NUR 221 Exam 2 ACTUAL EXAM
2026/2027 | NUR 221 Medical-Surgical
Nursing | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders
Q1: A 68-year-old male is admitted to the telemetry unit with a diagnosis of heart failure (HF). He
reports increasing shortness of breath and swelling in his ankles. Which assessment finding indicates
that the patient’s condition is progressing to acute decompensated heart failure?
A. Weight loss of 2 pounds over the last week.
B. Presence of an S3 heart sound upon auscultation. [CORRECT]
C. Blood pressure of 118/78 mm Hg.
D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: The S3 heart sound (ventricular gallop) is a classic sign of fluid volume overload and
decreased left ventricular compliance, indicating acute decompensated heart failure. Weight loss and
normal urine output suggest effective diuresis or stability. A BP of 118/78 is within normal limits. NCLEX
Tip: Recall that an S3 heart sound is pathologic in adults and often signals fluid overload/heart failure,
whereas an S4 is associated with stiff ventricles (e.g., hypertension).
Q2: The nurse is providing discharge teaching to a patient newly prescribed furosemide (Lasix) for heart
failure. Which statement by the patient indicates a need for further teaching?
A. "I should stand up slowly to prevent dizziness."
B. "I will eat more bananas and spinach." [CORRECT]
,C. "I need to weigh myself every morning after using the bathroom."
D. "I will take this medication in the morning so I don't have to wake up at night."
Correct Answer: B
Rationale: While increasing potassium intake is generally good advice for patients on loop diuretics,
simply "eating more" is not precise enough and can lead to hyperkalemia if the patient has renal issues
or is on potassium-sparing agents; the patient requires specific dietary guidance or monitoring of
potassium levels. Options A, C, and D are correct safety and management strategies. Correction: Option
B is technically "correct" advice but the stem asks for a need for further teaching. Let's re-evaluate
distractors.
Correction for Q2: Let's change Option B to a dangerous action.
Revised Q2 Option B: "I will take an extra dose if my ankles are swollen."
Revised Correct Answer: B.
Rationale for Revised Option B: Self-prescribing or increasing diuretic doses can lead to severe
dehydration, hypotension, and electrolyte imbalances. This statement indicates a misunderstanding of
the medication regimen. Options A, C, and D are appropriate. NCLEX Tip: Look for the option that is
dangerous or violates the prescription.
Q3: A patient is diagnosed with a deep vein thrombosis (DVT) in the left leg. Which nursing intervention
is most appropriate to prevent complications?
A. Massage the affected leg to reduce pain.
B. Apply a heating pad to the affected area.
C. Elevate the affected leg above the level of the heart. [CORRECT]
D. Encourage the patient to keep the leg dependent to promote perfusion.
Correct Answer: C
Rationale: Elevation promotes venous return and reduces edema. Massaging the affected leg or
applying heat can dislodge the clot, leading to a pulmonary embolism. Keeping the leg dependent
increases edema. NCLEX Tip: Never massage a limb with a suspected or confirmed DVT; this is a critical
safety precaution.
,Q4: A patient arrives in the Emergency Department with chest pain. An electrocardiogram (ECG) shows
ST-segment elevation in leads V1 through V4. The nurse recognizes this finding is consistent with which
type of myocardial infarction (MI)?
A. Inferior wall MI.
B. Lateral wall MI.
C. Anterior wall MI. [CORRECT]
D. Posterior wall MI.
Correct Answer: C
Rationale: Leads V1–V4 view the anterior wall of the left ventricle. An anterior MI is often associated
with left ventricular failure and cardiogenic shock. Inferior MI involves leads II, III, and aVF. NCLEX Tip:
Memorize lead placement correlations: V1–V4 (Anterior), II/III/aVF (Inferior), I/aVL/V5/V6 (Lateral).
Q5: The nurse is caring for a patient who is 24 hours post-coronary artery bypass graft (CABG) surgery.
The nurse notes constant bubbling in the water-seal chamber of the mediastinal chest tube drainage
system. What is the priority nursing action?
A. Clamp the chest tube near the insertion site.
B. Assess the patient’s respiratory status. [CORRECT]
C. Check for loose connections in the drainage system.
D. Notify the surgeon immediately.
Correct Answer: C
Rationale: Constant bubbling in the water-seal chamber indicates an air leak. The first step is to check
for loose connections, which is a common and easily fixable cause. Clamping the tube is dangerous as it
can cause tension pneumothorax. Assessing the patient is vital, but identifying the source of the leak is
the immediate priority intervention. Correction: The priority is to find the cause. Let's refine.
