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Kaplan Medical-Surgical Nursing II
(Med Surg 2) Test Bank by Kaplan
Nursing, 2025-2026 Edition |
Comprehensive Q&A .
**Q1. A client with a history of heart failure is receiving furosemide
(Lasix) 40 mg IV push. Which assessment is most important for the
nurse to monitor?**
A) Respiratory rate
B) Oxygen saturation
C) Serum potassium level
D) Blood pressure
**Answer: C) Serum potassium level**
**Rationale:** Furosemide is a loop diuretic that causes significant
potassium excretion. Hypokalemia can precipitate life-threatening
dysrhythmias, especially in clients with heart failure who may also be
taking digoxin .
**Q2. A client with atrial fibrillation is prescribed warfarin (Coumadin).
Which statement by the client indicates a need for further teaching?**
A) "I will use an electric razor for shaving."
,B) "I should report black, tarry stools to my provider."
C) "I will increase my intake of green leafy vegetables."
D) "I will wear a medical alert bracelet."
**Answer: C) "I will increase my intake of green leafy vegetables."**
**Rationale:** Green leafy vegetables are high in vitamin K, which
antagonizes the effects of warfarin. Intake should be consistent, not
increased. The other options are correct safety measures for clients on
anticoagulants .
**Q3. A client is admitted with a blood pressure of 210/120 mm Hg and
reports a severe headache and blurred vision. Which medication should
the nurse anticipate administering first?**
A) Metoprolol (Lopressor) PO
B) Furosemide (Lasix) IV
C) Nitroprusside (Nitropress) IV
D) Lisinopril (Zestril) PO
**Answer: C) Nitroprusside (Nitropress) IV**
**Rationale:** This client is experiencing a hypertensive emergency,
requiring immediate blood pressure reduction with a rapid-acting IV
agent like nitroprusside to prevent end-organ damage .
**Q4. A client with heart failure has bilateral crackles and an oxygen
saturation of 88%. What should the nurse do first?**
A) Increase oral fluids
,B) Place the client in high Fowler's position
C) Encourage ambulation
D) Restrict oxygen therapy
**Answer: B) Place the client in high Fowler's position**
**Rationale:** Upright positioning (high Fowler's) uses gravity to
reduce venous return (preload) and improves lung expansion and
oxygenation, offering immediate relief .
**Q5. A client returns from a cardiac catheterization via the femoral
artery. Which finding requires immediate intervention?**
A) Heart rate of 82 beats/min
B) Client reports feeling "warm all over"
C) The pedal pulse on the operative leg is +1 and the leg is pale
D) Small amount of serosanguineous drainage at the insertion site
**Answer: C) The pedal pulse on the operative leg is +1 and the leg is
pale**
**Rationale:** Diminished pulse and pallor in the operative leg suggest
arterial occlusion or thrombus formation, which is a medical emergency
requiring immediate notification of the provider .
**Q6. A nurse is assessing a client 12 hours post-cardiac
catheterization. The client's groin site is free of hematoma, but the
client reports severe back pain. What is the priority nursing action?**
A) Administer prescribed PRN analgesic
, B) Assess the client's blood pressure and heart rate
C) Reposition the client onto the left side
D) Encourage the client to ambulate in the hall
**Answer: B) Assess the client's blood pressure and heart rate**
**Rationale:** Severe back pain after a catheterization can be a sign of
retroperitoneal bleeding, a serious complication. The nurse must first
assess for signs of hypovolemic shock (tachycardia, hypotension) .
**Q7. A client is prescribed digoxin (Lanoxin) 0.25 mg PO daily. Prior to
administration, the nurse should:**
A) Assess the client's blood pressure
B) Assess the apical pulse for one full minute
C) Assess the client's oxygen saturation
D) Assess the client's pain level
**Answer: B) Assess the apical pulse for one full minute**
**Rationale:** Digoxin can cause bradycardia and heart blocks. The
apical pulse must be assessed for one full minute before
administration. The dose should be held and the provider notified if the
heart rate is below 60 beats/min in an adult .
