NUR 265 Exam 3 Practice Advanced Concepts In
Medical-Surgical Nursing 2026-2027 Questions
And Answers With Rationales
1. A client with COPD is admitted with acute exacerbation. Arterial blood gas
results show pH 7.25, PaCO2 72 mmHg, HCO3- 32 mEq/L. Which acid-base
disorder is present?
A) Respiratory acidosis with metabolic compensation
B) Metabolic alkalosis with respiratory compensation
C) Respiratory alkalosis with partial metabolic compensation
D) Mixed respiratory and metabolic acidosis
Correct Answer: A) Respiratory acidosis with metabolic compensation
Expert Rationale: The pH of 7.25 is acidic (normal 7.35-7.45). PaCO2 of 72 mmHg
is elevated (normal 35-45), indicating respiratory acidosis as the primary disorder.
HCO3- of 32 mEq/L is elevated (normal 22-26), showing metabolic compensation
by the kidneys (retaining bicarbonate). In COPD clients, chronic CO2 retention leads
to compensated respiratory acidosis. Acute exacerbations can decompensate this
balance. The nurse should monitor for worsening ventilation and prepare for non-
invasive positive pressure ventilation (BiPAP) if indicated.
2. A client with asthma is prescribed a combination inhaler containing fluticasone
and salmeterol (Advair). Which instruction should the nurse emphasize?
A) Use the inhaler only during acute asthma attacks for quick relief
B) Rinse the mouth with water after each use to prevent oral candidiasis
C) Shake the inhaler vigorously for 30 seconds before each puff
D) Discontinue the medication if wheezing improves after 1 week
Correct Answer: B) Rinse the mouth with water after each use to prevent oral
candidiasis
Expert Rationale: Fluticasone is an inhaled corticosteroid (ICS) that suppresses
local immunity and can cause oral candidiasis (thrush) and dysphonia. Rinsing the
, mouth, gargling, and spitting after each use prevents fungal overgrowth. Salmeterol
is a long-acting beta-agonist (LABA) used for maintenance, NOT rescue. Advair is a
controller medication taken daily, not PRN. The client should also have a short-
acting beta-agonist (albuterol) for rescue. ICS should NOT be stopped abruptly; they
are long-term controllers.
3. The nurse is caring for a client with a new tracheostomy who is on a mechanical
ventilator. Which action is the HIGHEST priority during tracheostomy care?
A) Changing the tracheostomy ties every 24 hours
B) Maintaining cuff pressure at 20-30 cm H2O and ensuring adequate humidification
C) Suctioning the oropharynx every 15 minutes to prevent aspiration
D) Removing the inner cannula for cleaning every 4 hours
Correct Answer: B) Maintaining cuff pressure at 20-30 cm H2O and ensuring
adequate humidification
Expert Rationale: For a ventilated client with a tracheostomy, the HIGHEST
priority is maintaining cuff pressure at 20-30 cm H2O to prevent aspiration (too low)
and tracheal damage (too high), AND ensuring adequate humidification since the
upper airway is bypassed. Dry secretions can cause mucus plugging and airway
obstruction. While tie changes and inner cannula cleaning are important, they are not
as immediately life-threatening as cuff pressure and humidification. Oropharyngeal
suctioning every 15 minutes is excessive and traumatic.
4. A client with active pulmonary tuberculosis (TB) is started on the standard four-
drug regimen. Which instruction is MOST important for the nurse to provide?
A) Take all four medications together once daily for 2 weeks, then stop when
symptoms resolve
B) Take medications exactly as prescribed for at least 6 months, even if feeling
better, to prevent multidrug-resistant TB
C) Take rifampin with antacids to reduce GI upset and orange-colored urine
D) Avoid all sun exposure while taking isoniazid to prevent photosensitivity
, Correct Answer: B) Take medications exactly as prescribed for at least 6 months,
even if feeling better, to prevent multidrug-resistant TB
Expert Rationale: The standard TB regimen (RIPE: rifampin, isoniazid,
pyrazinamide, ethambutol) requires 6-9 months of adherence. Premature
discontinuation leads to treatment failure and multidrug-resistant TB (MDR-TB), a
global health threat. Directly Observed Therapy (DOT) may be required. Rifampin
causes orange body fluids (urine, tears, sweat) and reduces effectiveness of oral
contraceptives and warfarin. Isoniazid requires pyridoxine (B6) to prevent peripheral
neuropathy, not sun avoidance. Antacids reduce rifampin absorption.
5. A client with lung cancer is scheduled for a pneumonectomy. Which preoperative
nursing intervention is MOST important?
A) Teaching the client to perform deep breathing and coughing exercises using an
incentive spirometer
B) Restricting fluids to 1000 mL/day to reduce postoperative pulmonary edema
C) Administering prophylactic antibiotics for 7 days before surgery
D) Instructing the client to sleep on the operative side for 2 weeks before surgery
Correct Answer: A) Teaching the client to perform deep breathing and coughing
exercises using an incentive spirometer
Expert Rationale: Preoperative pulmonary rehabilitation (deep breathing, incentive
spirometry, coughing exercises) is critical for pneumonectomy clients to expand
remaining lung tissue, prevent atelectasis, and clear secretions postoperatively. Fluid
restriction is not standard pre-op and could cause dehydration. Prophylactic
antibiotics are given within 60 minutes of incision, not for days. Sleeping on the
operative side is sometimes taught POST-operatively to promote drainage and
expansion of the remaining lung, not pre-operatively.
