Updated NUR 265 Medical-Surgical Nursing Exam 3 with correct
answers and rationales /instant pdf 2026/2027 version
1. A nurse is caring for a patient diagnosed with congestive heart failure (CHF).
Which assessment finding requires immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 2 pounds in one week
C. Oxygen saturation of 86% on room air
D. Mild fatigue after activity
✅ Correct Answer: C — Oxygen saturation of 86% on room air
Rationale:
An oxygen saturation of 86% indicates hypoxemia and impaired oxygen delivery. The nurse
should prioritize respiratory status using the ABC approach (Airway, Breathing, Circulation).
• Edema and weight gain are common CHF findings but are not immediately life-
threatening.
• Hypoxia requires prompt intervention.
2. A patient with hypertension asks why medication must be taken every day
even when feeling healthy. Which response by the nurse is best?
A. "The medication permanently cures hypertension."
B. "High blood pressure can damage your organs even when you have no symptoms."
C. "You only need medication when your blood pressure is elevated."
D. "The medication prevents every cardiovascular problem."
✅ Correct Answer: B
Rationale:
Hypertension is often asymptomatic but can cause serious complications such as stroke, kidney
failure, heart disease, and vision problems.
3. A patient has a potassium level of 2.7 mEq/L. Which finding should the nurse
expect?
A. Muscle weakness
B. Severe hypertension
,C. Increased bowel sounds
D. Hyperactive reflexes
✅ Correct Answer: A
Rationale:
Hypokalemia (low potassium) can cause:
• Muscle weakness
• Fatigue
• Paralysis
• Cardiac dysrhythmias
• Decreased bowel motility
4. A patient with chronic obstructive pulmonary disease (COPD) is experiencing
shortness of breath. Which position should the nurse place the patient in?
A. Supine
B. Trendelenburg
C. High-Fowler position
D. Flat prone position
✅ Correct Answer: C
Rationale:
High-Fowler positioning improves lung expansion and decreases pressure on the diaphragm,
making breathing easier.
5. A patient with asthma is experiencing an acute exacerbation. Which finding
indicates worsening respiratory status?
A. Ability to speak in complete sentences
B. Increased wheezing and difficulty speaking
C. Respiratory rate within normal limits
D. Decreased anxiety
✅ Correct Answer: B
Rationale:
Difficulty speaking, increased wheezing, and respiratory distress indicate worsening airway
obstruction.
,6. A patient with diabetes has a blood glucose level of 48 mg/dL and is alert.
What is the nurse’s priority action?
A. Administer insulin
B. Give 15 grams of a fast-acting carbohydrate
C. Encourage exercise
D. Restrict food intake
✅ Correct Answer: B
Rationale:
A glucose level below 70 mg/dL indicates hypoglycemia. The patient should receive a rapid
source of glucose and have blood sugar rechecked.
7. Which finding is commonly associated with hyperglycemia?
A. Sweating and tremors
B. Increased thirst and frequent urination
C. Slow heart rate only
D. Low temperature
✅ Correct Answer: B
Rationale:
Hyperglycemia causes:
• Polyuria
• Polydipsia
• Polyphagia
• Fatigue
8. A nurse is caring for a patient with pneumonia. Which assessment finding
should be monitored closely?
A. Hair condition
B. Oxygen saturation
C. Nail length
D. Appetite preference
, ✅ Correct Answer: B
Rationale:
Pneumonia affects oxygen exchange. Monitoring oxygen saturation helps identify respiratory
deterioration.
9. Which electrolyte imbalance places a patient at highest risk for cardiac
dysrhythmias?
A. Potassium imbalance
B. Mild chloride change
C. Normal sodium level
D. Normal calcium level
✅ Correct Answer: A
Rationale:
Potassium abnormalities affect cardiac conduction and may cause life-threatening dysrhythmias.
10. A patient with chronic kidney disease develops crackles and edema. What
does the nurse suspect?
A. Dehydration
B. Fluid overload
C. Infection
D. Hypoglycemia
✅ Correct Answer: B
Rationale:
Kidney dysfunction reduces the body's ability to remove fluid, leading to fluid retention, edema,
hypertension, and pulmonary congestion.
11. A nurse is caring for a patient with chronic kidney disease (CKD). Which
laboratory value should the nurse monitor closely?