**Q8. A client is receiving a blood transfusion and reports chills and
back pain. What is the nurse's priority action?**
A) Slow the infusion rate
B) Administer prescribed acetaminophen
Kaplan Medical-Surgical Nursing II
(Med Surg 2) Test Bank by Kaplan
Nursing, 2025-2026 Edition |
Comprehensive Q&A .
**Q1. A client with a history of heart failure is receiving furosemide
(Lasix) 40 mg IV push. Which assessment is most important for the
nurse to monitor?**
A) Respiratory rate
B) Oxygen saturation
C) Serum potassium level
D) Blood pressure
**Answer: C) Serum potassium level**
**Rationale:** Furosemide is a loop diuretic that causes significant
potassium excretion. Hypokalemia can precipitate life-threatening
dysrhythmias, especially in clients with heart failure who may also be
taking digoxin .
**Q2. A client with atrial fibrillation is prescribed warfarin (Coumadin).
Which statement by the client indicates a need for further teaching?**
A) "I will use an electric razor for shaving."
,B) "I should report black, tarry stools to my provider."
C) "I will increase my intake of green leafy vegetables."
D) "I will wear a medical alert bracelet."
**Answer: C) "I will increase my intake of green leafy vegetables."**
**Rationale:** Green leafy vegetables are high in vitamin K, which
antagonizes the effects of warfarin. Intake should be consistent, not
increased. The other options are correct safety measures for clients on
anticoagulants .
**Q3. A client is admitted with a blood pressure of 210/120 mm Hg and
reports a severe headache and blurred vision. Which medication should
the nurse anticipate administering first?**
A) Metoprolol (Lopressor) PO
B) Furosemide (Lasix) IV
C) Nitroprusside (Nitropress) IV
D) Lisinopril (Zestril) PO
**Answer: C) Nitroprusside (Nitropress) IV**
**Rationale:** This client is experiencing a hypertensive emergency,
requiring immediate blood pressure reduction with a rapid-acting IV
agent like nitroprusside to prevent end-organ damage .
**Q4. A client with heart failure has bilateral crackles and an oxygen
saturation of 88%. What should the nurse do first?**
A) Increase oral fluids
,B) Place the client in high Fowler's position
C) Encourage ambulation
D) Restrict oxygen therapy
**Answer: B) Place the client in high Fowler's position**
**Rationale:** Upright positioning (high Fowler's) uses gravity to
reduce venous return (preload) and improves lung expansion and
oxygenation, offering immediate relief .
**Q5. A client returns from a cardiac catheterization via the femoral
artery. Which finding requires immediate intervention?**
A) Heart rate of 82 beats/min
B) Client reports feeling "warm all over"
C) The pedal pulse on the operative leg is +1 and the leg is pale
D) Small amount of serosanguineous drainage at the insertion site
**Answer: C) The pedal pulse on the operative leg is +1 and the leg is
pale**
**Rationale:** Diminished pulse and pallor in the operative leg suggest
arterial occlusion or thrombus formation, which is a medical emergency
requiring immediate notification of the provider .
**Q6. A nurse is assessing a client 12 hours post-cardiac
catheterization. The client's groin site is free of hematoma, but the
client reports severe back pain. What is the priority nursing action?**
A) Administer prescribed PRN analgesic
, B) Assess the client's blood pressure and heart rate
C) Reposition the client onto the left side
D) Encourage the client to ambulate in the hall
**Answer: B) Assess the client's blood pressure and heart rate**
**Rationale:** Severe back pain after a catheterization can be a sign of
retroperitoneal bleeding, a serious complication. The nurse must first
assess for signs of hypovolemic shock (tachycardia, hypotension) .
**Q7. A client is prescribed digoxin (Lanoxin) 0.25 mg PO daily. Prior to
administration, the nurse should:**
A) Assess the client's blood pressure
B) Assess the apical pulse for one full minute
C) Assess the client's oxygen saturation
D) Assess the client's pain level
**Answer: B) Assess the apical pulse for one full minute**
**Rationale:** Digoxin can cause bradycardia and heart blocks. The
apical pulse must be assessed for one full minute before
administration. The dose should be held and the provider notified if the
heart rate is below 60 beats/min in an adult .
**Q8. A client is receiving a blood transfusion and reports chills and
back pain. What is the nurse's priority action?**
A) Slow the infusion rate
B) Administer prescribed acetaminophen