6. A client with a pulmonary embolism (PE) is receiving a heparin infusion. The
nurse notes the aPTT is 98 seconds (therapeutic range 60-80 seconds). Which action
should the nurse take FIRST?
A) Stop the heparin infusion immediately and notify the provider
B) Continue the infusion and recheck the aPTT in 2 hours
, C) Reduce the infusion rate per protocol and recheck aPTT in 4-6 hours
D) Administer protamine sulfate as an antidote
Correct Answer: C) Reduce the infusion rate per protocol and recheck aPTT in 4-6
hours
Expert Rationale: An aPTT of 98 seconds is supratherapeutic but not in the critical
range (>120 seconds or >2.5x control) that would require stopping the infusion. The
nurse should reduce the infusion rate per institutional protocol and recheck aPTT in
4-6 hours. Protamine sulfate is reserved for life-threatening bleeding or severe
overdose. Continuing at the same rate increases bleeding risk. Stopping completely
may cause clot extension. The nurse should also assess for bleeding (gums, bruising,
hematuria, melena).
7. A client with flail chest from a motor vehicle accident has paradoxical chest wall
movement. Which intervention is the HIGHEST priority?
A) Taping the chest wall with adhesive tape to stabilize the fracture segments
B) Administering high-flow oxygen and preparing for endotracheal intubation and
positive pressure ventilation
C) Placing the client in prone position to reduce chest wall movement
D) Administering morphine and encouraging the client to take shallow breaths to
reduce pain
Correct Answer: B) Administering high-flow oxygen and preparing for
endotracheal intubation and positive pressure ventilation
Expert Rationale: Flail chest occurs when multiple contiguous ribs fracture in two
places, creating a free-floating segment that moves paradoxically (inward on
inspiration, outward on expiration). This causes severe pain, hypoventilation, and
underlying pulmonary contusion. The HIGHEST priority is ensuring adequate
oxygenation and ventilation. High-flow oxygen, pain control (epidural or nerve
blocks preferred over systemic opioids), and possible mechanical ventilation with
PEEP stabilize the chest wall internally. Taping is CONTRAINDICATED as it
restricts ventilation. Shallow breathing causes atelectasis.
Medical-Surgical Nursing 2026-2027 Questions
And Answers With Rationales
1. A client with COPD is admitted with acute exacerbation. Arterial blood gas
results show pH 7.25, PaCO2 72 mmHg, HCO3- 32 mEq/L. Which acid-base
disorder is present?
A) Respiratory acidosis with metabolic compensation
B) Metabolic alkalosis with respiratory compensation
C) Respiratory alkalosis with partial metabolic compensation
D) Mixed respiratory and metabolic acidosis
Correct Answer: A) Respiratory acidosis with metabolic compensation
Expert Rationale: The pH of 7.25 is acidic (normal 7.35-7.45). PaCO2 of 72 mmHg
is elevated (normal 35-45), indicating respiratory acidosis as the primary disorder.
HCO3- of 32 mEq/L is elevated (normal 22-26), showing metabolic compensation
by the kidneys (retaining bicarbonate). In COPD clients, chronic CO2 retention leads
to compensated respiratory acidosis. Acute exacerbations can decompensate this
balance. The nurse should monitor for worsening ventilation and prepare for non-
invasive positive pressure ventilation (BiPAP) if indicated.
2. A client with asthma is prescribed a combination inhaler containing fluticasone
and salmeterol (Advair). Which instruction should the nurse emphasize?
A) Use the inhaler only during acute asthma attacks for quick relief
B) Rinse the mouth with water after each use to prevent oral candidiasis
C) Shake the inhaler vigorously for 30 seconds before each puff
D) Discontinue the medication if wheezing improves after 1 week
Correct Answer: B) Rinse the mouth with water after each use to prevent oral
candidiasis
Expert Rationale: Fluticasone is an inhaled corticosteroid (ICS) that suppresses
local immunity and can cause oral candidiasis (thrush) and dysphonia. Rinsing the
, mouth, gargling, and spitting after each use prevents fungal overgrowth. Salmeterol
is a long-acting beta-agonist (LABA) used for maintenance, NOT rescue. Advair is a
controller medication taken daily, not PRN. The client should also have a short-
acting beta-agonist (albuterol) for rescue. ICS should NOT be stopped abruptly; they
are long-term controllers.
3. The nurse is caring for a client with a new tracheostomy who is on a mechanical
ventilator. Which action is the HIGHEST priority during tracheostomy care?
