,Galen College NUR 242 Exam 3 (pdf) | 2026/2027 | Med-Surg Q&A |
Medical-Surgical Nursing
**1. A nurse is caring for a client with heart failure. Which assessment finding
is a late sign of heart failure?**
A) Weight gain of 2 kg in 3 days
B) Peripheral edema
C) Paroxysmal nocturnal dyspnea
D) Jugular vein distension
**Correct Answer: Peripheral edema**
**Rationale:** Peripheral edema is a late sign of heart failure, indicating
significant fluid overload. It develops when the right ventricle cannot pump
blood effectively into the pulmonary circulation, causing fluid to back up into
the systemic venous system and leak into the interstitial spaces.
**2. When caring for a client with right ventricular heart failure, which
assessment findings would the nurse expect? Select all that apply.**
A) Dependent edema
B) Swollen hands and fingers
C) Right upper quadrant discomfort
D) Tachypnea and crackles
**Correct Answer: Dependent edema, Swollen hands and fingers, Right upper
quadrant discomfort**
**Rationale:** Right-sided heart failure leads to systemic venous congestion,
resulting in dependent edema, peripheral swelling (hands, fingers), and
hepatomegaly causing right upper quadrant discomfort. Tachypnea and
crackles are signs of left-sided failure.
,**3. A client with heart failure experiences an episode of paroxysmal
nocturnal dyspnea (PND). Which action should the nurse take first?**
A) Administer oxygen via nasal cannula
B) Place the client in high-Fowler position
C) Assist the client to sit on the edge of the bed
D) Prepare for rapid sequence intubation
**Correct Answer: Assist the client to sit on the edge of the bed**
**Rationale:** PND occurs when fluid shifts from the lower extremities to the
lungs while supine. The priority is to help the client sit upright on the edge of
the bed (dangling position), which uses gravity to reduce preload and relieve
pulmonary congestion.
**4. A nurse is teaching a group of clients with heart failure about dietary
interventions to prevent fluid overload. Which topic should be included?**
A) Use of fresh or frozen vegetables instead of canned ones
B) Increasing daily fluid intake to 3 liters
C) Adding salt to food to improve taste
D) Avoiding all potassium-rich foods
**Correct Answer: Use of fresh or frozen vegetables instead of canned ones**
**Rationale:** Canned vegetables are often high in sodium, which
contributes to fluid retention and worsening heart failure. Fresh or frozen
vegetables without added salt are recommended to help control sodium
intake and prevent fluid overload.
, **5. An older adult client with a history of congestive heart failure is
concerned about potential exposure to tuberculosis (TB) from a roommate at
an extended care facility. The roommate coughs frequently and sometimes
spits up blood. What is the primary reason the nurse pursues more
information about the roommate?**
A) TB is always fatal in older adults
B) Older adults are more likely to transmit TB
C) TB adversely affects older adults with chronic illness
D) TB is a contraindication to heart failure medications
**Correct Answer: TB adversely affects older adults with chronic illness**
**Rationale:** Older adults with chronic conditions such as heart failure are
at higher risk for severe TB infection because of age-related immune decline
and the physiological stress of a comorbid illness. Prompt investigation helps
prevent transmission and serious complications.
**6. Which assessment finding would indicate improvement in a 4-month-old
infant admitted with congestive heart failure?**
A) Weight loss during the next 2 days
B) Increased respiratory rate
C) Worsening periorbital edema
D) Decreased urine output
**Correct Answer: Weight loss during the next 2 days**
**Rationale:** Weight loss indicates a reduction in total body water,
reflecting successful diuresis and improved cardiac function. Daily weight
monitoring is the most sensitive indicator of fluid status in infants with heart
failure.
Medical-Surgical Nursing
**1. A nurse is caring for a client with heart failure. Which assessment finding
is a late sign of heart failure?**
A) Weight gain of 2 kg in 3 days
B) Peripheral edema
C) Paroxysmal nocturnal dyspnea
D) Jugular vein distension
**Correct Answer: Peripheral edema**
**Rationale:** Peripheral edema is a late sign of heart failure, indicating
significant fluid overload. It develops when the right ventricle cannot pump
blood effectively into the pulmonary circulation, causing fluid to back up into
the systemic venous system and leak into the interstitial spaces.
**2. When caring for a client with right ventricular heart failure, which
assessment findings would the nurse expect? Select all that apply.**
A) Dependent edema
B) Swollen hands and fingers
C) Right upper quadrant discomfort
D) Tachypnea and crackles
**Correct Answer: Dependent edema, Swollen hands and fingers, Right upper
quadrant discomfort**
**Rationale:** Right-sided heart failure leads to systemic venous congestion,
resulting in dependent edema, peripheral swelling (hands, fingers), and
hepatomegaly causing right upper quadrant discomfort. Tachypnea and
crackles are signs of left-sided failure.
,**3. A client with heart failure experiences an episode of paroxysmal
nocturnal dyspnea (PND). Which action should the nurse take first?**
A) Administer oxygen via nasal cannula
B) Place the client in high-Fowler position
C) Assist the client to sit on the edge of the bed
D) Prepare for rapid sequence intubation
**Correct Answer: Assist the client to sit on the edge of the bed**
**Rationale:** PND occurs when fluid shifts from the lower extremities to the
lungs while supine. The priority is to help the client sit upright on the edge of
the bed (dangling position), which uses gravity to reduce preload and relieve
pulmonary congestion.
**4. A nurse is teaching a group of clients with heart failure about dietary
interventions to prevent fluid overload. Which topic should be included?**
A) Use of fresh or frozen vegetables instead of canned ones
B) Increasing daily fluid intake to 3 liters
C) Adding salt to food to improve taste
D) Avoiding all potassium-rich foods
**Correct Answer: Use of fresh or frozen vegetables instead of canned ones**
**Rationale:** Canned vegetables are often high in sodium, which
contributes to fluid retention and worsening heart failure. Fresh or frozen
vegetables without added salt are recommended to help control sodium
intake and prevent fluid overload.
, **5. An older adult client with a history of congestive heart failure is
concerned about potential exposure to tuberculosis (TB) from a roommate at
an extended care facility. The roommate coughs frequently and sometimes
spits up blood. What is the primary reason the nurse pursues more
information about the roommate?**
A) TB is always fatal in older adults
B) Older adults are more likely to transmit TB
C) TB adversely affects older adults with chronic illness
D) TB is a contraindication to heart failure medications
**Correct Answer: TB adversely affects older adults with chronic illness**
**Rationale:** Older adults with chronic conditions such as heart failure are
at higher risk for severe TB infection because of age-related immune decline
and the physiological stress of a comorbid illness. Prompt investigation helps
prevent transmission and serious complications.
**6. Which assessment finding would indicate improvement in a 4-month-old
infant admitted with congestive heart failure?**
A) Weight loss during the next 2 days
B) Increased respiratory rate
C) Worsening periorbital edema
D) Decreased urine output
**Correct Answer: Weight loss during the next 2 days**
**Rationale:** Weight loss indicates a reduction in total body water,
reflecting successful diuresis and improved cardiac function. Daily weight
monitoring is the most sensitive indicator of fluid status in infants with heart
failure.