A. Hemoglobin A1c
B. Serum creatinine
C. Bilirubin
D. Troponin
answers and rationales /instant pdf 2026/2027 version
1. A nurse is caring for a patient diagnosed with congestive heart failure (CHF).
Which assessment finding requires immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 2 pounds in one week
C. Oxygen saturation of 86% on room air
D. Mild fatigue after activity
✅ Correct Answer: C — Oxygen saturation of 86% on room air
Rationale:
An oxygen saturation of 86% indicates hypoxemia and impaired oxygen delivery. The nurse
should prioritize respiratory status using the ABC approach (Airway, Breathing, Circulation).
• Edema and weight gain are common CHF findings but are not immediately life-
threatening.
• Hypoxia requires prompt intervention.
2. A patient with hypertension asks why medication must be taken every day
even when feeling healthy. Which response by the nurse is best?
A. "The medication permanently cures hypertension."
B. "High blood pressure can damage your organs even when you have no symptoms."
C. "You only need medication when your blood pressure is elevated."
D. "The medication prevents every cardiovascular problem."
✅ Correct Answer: B
Rationale:
Hypertension is often asymptomatic but can cause serious complications such as stroke, kidney
failure, heart disease, and vision problems.
3. A patient has a potassium level of 2.7 mEq/L. Which finding should the nurse
expect?
A. Muscle weakness
B. Severe hypertension
,C. Increased bowel sounds
D. Hyperactive reflexes
✅ Correct Answer: A
Rationale:
Hypokalemia (low potassium) can cause:
• Muscle weakness
• Fatigue
• Paralysis
• Cardiac dysrhythmias
• Decreased bowel motility
4. A patient with chronic obstructive pulmonary disease (COPD) is experiencing
shortness of breath. Which position should the nurse place the patient in?
A. Supine
B. Trendelenburg
C. High-Fowler position
D. Flat prone position
✅ Correct Answer: C
Rationale:
High-Fowler positioning improves lung expansion and decreases pressure on the diaphragm,
making breathing easier.
5. A patient with asthma is experiencing an acute exacerbation. Which finding
indicates worsening respiratory status?
A. Ability to speak in complete sentences
B. Increased wheezing and difficulty speaking
C. Respiratory rate within normal limits
D. Decreased anxiety
✅ Correct Answer: B
Rationale:
Difficulty speaking, increased wheezing, and respiratory distress indicate worsening airway
obstruction.
,6. A patient with diabetes has a blood glucose level of 48 mg/dL and is alert.
What is the nurse’s priority action?
A. Administer insulin
B. Give 15 grams of a fast-acting carbohydrate
C. Encourage exercise
D. Restrict food intake
✅ Correct Answer: B
Rationale:
A glucose level below 70 mg/dL indicates hypoglycemia. The patient should receive a rapid
source of glucose and have blood sugar rechecked.
7. Which finding is commonly associated with hyperglycemia?
A. Sweating and tremors
B. Increased thirst and frequent urination
C. Slow heart rate only
D. Low temperature
✅ Correct Answer: B
Rationale:
Hyperglycemia causes:
• Polyuria
• Polydipsia
• Polyphagia
• Fatigue
8. A nurse is caring for a patient with pneumonia. Which assessment finding
should be monitored closely?
A. Hair condition
B. Oxygen saturation
C. Nail length
D. Appetite preference
, ✅ Correct Answer: B
Rationale:
Pneumonia affects oxygen exchange. Monitoring oxygen saturation helps identify respiratory
deterioration.
9. Which electrolyte imbalance places a patient at highest risk for cardiac
dysrhythmias?
A. Potassium imbalance
B. Mild chloride change
C. Normal sodium level
D. Normal calcium level
✅ Correct Answer: A
Rationale:
Potassium abnormalities affect cardiac conduction and may cause life-threatening dysrhythmias.
10. A patient with chronic kidney disease develops crackles and edema. What
does the nurse suspect?
A. Dehydration
B. Fluid overload
C. Infection
D. Hypoglycemia
✅ Correct Answer: B
Rationale:
Kidney dysfunction reduces the body's ability to remove fluid, leading to fluid retention, edema,
hypertension, and pulmonary congestion.
11. A nurse is caring for a patient with chronic kidney disease (CKD). Which
laboratory value should the nurse monitor closely?
A. Hemoglobin A1c
B. Serum creatinine
C. Bilirubin
D. Troponin
