NUR 242 MED SURG EXAM 3
NUR 242 MED SURG EXAM 3 2025 LATEST UPDATE ACTUAL EXAM 200
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral
digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item
would the nurse teach the mother to use when administering the medication? - ANSWER-
Calibrated syringe
An infant with a diagnosis of heart failure is being given furosemide twice a day. Which
laboratory value would the nurse report to the health care provider? - ANSWER-Potassium of
3.0 mEq/L (3.0 mmol/L)
A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The
registered nurse identifies that which items on the client's care plan are appropriate for a
licensed practical nurse (LPN) to perform? Select all that apply. One, some, or all responses may
be correct. - ANSWER-Help the client ambulate when required.
Monitor the client's vitals every 30 minutes
Administer adequate oral fluids to the client
The nurse taught a client with heart failure who is scheduled for discharge about how
medications, diet, and exercise improve activity tolerance. During a follow-up visit, the nurse
finds that the client has learned how to adapt his or her exercise prescription to increase activity
tolerance. Which theory did the nurse follow to achieve this positive outcome? - ANSWER-Roy's
theory
Which intervention would the nurse use after observing that a 6-month-old child lies quietly,
rarely smiles or babbles, and has his basic needs barely met by the primary caregiver, who is a
grandparent with chronic heart failure? - ANSWER-Initiate a referral for assessment of home
health and schedule a family conference.
1|Page
, NUR 242 MED SURG EXAM 3
A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1
kg). How many milliliters of fluid has the client retained? . ___mL - ANSWER-2700 ml
An infant with a congenital heart defect is in heart failure and is receiving daily weight
measurements. Which complication of heart failure would daily weights help monitor? -
ANSWER-Fluid retention
Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot
and heart failure? - ANSWER-Providing small, frequent feedings
The nurse provides teaching to a client who is being discharged after an acute exacerbation of
chronic obstructive pulmonary disease (COPD). The nurse would instruct the client to monitor
for which indication of right-sided heart failure? - ANSWER-Weight gain
When a client with heart failure reports frequent sudden waking during the night with
shortness of breath, how will the nurse document this finding? - ANSWER-Paroxysmal nocturnal
dyspnea
The nurse explains to a pregnant client with a class II heart failure that in pregnancy the cardiac
system is most compromised during which time? - ANSWER-First 2 days after the birth
Which sign would indicate possible heart failure in a client with heart disease in the immediate
postpartum period? - ANSWER-Tachypnea
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to
drink a glass of orange juice every day? - ANSWER-Maintaining potassium levels
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to
drink a glass of orange juice every day? - ANSWER-Maintaining potassium levels
2|Page
, NUR 242 MED SURG EXAM 3
When a client with type 1 diabetes develops heart failure, digoxin is prescribed. Which nursing
action is important to include when planning care? - ANSWER-Monitor the client for cardiac
dysrhythmias.
A client with left ventricular heart failure and supraventricular tachycardia is prescribed digoxin
0.25 mg daily. Which changes would the nurse expect to find if this medication is therapeutically
effective? Select all that apply. One, some, or all responses may be correct. - ANSWER-Diuresis
Decreased edema
Decreased pulse rate
A client with hypertensive heart disease who had an acute episode of heart failure is to be
discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate
when metoprolol is administered with digoxin? - ANSWER-Bradycardia
A health care provider prescribes milrinone for a client with congestive heart failure. Which
action would the nurse perform first? - ANSWER-Have the prescription, dosage calculations, and
pump settings checked by a second nurse
Which care plan would the nurse implement for an infant admitted to the pediatric unit with
the diagnosis of heart failure? - ANSWER-Offer the infant small, frequent feedings
Which parent education would the nurse provide as rationale for gavage feedings in an infant
with congestive heart failure? - ANSWER-The energy that would have been expended on
suckling is conserved
Which assessment finding for a client with heart failure who is taking digoxin will be most
important to communicate to the health care provider? - ANSWER-Premature ventricular
contractions
3|Page
, NUR 242 MED SURG EXAM 3
Which statement made by the nursing student requires correction regarding the effect of
applying the Roy adaptation model on improved functional status in clients with heart failure? -
ANSWER-Use of literature resources supports practical-based nursing interventions."
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and
peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? -
ANSWER-Shift of fluid into the interstitial spaces
An older client with a history of congestive heart failure expresses concern about potential
exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The
roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that
the nurse pursues more information about the roommate? - ANSWER-TB adversely affects older
adults with chronic illness
When the clinic nurse is teaching a group of clients with heart failure (HF) about dietary
interventions to prevent fluid overload, which topic will be included? - ANSWER-Use of fresh or
frozen vegetables instead of canned ones / low sodium
Which action would the nurse take first when a client with heart failure has an episode of
paroxysmal nocturnal dyspnea (PND)? - ANSWER-Assist the client to sit on the edge of the bed
When caring for a client with a diagnosis of right ventricular heart failure, the nurse expects
which assessment findings? Select all that apply. One, some, or all responses may be correct. -
ANSWER-Dependent edema
Swollen hands and fingers
Right upper quadrant discomfort
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral
crackles. Which is the priority nursing intervention? - ANSWER-Place client in a high-Fowler
position.
