NUR 265 Advanced Med-Surg Complete
Exam Bundle (Exams 1–3 + Final) |
2026/2027 NCLEX Prep
Question 1
A patient with chronic kidney disease (CKD) is receiving peritoneal dialysis.
The nurse notes that the dialysate drain fluid is cloudy. Which action should the
nurse take first?
A. Flush the peritoneal catheter with heparinized saline.
B. Obtain a sample of the drainage fluid for culture and sensitivity.
C. Assess the patient for rebound abdominal tenderness and fever.
D. Change the dialysis solution bag to a higher dextrose concentration.
,VERIFIED ANSWER: C. Assess the patient for rebound abdominal
tenderness and fever.
EXPLANATION: Cloudy dialysate fluid is an early sign of peritonitis, a
major and severe complication of peritoneal dialysis. The nurse must
immediately assess the patient for systemic and localized signs of infection,
such as rebound tenderness, abdominal pain, and fever. Obtaining a fluid
culture (Choice B) is necessary but follows the physical assessment. Flushes
(Choice A) and altering dextrose concentrations (Choice D) do not address
the suspected infectious process.
Question 2
An intensive care nurse is assessing a patient following an acute ischemic
stroke. Which clinical finding indicates the potential development of Cushing's
Triad and increased intracranial pressure (ICP)?
A. Tachycardia, hypotension, and tachypnea.
B. Bradycardia, widening pulse pressure, and irregular respirations.
C. Bradycardia, hypotension, and Kussmaul respirations.
D. Tachycardia, hypertension, and Cheyne-Stokes respirations.
VERIFIED ANSWER: B. Bradycardia, widening pulse pressure, and
irregular respirations.
EXPLANATION: Cushing's Triad is a classic, late sign of severely increased
intracranial pressure and impending brain herniation. It is characterized by
three distinct signs: a slow heart rate (bradycardia), a widening pulse pressure
(increasing systolic blood pressure while diastolic remains stable or drops),
,and altered, irregular respiratory patterns. Options A, C, and D do not
accurately describe this neurological phenomenon.
Question 3
A patient diagnosed with Guillain-Barré Syndrome is admitted to the medical-
surgical floor. Which assessment is the absolute priority for the nurse to
perform?
A. Deep tendon reflexes in the lower extremities.
B. Hourly measurement of urinary output.
C. Vital capacity and respiratory rate.
D. Cranial nerve assessment for facial symmetry.
VERIFIED ANSWER: C. Vital capacity and respiratory rate.
EXPLANATION: Guillain-Barré Syndrome causes an ascending, progressive
paralysis that can quickly involve the diaphragm and intercostal muscles,
leading to acute respiratory failure. Monitoring pulmonary function via vital
capacity, respiratory effort, and oxygen saturation is the highest safety
priority. While tracking reflexes (Choice A), output (Choice B), and cranial
nerves (Choice D) are standard parts of care, they do not take precedence over
respiratory stability.
Question 4
The nurse is preparing to administer an intravenous infusion of potassium
chloride to a patient with severe hypokalemia. Which administration parameter
, must the nurse enforce to ensure safety?
A. Infuse the medication via a rapid IV push over 2 to 3 minutes.
B. Ensure the concentration does not exceed 10 mEq/hr in a peripheral line
without telemetry.
C. Maintain a strict fluid restriction of 500 mL per shift during the infusion.
D. Mix the potassium chloride with a 50% dextrose solution bag before
administration.
VERIFIED ANSWER: B. Ensure the concentration does not exceed 10
mEq/hr in a peripheral line without telemetry.
EXPLANATION: Intravenous potassium chloride is a high-alert medication
that must never be given as an IV push (Choice A) due to the risk of cardiac
arrest. For standard peripheral administration without continuous cardiac
telemetry monitoring, the infusion rate must not exceed 10 mEq/hr to prevent
local tissue irritation and severe dysrhythmias. Dextrose mixtures (Choice D)
can drive potassium into cells, initially worsening hypokalemia, and fluid
restriction (Choice C) is contraindicated.
Question 5
A patient who is 2 days postoperative following a total gastrectomy reports
dizziness, sweating, and palpitations approximately 20 minutes after eating a
meal high in carbohydrates. Which instruction should the nurse include in
patient teaching?
A. Drink 8 ounces of water or fruit juice during every meal.
B. Assume a recumbent or semi-Fowler's position for 30 minutes after eating.
C. Increase the consumption of simple sugars to prevent reactive hypoglycemia.
D. Eat three large, calorie-dense meals daily to preserve body weight.
Exam Bundle (Exams 1–3 + Final) |
2026/2027 NCLEX Prep
Question 1
A patient with chronic kidney disease (CKD) is receiving peritoneal dialysis.
