LATEST UPDATED NUR 242 MED SURG EXAM 2
- MEDICAL-SURGICAL NURSING | COMPLETE
EXAM WITH CORRECT ANSWERS AND
RATIONALES. A+ GUARANTEED SUCCESS
1. A nurse is caring for a client with heart
failure who has been prescribed furosemide.
Which laboratory value requires immediate
notification of the healthcare provider?
A) Serum sodium of 135 mEq/L
B) Serum potassium of 3.1 mEq/L
C) Serum creatinine of 0.9 mg/dL
D) Blood glucose of 110 mg/dL
Correct answer: B
Rationale: Furosemide is a loop diuretic that
causes potassium wasting. A serum potassium
of 3.1 mEq/L indicates hypokalemia, which can
lead to cardiac dysrhythmias. The other values
are within normal limits.
2. A nurse is assessing a client with chronic
obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L per minute via nasal
,cannula. Which finding indicates an adverse
effect of oxygen therapy?
A) Oxygen saturation of 91%
B) Respiratory rate of 22 breaths per minute
C) The client reports increased drowsiness and
lethargy
D) The client has a productive cough with
green sputum
Correct answer: C
Rationale: In clients with COPD who retain
carbon dioxide, high oxygen delivery can
reduce the hypoxic drive, leading to increased
drowsiness, lethargy, and eventually
respiratory failure. An oxygen saturation of
91% is acceptable. A respiratory rate of 22 is
mildly elevated. Productive cough is related to
the disease, not oxygen therapy.
3. A nurse is caring for a client who is 2 days
postoperative after a total hip replacement.
Which finding requires immediate intervention?
A) The client reports pain of 5 on a 0-to-10
scale
B) The surgical leg is externally rotated
,C) The client's hemoglobin is 11 g/dL
D) The client has a temperature of 37.8
degrees Celsius (100.0 degrees Fahrenheit)
Correct answer: B
Rationale: External rotation of the surgical leg
after hip replacement may indicate dislocation
of the prosthesis, which requires immediate
provider notification. Mild pain is expected. A
hemoglobin of 11 g/dL is slightly low but not
critical immediately post-op. Low-grade fever
is common after surgery.
4. A nurse is providing discharge teaching to a
client with a new diagnosis of heart failure.
Which statement by the client indicates a need
for further teaching?
A) I will weigh myself every morning before
breakfast
B) I will call my provider if I gain 2 pounds in
one day
C) I can add salt to my food at the table as long
as I do not cook with salt
D) I will take my diuretic in the morning so I do
not wake up at night
, Correct answer: C
Rationale: Clients with heart failure should
follow a low-sodium diet, which includes
avoiding adding salt at the table and limiting
salt in cooking. Adding salt at the table
significantly increases sodium intake. Daily
weights, calling for a 2-3 pound gain in a day,
and taking diuretics in the morning are correct.
5. A nurse is assessing a client who is
receiving a blood transfusion. Fifteen minutes
after the transfusion begins, the client reports
low back pain and chills. What is the priority
action?
A) Slow the transfusion rate
B) Stop the transfusion
C) Administer acetaminophen as ordered
D) Notify the healthcare provider
Correct answer: B
Rationale: Low back pain and chills suggest a
hemolytic transfusion reaction. The transfusion
must be stopped immediately to prevent
further harm. After stopping, the nurse notifies
the provider and then administers symptomatic
- MEDICAL-SURGICAL NURSING | COMPLETE
EXAM WITH CORRECT ANSWERS AND
RATIONALES. A+ GUARANTEED SUCCESS
1. A nurse is caring for a client with heart
failure who has been prescribed furosemide.
Which laboratory value requires immediate
notification of the healthcare provider?
A) Serum sodium of 135 mEq/L
B) Serum potassium of 3.1 mEq/L
C) Serum creatinine of 0.9 mg/dL
D) Blood glucose of 110 mg/dL
Correct answer: B
Rationale: Furosemide is a loop diuretic that
causes potassium wasting. A serum potassium
of 3.1 mEq/L indicates hypokalemia, which can
lead to cardiac dysrhythmias. The other values
are within normal limits.
2. A nurse is assessing a client with chronic
obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L per minute via nasal
,cannula. Which finding indicates an adverse
effect of oxygen therapy?
A) Oxygen saturation of 91%
B) Respiratory rate of 22 breaths per minute
C) The client reports increased drowsiness and
lethargy
D) The client has a productive cough with
green sputum
Correct answer: C
Rationale: In clients with COPD who retain
carbon dioxide, high oxygen delivery can
reduce the hypoxic drive, leading to increased
drowsiness, lethargy, and eventually
respiratory failure. An oxygen saturation of
91% is acceptable. A respiratory rate of 22 is
mildly elevated. Productive cough is related to
the disease, not oxygen therapy.
3. A nurse is caring for a client who is 2 days
postoperative after a total hip replacement.
Which finding requires immediate intervention?
A) The client reports pain of 5 on a 0-to-10
scale
B) The surgical leg is externally rotated
,C) The client's hemoglobin is 11 g/dL
D) The client has a temperature of 37.8
degrees Celsius (100.0 degrees Fahrenheit)
Correct answer: B
Rationale: External rotation of the surgical leg
after hip replacement may indicate dislocation
of the prosthesis, which requires immediate
provider notification. Mild pain is expected. A
hemoglobin of 11 g/dL is slightly low but not
critical immediately post-op. Low-grade fever
is common after surgery.
4. A nurse is providing discharge teaching to a
client with a new diagnosis of heart failure.
Which statement by the client indicates a need
for further teaching?
A) I will weigh myself every morning before
breakfast
B) I will call my provider if I gain 2 pounds in
one day
C) I can add salt to my food at the table as long
as I do not cook with salt
D) I will take my diuretic in the morning so I do
not wake up at night
, Correct answer: C
Rationale: Clients with heart failure should
follow a low-sodium diet, which includes
avoiding adding salt at the table and limiting
salt in cooking. Adding salt at the table
significantly increases sodium intake. Daily
weights, calling for a 2-3 pound gain in a day,
and taking diuretics in the morning are correct.
5. A nurse is assessing a client who is
receiving a blood transfusion. Fifteen minutes
after the transfusion begins, the client reports
low back pain and chills. What is the priority
action?
A) Slow the transfusion rate
B) Stop the transfusion
C) Administer acetaminophen as ordered
D) Notify the healthcare provider
Correct answer: B
Rationale: Low back pain and chills suggest a
hemolytic transfusion reaction. The transfusion
must be stopped immediately to prevent
further harm. After stopping, the nurse notifies
the provider and then administers symptomatic