Refined Rationale: Constant bubbling indicates an air leak. The nurse should first check the connections
from the patient to the system to rule out a simple loose connection. If the leak persists, the physician is
notified. Clamping is contraindicated. NCLEX Tip: Troubleshoot the equipment (connections) before
invasive interventions or calling the doctor if the patient is stable.
Q6: A patient is receiving intravenous nitroglycerin (Tridil) for unstable angina. Which assessment
finding requires immediate intervention by the nurse?
, A. Heart rate of 94 beats/minute.
B. Blood pressure of 86/44 mm Hg. [CORRECT]
C. Respiratory rate of 18 breaths/minute.
D. Complaints of a headache.
Correct Answer: B
Rationale: Nitroglycerin is a potent vasodilator. A blood pressure of 86/44 indicates hypotension, which
compromises organ perfusion and is an adverse effect requiring immediate stopping or titration of the
infusion. Headache is a common side effect due to vasodilation. NCLEX Tip: Hypotension is a priority
safety risk for vasodilators; if BP drops significantly, stop the infusion.
Q7: The nurse is caring for a patient with a diagnosis of hypertension who is starting on a low-sodium
diet. Which food selection by the patient indicates an understanding of the teaching?
A. Canned tomato soup.
B. Grilled chicken breast with steamed broccoli. [CORRECT]
C. Ham sandwich with pickles.
D. Processed cheese and crackers.
Correct Answer: B
Rationale: Grilled chicken and fresh vegetables are naturally low in sodium. Canned soups, ham, pickles,
processed cheese, and crackers are typically very high in sodium. NCLEX Tip: "Fresh is best." Avoid
canned, processed, cured, or smoked foods for low-sodium diets.
Q8: A patient is scheduled for a stress test. The nurse should hold the test and contact the provider if
the patient reports which finding?
A. Inability to walk on a treadmill due to knee arthritis.
B. Taking metformin (Glucophage) this morning.
C. Experiencing chest pain at rest this morning. [CORRECT]
D. A history of asthma controlled by albuterol.
Correct Answer: C
2026/2027 | NUR 221 Medical-Surgical
Nursing | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders
Q1: A 68-year-old male is admitted to the telemetry unit with a diagnosis of heart failure (HF). He
reports increasing shortness of breath and swelling in his ankles. Which assessment finding indicates
that the patient’s condition is progressing to acute decompensated heart failure?
A. Weight loss of 2 pounds over the last week.
B. Presence of an S3 heart sound upon auscultation. [CORRECT]
C. Blood pressure of 118/78 mm Hg.
D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: The S3 heart sound (ventricular gallop) is a classic sign of fluid volume overload and
decreased left ventricular compliance, indicating acute decompensated heart failure. Weight loss and
normal urine output suggest effective diuresis or stability. A BP of 118/78 is within normal limits. NCLEX
Tip: Recall that an S3 heart sound is pathologic in adults and often signals fluid overload/heart failure,
whereas an S4 is associated with stiff ventricles (e.g., hypertension).
Q2: The nurse is providing discharge teaching to a patient newly prescribed furosemide (Lasix) for heart
failure. Which statement by the patient indicates a need for further teaching?
A. "I should stand up slowly to prevent dizziness."
B. "I will eat more bananas and spinach." [CORRECT]
,C. "I need to weigh myself every morning after using the bathroom."
D. "I will take this medication in the morning so I don't have to wake up at night."
Correct Answer: B
Rationale: While increasing potassium intake is generally good advice for patients on loop diuretics,
simply "eating more" is not precise enough and can lead to hyperkalemia if the patient has renal issues
or is on potassium-sparing agents; the patient requires specific dietary guidance or monitoring of
potassium levels. Options A, C, and D are correct safety and management strategies. Correction: Option
B is technically "correct" advice but the stem asks for a need for further teaching. Let's re-evaluate
distractors.
Correction for Q2: Let's change Option B to a dangerous action.
Revised Q2 Option B: "I will take an extra dose if my ankles are swollen."
Revised Correct Answer: B.
Rationale for Revised Option B: Self-prescribing or increasing diuretic doses can lead to severe
dehydration, hypotension, and electrolyte imbalances. This statement indicates a misunderstanding of
the medication regimen. Options A, C, and D are appropriate. NCLEX Tip: Look for the option that is
dangerous or violates the prescription.
