NUR 265 ADVANCED MEDSURG — EXAM 3 verified with correct answers plus rationales
2026/2027 pdf
1. A client with heart failure reports increasing dyspnea, orthopnea, and a 3-kg weight gain
over 3 days. Which finding requires the nurse's priority attention?
A. Mild ankle edema
B. Dyspnea at rest
C. Fatigue after walking
D. Decreased appetite
Correct Answer: B
Rationale: Dyspnea at rest suggests worsening pulmonary congestion and impaired oxygenation.
Airway and breathing take priority.
2. A client with acute pulmonary edema is severely dyspneic and has pink, frothy sputum.
Which intervention should the nurse implement first?
A. Place the client in a high-Fowler position
B. Encourage oral fluids
C. Place the client flat
D. Encourage ambulation
Correct Answer: A
Rationale: High-Fowler positioning improves lung expansion and decreases venous return,
helping reduce pulmonary congestion.
3. A client receiving digoxin has a potassium level of 2.8 mEq/L. Which action is most
appropriate?
A. Administer the digoxin as prescribed
B. Hold the digoxin and notify the provider
C. Restrict potassium intake
D. Administer an additional dose of digoxin
Correct Answer: B
Rationale: Hypokalemia increases the risk of digoxin toxicity. The medication should be
withheld and the abnormal potassium level addressed.
,4. Which assessment finding is most concerning in a client with atrial fibrillation?
A. Irregular pulse
B. Heart rate of 78/min
C. Sudden unilateral weakness
D. Mild fatigue
Correct Answer: C
Rationale: Atrial fibrillation increases the risk of thromboembolism and stroke. Sudden
unilateral weakness is an emergency finding.
5. A client receiving warfarin has an INR of 5.8 and reports bleeding gums. What should
the nurse do?
A. Administer the next dose
B. Hold the medication and notify the provider
C. Encourage foods high in vitamin K without further evaluation
D. Increase the dose
Correct Answer: B
Rationale: A markedly elevated INR with active bleeding indicates increased bleeding risk and
requires prompt intervention.
6. A client with COPD is receiving oxygen therapy. Which finding requires immediate
reassessment?
A. Oxygen saturation of 90%
B. Respiratory rate of 18/min
C. Increasing somnolence and difficulty arousing
D. Productive cough
Correct Answer: C
Rationale: Increasing somnolence can indicate worsening respiratory failure and carbon dioxide
retention, requiring immediate assessment.
,7. Which finding is most consistent with an acute exacerbation of COPD?
A. Increased dyspnea and sputum production
B. Improved exercise tolerance
C. Decreased respiratory effort
D. Clear breath sounds with no symptoms
Correct Answer: A
Rationale: Increased dyspnea, cough, and sputum changes are common manifestations of COPD
exacerbation.
8. A client with pneumonia has a respiratory rate of 32/min, oxygen saturation of 84%, and
new confusion. What is the priority?
A. Encourage oral fluids
B. Initiate appropriate oxygenation and urgently assess respiratory status
C. Obtain a dietary history
D. Encourage ambulation
Correct Answer: B
Rationale: Severe hypoxemia and altered mental status indicate possible respiratory failure and
require immediate intervention.
9. A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which finding is
most concerning?
A. Muscle weakness
B. Peaked T waves on ECG
C. Mild fatigue
D. Increased thirst
Correct Answer: B
Rationale: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias. ECG changes
require immediate intervention.
10. Which food should a client with significant hyperkalemia generally avoid unless
specifically directed otherwise?
, A. Apples
B. White rice
C. Bananas
D. Bread
Correct Answer: C
Rationale: Bananas are relatively high in potassium and may need to be limited in clients with
hyperkalemia depending on the prescribed renal diet.
Select All That Apply
11. A nurse is assessing a client with acute kidney injury. Which findings may occur?
A. Decreased urine output
B. Elevated serum creatinine
C. Fluid retention
D. Electrolyte abnormalities
E. Improved renal filtration
Correct Answers: A, B, C, D
Rationale: Acute kidney injury can cause oliguria, rising creatinine, fluid retention, and
electrolyte disturbances.
12. Which findings may indicate worsening heart failure?
A. Rapid weight gain
B. Orthopnea
C. Crackles
D. Peripheral edema
E. Improved exercise tolerance
Correct Answers: A, B, C, D
Rationale: Fluid retention and pulmonary/systemic congestion commonly produce weight gain,
orthopnea, crackles, and edema.
