Correct Answer: B) Serum creatinine
Rationale: Coronary angiography involves the use of iodine-based contrast dye, which is
nephrotoxic. The kidneys are responsible for excreting this dye; therefore, the nurse must
assess the client’s renal function (Creatinine and GFR) to determine the risk for contrast-
induced nephropathy. While other labs are important, the immediate safety concern
regarding the procedure’s medium is kidney function.
Question 3
A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which
of the following instructions should the nurse include?
A) "You may resume lifting heavy objects after 48 hours."
B) "Avoid standing near microwaves while they are in use."
C) "Do not use a cell phone on the side of your body where the pacemaker is located."
D) "Check your pulse for 15 seconds every morning."
E) "Notify the provider if your heart rate is 5 beats faster than the set rate."
, 2
Correct Answer: C) "Do not use a cell phone on the side of your body where the pacemaker
is located."
Rationale: To prevent electromagnetic interference (EMI) with the pacemaker's function,
clients are instructed to use their cell phone on the ear opposite the device and not to carry
the phone in a breast pocket directly over the generator. Heavy lifting is restricted for
several weeks to prevent lead displacement. Modern microwaves are safe. The pulse should
be checked for a full minute, and the provider should be notified if the rate is slower than
the set rate.
Question 4
A nurse is assessing a client who has pericarditis. Which of the following findings should the
nurse expect?
A) Pain that decreases when the client lies flat
B) Presence of a friction rub on auscultation
C) Widened pulse pressure
D) Bradycardia with ST-segment depression
E) Heart sounds that are loud and bounding
Correct Answer: B) Presence of a friction rub on auscultation
Rationale: Pericarditis is an inflammation of the pericardial sac. As the inflamed layers of
the pericardium rub against each other during the cardiac cycle, they produce a scratchy,
high-pitched sound known as a pericardial friction rub. Pain usually increases when lying
flat and decreases when leaning forward. Pericarditis typically shows ST-segment elevation
across most leads, not depression.
Question 5
A nurse is reviewing the EKG of a client who has a potassium level of 6.2 mEq/L. Which of the
following changes should the nurse expect?
A) Prominent U waves
B) Shortened PR interval
C) Tall, peaked T waves
D) ST-segment depression
E) Narrowed QRS complex
Correct Answer: C) Tall, peaked T waves
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) affects the repolarization phase of the
cardiac cycle, which is represented by the T wave. Tall, peaked T waves are one of the
earliest signs of hyperkalemia. As levels increase, the PR interval prolongs and the QRS
complex widens, eventually leading to cardiac arrest. U waves and ST depression are
associated with hypokalemia.
, 3
Question 6
A nurse is caring for a client who has an abdominal aortic aneurysm (AAA). Which of the
following findings indicates that the aneurysm is expanding or at risk of rupture?
A) Increased bowel sounds
B) Sudden, severe back or abdominal pain
C) Hypertension
D) Increased appetite
E) Warmth and redness in the extremities
Correct Answer: B) Sudden, severe back or abdominal pain
Rationale: As an abdominal aortic aneurysm expands, it may exert pressure on the
surrounding nerves and structures, causing constant or intermittent back or abdominal
pain. A sudden, sharp, and severe onset of pain often indicates that the aneurysm is
dissecting or has ruptured, which is a surgical emergency. Hypertension would worsen the
risk, but the pain is the hallmark sign of expansion/rupture.
Question 7
A nurse is preparing to administer digoxin to a client with heart failure. Which of the following
findings should the nurse identify as a manifestation of digoxin toxicity?
A) Tachycardia
B) Hypertension
C) Vision changes, such as yellow halos
D) Increased urinary output
E) Constipation
Correct Answer: C) Vision changes, such as yellow halos
Rationale: Digoxin toxicity is characterized by gastrointestinal distress (nausea, vomiting,
anorexia) and neurological/visual disturbances. Clients often report seeing yellow, green, or
white halos around objects. Dysrhythmias, especially bradycardia, are also common.
Digoxin does not cause hypertension or constipation; rather, it increases the force of
contraction (positive inotrope) and slows the heart rate (negative chronotrope).
Question 8
A nurse is teaching a client about the prevention of infective endocarditis. Which of the
following statements by the client indicates an understanding of the teaching?
A) "I will take antibiotics before I have any dental work done."
B) "I should use a firm toothbrush to keep my gums clean."
C) "I will limit my fluid intake to 1 liter per day."
D) "I don't need to worry about skin cuts as long as they aren't on my chest."
E) "I will stop my heart medications if I get a fever."
, 4
Correct Answer: A) "I will take antibiotics before I have any dental work done."
Rationale: Infective endocarditis involves bacteria entering the bloodstream and attaching
to heart valves. High-risk clients (those with prosthetic valves or a history of endocarditis)
require prophylactic antibiotic therapy before invasive procedures, including dental work,
to prevent bacteremia. Firm toothbrushes should be avoided as they can cause gum
bleeding, providing an entry point for bacteria.
Question 9
A nurse is caring for a client who is 4 hours postoperative following a carotid endarterectomy.
Which of the following is the priority assessment?
A) Bowel sounds
B) Urinary output
C) Respiratory status and airway patency
D) Pedal pulses
E) Incisional pain level
Correct Answer: C) Respiratory status and airway patency
Rationale: A carotid endarterectomy involves an incision in the neck. Postoperative
complications include hematoma formation, which can rapidly compress the trachea and
obstruct the airway. The nurse must prioritize monitoring for respiratory distress, tracheal
deviation, and neck swelling (ABC priority). While pain and output are important, airway
stability is life-critical.
Question 10
A nurse is assessing a client for manifestations of Buerger's disease (thromboangiitis obliterans).
Which of the following questions should the nurse ask?
A) "Do you have a history of high blood pressure?"
B) "Do you currently use tobacco products?"
C) "Do you have a family history of diabetes?"
D) "Are you allergic to shellfish or iodine?"
E) "How much alcohol do you consume daily?"
Correct Answer: B) "Do you currently use tobacco products?"
Rationale: Buerger's disease is an inflammatory disease of the small and medium-sized
arteries and veins. It is most common in young men and is strongly associated with tobacco
use (smoking or chewing). The primary treatment is the complete cessation of tobacco;
without it, the disease progresses to gangrene and amputation. Hypertension and diabetes
are risk factors for general atherosclerosis, but not specific to Buerger's.
Question 11
A nurse is providing teaching to a client with Raynaud's phenomenon. Which of the following
interventions should the nurse recommend?