Q3: A patient is diagnosed with a deep vein thrombosis (DVT) in the left leg. Which nursing intervention
is most appropriate to prevent complications?
A. Massage the affected leg to reduce pain.
B. Apply a heating pad to the affected area.
C. Elevate the affected leg above the level of the heart. [CORRECT]
D. Encourage the patient to keep the leg dependent to promote perfusion.
Correct Answer: C
Rationale: Elevation promotes venous return and reduces edema. Massaging the affected leg or
applying heat can dislodge the clot, leading to a pulmonary embolism. Keeping the leg dependent
increases edema. NCLEX Tip: Never massage a limb with a suspected or confirmed DVT; this is a critical
safety precaution.
,Q4: A patient arrives in the Emergency Department with chest pain. An electrocardiogram (ECG) shows
ST-segment elevation in leads V1 through V4. The nurse recognizes this finding is consistent with which
type of myocardial infarction (MI)?
A. Inferior wall MI.
B. Lateral wall MI.
C. Anterior wall MI. [CORRECT]
D. Posterior wall MI.
Correct Answer: C
Rationale: Leads V1–V4 view the anterior wall of the left ventricle. An anterior MI is often associated
with left ventricular failure and cardiogenic shock. Inferior MI involves leads II, III, and aVF. NCLEX Tip:
Memorize lead placement correlations: V1–V4 (Anterior), II/III/aVF (Inferior), I/aVL/V5/V6 (Lateral).
Q5: The nurse is caring for a patient who is 24 hours post-coronary artery bypass graft (CABG) surgery.
The nurse notes constant bubbling in the water-seal chamber of the mediastinal chest tube drainage
system. What is the priority nursing action?
A. Clamp the chest tube near the insertion site.
B. Assess the patient’s respiratory status. [CORRECT]
C. Check for loose connections in the drainage system.
D. Notify the surgeon immediately.
Correct Answer: C
Rationale: Constant bubbling in the water-seal chamber indicates an air leak. The first step is to check
for loose connections, which is a common and easily fixable cause. Clamping the tube is dangerous as it
can cause tension pneumothorax. Assessing the patient is vital, but identifying the source of the leak is
the immediate priority intervention. Correction: The priority is to find the cause. Let's refine.
Refined Rationale: Constant bubbling indicates an air leak. The nurse should first check the connections
from the patient to the system to rule out a simple loose connection. If the leak persists, the physician is
notified. Clamping is contraindicated. NCLEX Tip: Troubleshoot the equipment (connections) before
invasive interventions or calling the doctor if the patient is stable.
Q6: A patient is receiving intravenous nitroglycerin (Tridil) for unstable angina. Which assessment
finding requires immediate intervention by the nurse?
, A. Heart rate of 94 beats/minute.
B. Blood pressure of 86/44 mm Hg. [CORRECT]
C. Respiratory rate of 18 breaths/minute.
D. Complaints of a headache.
Correct Answer: B
Rationale: Nitroglycerin is a potent vasodilator. A blood pressure of 86/44 indicates hypotension, which
compromises organ perfusion and is an adverse effect requiring immediate stopping or titration of the
infusion. Headache is a common side effect due to vasodilation. NCLEX Tip: Hypotension is a priority
safety risk for vasodilators; if BP drops significantly, stop the infusion.
Q7: The nurse is caring for a patient with a diagnosis of hypertension who is starting on a low-sodium
diet. Which food selection by the patient indicates an understanding of the teaching?
A. Canned tomato soup.
B. Grilled chicken breast with steamed broccoli. [CORRECT]
C. Ham sandwich with pickles.
D. Processed cheese and crackers.
Correct Answer: B
Rationale: Grilled chicken and fresh vegetables are naturally low in sodium. Canned soups, ham, pickles,
processed cheese, and crackers are typically very high in sodium. NCLEX Tip: "Fresh is best." Avoid
canned, processed, cured, or smoked foods for low-sodium diets.
Q8: A patient is scheduled for a stress test. The nurse should hold the test and contact the provider if
the patient reports which finding?
A. Inability to walk on a treadmill due to knee arthritis.
B. Taking metformin (Glucophage) this morning.
C. Experiencing chest pain at rest this morning. [CORRECT]
D. A history of asthma controlled by albuterol.
Correct Answer: C