A) Changing the tracheostomy ties every 24 hours
B) Maintaining cuff pressure at 20-30 cm H2O and ensuring adequate humidification
C) Suctioning the oropharynx every 15 minutes to prevent aspiration
D) Removing the inner cannula for cleaning every 4 hours
Correct Answer: B) Maintaining cuff pressure at 20-30 cm H2O and ensuring
adequate humidification
Expert Rationale: For a ventilated client with a tracheostomy, the HIGHEST
priority is maintaining cuff pressure at 20-30 cm H2O to prevent aspiration (too low)
and tracheal damage (too high), AND ensuring adequate humidification since the
upper airway is bypassed. Dry secretions can cause mucus plugging and airway
obstruction. While tie changes and inner cannula cleaning are important, they are not
as immediately life-threatening as cuff pressure and humidification. Oropharyngeal
suctioning every 15 minutes is excessive and traumatic.
4. A client with active pulmonary tuberculosis (TB) is started on the standard four-
drug regimen. Which instruction is MOST important for the nurse to provide?
A) Take all four medications together once daily for 2 weeks, then stop when
symptoms resolve
B) Take medications exactly as prescribed for at least 6 months, even if feeling
better, to prevent multidrug-resistant TB
C) Take rifampin with antacids to reduce GI upset and orange-colored urine
D) Avoid all sun exposure while taking isoniazid to prevent photosensitivity
, Correct Answer: B) Take medications exactly as prescribed for at least 6 months,
even if feeling better, to prevent multidrug-resistant TB
Expert Rationale: The standard TB regimen (RIPE: rifampin, isoniazid,
pyrazinamide, ethambutol) requires 6-9 months of adherence. Premature
discontinuation leads to treatment failure and multidrug-resistant TB (MDR-TB), a
global health threat. Directly Observed Therapy (DOT) may be required. Rifampin
causes orange body fluids (urine, tears, sweat) and reduces effectiveness of oral
contraceptives and warfarin. Isoniazid requires pyridoxine (B6) to prevent peripheral
neuropathy, not sun avoidance. Antacids reduce rifampin absorption.
5. A client with lung cancer is scheduled for a pneumonectomy. Which preoperative
nursing intervention is MOST important?
A) Teaching the client to perform deep breathing and coughing exercises using an
incentive spirometer
B) Restricting fluids to 1000 mL/day to reduce postoperative pulmonary edema
C) Administering prophylactic antibiotics for 7 days before surgery
D) Instructing the client to sleep on the operative side for 2 weeks before surgery
Correct Answer: A) Teaching the client to perform deep breathing and coughing
exercises using an incentive spirometer
Expert Rationale: Preoperative pulmonary rehabilitation (deep breathing, incentive
spirometry, coughing exercises) is critical for pneumonectomy clients to expand
remaining lung tissue, prevent atelectasis, and clear secretions postoperatively. Fluid
restriction is not standard pre-op and could cause dehydration. Prophylactic
antibiotics are given within 60 minutes of incision, not for days. Sleeping on the
operative side is sometimes taught POST-operatively to promote drainage and
expansion of the remaining lung, not pre-operatively.
6. A client with a pulmonary embolism (PE) is receiving a heparin infusion. The
nurse notes the aPTT is 98 seconds (therapeutic range 60-80 seconds). Which action
should the nurse take FIRST?
A) Stop the heparin infusion immediately and notify the provider
B) Continue the infusion and recheck the aPTT in 2 hours
, C) Reduce the infusion rate per protocol and recheck aPTT in 4-6 hours
D) Administer protamine sulfate as an antidote
Correct Answer: C) Reduce the infusion rate per protocol and recheck aPTT in 4-6
hours
Expert Rationale: An aPTT of 98 seconds is supratherapeutic but not in the critical
range (>120 seconds or >2.5x control) that would require stopping the infusion. The
nurse should reduce the infusion rate per institutional protocol and recheck aPTT in
4-6 hours. Protamine sulfate is reserved for life-threatening bleeding or severe
overdose. Continuing at the same rate increases bleeding risk. Stopping completely
may cause clot extension. The nurse should also assess for bleeding (gums, bruising,
hematuria, melena).
7. A client with flail chest from a motor vehicle accident has paradoxical chest wall
movement. Which intervention is the HIGHEST priority?
A) Taping the chest wall with adhesive tape to stabilize the fracture segments
B) Administering high-flow oxygen and preparing for endotracheal intubation and
positive pressure ventilation
C) Placing the client in prone position to reduce chest wall movement
D) Administering morphine and encouraging the client to take shallow breaths to
reduce pain
Correct Answer: B) Administering high-flow oxygen and preparing for
endotracheal intubation and positive pressure ventilation
Expert Rationale: Flail chest occurs when multiple contiguous ribs fracture in two
places, creating a free-floating segment that moves paradoxically (inward on
inspiration, outward on expiration). This causes severe pain, hypoventilation, and
underlying pulmonary contusion. The HIGHEST priority is ensuring adequate
oxygenation and ventilation. High-flow oxygen, pain control (epidural or nerve
blocks preferred over systemic opioids), and possible mechanical ventilation with
PEEP stabilize the chest wall internally. Taping is CONTRAINDICATED as it
restricts ventilation. Shallow breathing causes atelectasis.