4|Page
NUR 242 MED SURG EXAM 3 2025 LATEST UPDATE ACTUAL EXAM 200
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral
digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item
would the nurse teach the mother to use when administering the medication? - ANSWER-
Calibrated syringe
An infant with a diagnosis of heart failure is being given furosemide twice a day. Which
laboratory value would the nurse report to the health care provider? - ANSWER-Potassium of
3.0 mEq/L (3.0 mmol/L)
A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The
registered nurse identifies that which items on the client's care plan are appropriate for a
licensed practical nurse (LPN) to perform? Select all that apply. One, some, or all responses may
be correct. - ANSWER-Help the client ambulate when required.
Monitor the client's vitals every 30 minutes
Administer adequate oral fluids to the client
The nurse taught a client with heart failure who is scheduled for discharge about how
medications, diet, and exercise improve activity tolerance. During a follow-up visit, the nurse
finds that the client has learned how to adapt his or her exercise prescription to increase activity
tolerance. Which theory did the nurse follow to achieve this positive outcome? - ANSWER-Roy's
theory
Which intervention would the nurse use after observing that a 6-month-old child lies quietly,
rarely smiles or babbles, and has his basic needs barely met by the primary caregiver, who is a
grandparent with chronic heart failure? - ANSWER-Initiate a referral for assessment of home
health and schedule a family conference.
1|Page
, NUR 242 MED SURG EXAM 3
A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1
kg). How many milliliters of fluid has the client retained? . ___mL - ANSWER-2700 ml
An infant with a congenital heart defect is in heart failure and is receiving daily weight
measurements. Which complication of heart failure would daily weights help monitor? -
ANSWER-Fluid retention
Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot
and heart failure? - ANSWER-Providing small, frequent feedings
The nurse provides teaching to a client who is being discharged after an acute exacerbation of
chronic obstructive pulmonary disease (COPD). The nurse would instruct the client to monitor
for which indication of right-sided heart failure? - ANSWER-Weight gain
When a client with heart failure reports frequent sudden waking during the night with
shortness of breath, how will the nurse document this finding? - ANSWER-Paroxysmal nocturnal
dyspnea
The nurse explains to a pregnant client with a class II heart failure that in pregnancy the cardiac
system is most compromised during which time? - ANSWER-First 2 days after the birth
Which sign would indicate possible heart failure in a client with heart disease in the immediate
postpartum period? - ANSWER-Tachypnea
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to
drink a glass of orange juice every day? - ANSWER-Maintaining potassium levels
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to
drink a glass of orange juice every day? - ANSWER-Maintaining potassium levels
2|Page
, NUR 242 MED SURG EXAM 3
When a client with type 1 diabetes develops heart failure, digoxin is prescribed. Which nursing
action is important to include when planning care? - ANSWER-Monitor the client for cardiac
dysrhythmias.
A client with left ventricular heart failure and supraventricular tachycardia is prescribed digoxin
0.25 mg daily. Which changes would the nurse expect to find if this medication is therapeutically
effective? Select all that apply. One, some, or all responses may be correct. - ANSWER-Diuresis
Decreased edema
Decreased pulse rate
A client with hypertensive heart disease who had an acute episode of heart failure is to be
discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate
when metoprolol is administered with digoxin? - ANSWER-Bradycardia
A health care provider prescribes milrinone for a client with congestive heart failure. Which
action would the nurse perform first? - ANSWER-Have the prescription, dosage calculations, and
pump settings checked by a second nurse
Which care plan would the nurse implement for an infant admitted to the pediatric unit with
the diagnosis of heart failure? - ANSWER-Offer the infant small, frequent feedings
Which parent education would the nurse provide as rationale for gavage feedings in an infant
with congestive heart failure? - ANSWER-The energy that would have been expended on
suckling is conserved
Which assessment finding for a client with heart failure who is taking digoxin will be most
important to communicate to the health care provider? - ANSWER-Premature ventricular
contractions
3|Page
, NUR 242 MED SURG EXAM 3
Which statement made by the nursing student requires correction regarding the effect of
applying the Roy adaptation model on improved functional status in clients with heart failure? -
ANSWER-Use of literature resources supports practical-based nursing interventions."
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and
peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? -
ANSWER-Shift of fluid into the interstitial spaces
An older client with a history of congestive heart failure expresses concern about potential
exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The
roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that
the nurse pursues more information about the roommate? - ANSWER-TB adversely affects older
adults with chronic illness
When the clinic nurse is teaching a group of clients with heart failure (HF) about dietary
interventions to prevent fluid overload, which topic will be included? - ANSWER-Use of fresh or
frozen vegetables instead of canned ones / low sodium
Which action would the nurse take first when a client with heart failure has an episode of
paroxysmal nocturnal dyspnea (PND)? - ANSWER-Assist the client to sit on the edge of the bed
When caring for a client with a diagnosis of right ventricular heart failure, the nurse expects
which assessment findings? Select all that apply. One, some, or all responses may be correct. -
ANSWER-Dependent edema
Swollen hands and fingers
Right upper quadrant discomfort
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral
crackles. Which is the priority nursing intervention? - ANSWER-Place client in a high-Fowler
position.
4|Page