13. A client with diabetes is experiencing hypoglycemia. Which findings may occur?
2026/2027 pdf
1. A client with heart failure reports increasing dyspnea, orthopnea, and a 3-kg weight gain
over 3 days. Which finding requires the nurse's priority attention?
A. Mild ankle edema
B. Dyspnea at rest
C. Fatigue after walking
D. Decreased appetite
Correct Answer: B
Rationale: Dyspnea at rest suggests worsening pulmonary congestion and impaired oxygenation.
Airway and breathing take priority.
2. A client with acute pulmonary edema is severely dyspneic and has pink, frothy sputum.
Which intervention should the nurse implement first?
A. Place the client in a high-Fowler position
B. Encourage oral fluids
C. Place the client flat
D. Encourage ambulation
Correct Answer: A
Rationale: High-Fowler positioning improves lung expansion and decreases venous return,
helping reduce pulmonary congestion.
3. A client receiving digoxin has a potassium level of 2.8 mEq/L. Which action is most
appropriate?
A. Administer the digoxin as prescribed
B. Hold the digoxin and notify the provider
C. Restrict potassium intake
D. Administer an additional dose of digoxin
Correct Answer: B
Rationale: Hypokalemia increases the risk of digoxin toxicity. The medication should be
withheld and the abnormal potassium level addressed.
,4. Which assessment finding is most concerning in a client with atrial fibrillation?
A. Irregular pulse
B. Heart rate of 78/min
C. Sudden unilateral weakness
D. Mild fatigue
Correct Answer: C
Rationale: Atrial fibrillation increases the risk of thromboembolism and stroke. Sudden
unilateral weakness is an emergency finding.
5. A client receiving warfarin has an INR of 5.8 and reports bleeding gums. What should
the nurse do?
A. Administer the next dose
B. Hold the medication and notify the provider
C. Encourage foods high in vitamin K without further evaluation
D. Increase the dose
Correct Answer: B
Rationale: A markedly elevated INR with active bleeding indicates increased bleeding risk and
requires prompt intervention.
6. A client with COPD is receiving oxygen therapy. Which finding requires immediate
reassessment?
A. Oxygen saturation of 90%
B. Respiratory rate of 18/min
C. Increasing somnolence and difficulty arousing
D. Productive cough
Correct Answer: C
Rationale: Increasing somnolence can indicate worsening respiratory failure and carbon dioxide
retention, requiring immediate assessment.
,7. Which finding is most consistent with an acute exacerbation of COPD?
A. Increased dyspnea and sputum production
B. Improved exercise tolerance
C. Decreased respiratory effort
D. Clear breath sounds with no symptoms
Correct Answer: A
Rationale: Increased dyspnea, cough, and sputum changes are common manifestations of COPD
exacerbation.
8. A client with pneumonia has a respiratory rate of 32/min, oxygen saturation of 84%, and
new confusion. What is the priority?
A. Encourage oral fluids
B. Initiate appropriate oxygenation and urgently assess respiratory status
C. Obtain a dietary history
D. Encourage ambulation
Correct Answer: B
Rationale: Severe hypoxemia and altered mental status indicate possible respiratory failure and
require immediate intervention.
9. A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which finding is
most concerning?
A. Muscle weakness
B. Peaked T waves on ECG
C. Mild fatigue
D. Increased thirst
Correct Answer: B
Rationale: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias. ECG changes
require immediate intervention.
10. Which food should a client with significant hyperkalemia generally avoid unless
specifically directed otherwise?
, A. Apples
B. White rice
C. Bananas
D. Bread
Correct Answer: C
Rationale: Bananas are relatively high in potassium and may need to be limited in clients with
hyperkalemia depending on the prescribed renal diet.
Select All That Apply
11. A nurse is assessing a client with acute kidney injury. Which findings may occur?
A. Decreased urine output
B. Elevated serum creatinine
C. Fluid retention
D. Electrolyte abnormalities
E. Improved renal filtration
Correct Answers: A, B, C, D
Rationale: Acute kidney injury can cause oliguria, rising creatinine, fluid retention, and
electrolyte disturbances.
12. Which findings may indicate worsening heart failure?
A. Rapid weight gain
B. Orthopnea
C. Crackles
D. Peripheral edema
E. Improved exercise tolerance
Correct Answers: A, B, C, D
Rationale: Fluid retention and pulmonary/systemic congestion commonly produce weight gain,
orthopnea, crackles, and edema.
13. A client with diabetes is experiencing hypoglycemia. Which findings may occur?