The nurse notes that the dialysate drain fluid is cloudy. Which action should the
nurse take first?
A. Flush the peritoneal catheter with heparinized saline.
B. Obtain a sample of the drainage fluid for culture and sensitivity.
C. Assess the patient for rebound abdominal tenderness and fever.
D. Change the dialysis solution bag to a higher dextrose concentration.
,VERIFIED ANSWER: C. Assess the patient for rebound abdominal
tenderness and fever.
EXPLANATION: Cloudy dialysate fluid is an early sign of peritonitis, a
major and severe complication of peritoneal dialysis. The nurse must
immediately assess the patient for systemic and localized signs of infection,
such as rebound tenderness, abdominal pain, and fever. Obtaining a fluid
culture (Choice B) is necessary but follows the physical assessment. Flushes
(Choice A) and altering dextrose concentrations (Choice D) do not address
the suspected infectious process.
Question 2
An intensive care nurse is assessing a patient following an acute ischemic
stroke. Which clinical finding indicates the potential development of Cushing's
Triad and increased intracranial pressure (ICP)?
A. Tachycardia, hypotension, and tachypnea.
B. Bradycardia, widening pulse pressure, and irregular respirations.
C. Bradycardia, hypotension, and Kussmaul respirations.
D. Tachycardia, hypertension, and Cheyne-Stokes respirations.
VERIFIED ANSWER: B. Bradycardia, widening pulse pressure, and
irregular respirations.
EXPLANATION: Cushing's Triad is a classic, late sign of severely increased
intracranial pressure and impending brain herniation. It is characterized by
three distinct signs: a slow heart rate (bradycardia), a widening pulse pressure
(increasing systolic blood pressure while diastolic remains stable or drops),
,and altered, irregular respiratory patterns. Options A, C, and D do not
accurately describe this neurological phenomenon.
Question 3
A patient diagnosed with Guillain-Barré Syndrome is admitted to the medical-
surgical floor. Which assessment is the absolute priority for the nurse to
perform?
A. Deep tendon reflexes in the lower extremities.
B. Hourly measurement of urinary output.
C. Vital capacity and respiratory rate.
D. Cranial nerve assessment for facial symmetry.
VERIFIED ANSWER: C. Vital capacity and respiratory rate.
EXPLANATION: Guillain-Barré Syndrome causes an ascending, progressive
paralysis that can quickly involve the diaphragm and intercostal muscles,
leading to acute respiratory failure. Monitoring pulmonary function via vital
capacity, respiratory effort, and oxygen saturation is the highest safety
priority. While tracking reflexes (Choice A), output (Choice B), and cranial
nerves (Choice D) are standard parts of care, they do not take precedence over
respiratory stability.
Question 4
The nurse is preparing to administer an intravenous infusion of potassium
chloride to a patient with severe hypokalemia. Which administration parameter
, must the nurse enforce to ensure safety?
A. Infuse the medication via a rapid IV push over 2 to 3 minutes.
B. Ensure the concentration does not exceed 10 mEq/hr in a peripheral line
without telemetry.
C. Maintain a strict fluid restriction of 500 mL per shift during the infusion.
D. Mix the potassium chloride with a 50% dextrose solution bag before
administration.
VERIFIED ANSWER: B. Ensure the concentration does not exceed 10
mEq/hr in a peripheral line without telemetry.
EXPLANATION: Intravenous potassium chloride is a high-alert medication
that must never be given as an IV push (Choice A) due to the risk of cardiac
arrest. For standard peripheral administration without continuous cardiac
telemetry monitoring, the infusion rate must not exceed 10 mEq/hr to prevent
local tissue irritation and severe dysrhythmias. Dextrose mixtures (Choice D)
can drive potassium into cells, initially worsening hypokalemia, and fluid
restriction (Choice C) is contraindicated.
Question 5
A patient who is 2 days postoperative following a total gastrectomy reports
dizziness, sweating, and palpitations approximately 20 minutes after eating a
meal high in carbohydrates. Which instruction should the nurse include in
patient teaching?
A. Drink 8 ounces of water or fruit juice during every meal.
B. Assume a recumbent or semi-Fowler's position for 30 minutes after eating.
C. Increase the consumption of simple sugars to prevent reactive hypoglycemia.
D. Eat three large, calorie-dense meals daily to preserve body weight.
