Galen College of Nursing NUR 265 Exam 3
(This exam focuses on advanced adult medical-surgical topics such as cardiovascular,
respiratory, renal, gastrointestinal, hepatic, and multisystem disorders.)
1. A client with acute heart failure develops severe dyspnea, bilateral crackles, and an oxygen
saturation of 82%. Which intervention is the priority?
A. Encourage oral fluids
B. Place the client in high-Fowler position and provide oxygen as prescribed
C. Place the client flat
D. Encourage ambulation
Answer: B
Rationale: High-Fowler positioning improves lung expansion and oxygenation.
Supplemental oxygen should be provided as indicated.
2. Which assessment finding is most consistent with left-sided heart failure?
A. Pulmonary crackles and dyspnea
B. Ascites only
C. Enlarged liver without respiratory symptoms
D. Peripheral edema without pulmonary findings
Answer: A
Rationale: Left-sided heart failure causes pulmonary congestion, resulting in dyspnea and
crackles.
3. A client with heart failure reports a sudden 3-lb weight gain over 2 days. What should the
nurse suspect?
A. Loss of muscle mass
B. Improved cardiac function
C. Dehydration
D. Fluid retention
Answer: D
Rationale: Rapid weight gain is often an early indicator of fluid retention in heart failure.
4. Which instruction is most appropriate for a client with chronic heart failure?
A. Monitor daily weight under consistent conditions
B. Weigh only when symptoms become severe
(This exam focuses on advanced adult medical-surgical topics such as cardiovascular,
respiratory, renal, gastrointestinal, hepatic, and multisystem disorders.)
1. A client with acute heart failure develops severe dyspnea, bilateral crackles, and an oxygen
saturation of 82%. Which intervention is the priority?
A. Encourage oral fluids
B. Place the client in high-Fowler position and provide oxygen as prescribed
C. Place the client flat
D. Encourage ambulation
Answer: B
Rationale: High-Fowler positioning improves lung expansion and oxygenation.
Supplemental oxygen should be provided as indicated.
2. Which assessment finding is most consistent with left-sided heart failure?
A. Pulmonary crackles and dyspnea
B. Ascites only
C. Enlarged liver without respiratory symptoms
D. Peripheral edema without pulmonary findings
Answer: A
Rationale: Left-sided heart failure causes pulmonary congestion, resulting in dyspnea and
crackles.
3. A client with heart failure reports a sudden 3-lb weight gain over 2 days. What should the
nurse suspect?
A. Loss of muscle mass
B. Improved cardiac function
C. Dehydration
D. Fluid retention
Answer: D
Rationale: Rapid weight gain is often an early indicator of fluid retention in heart failure.
4. Which instruction is most appropriate for a client with chronic heart failure?
A. Monitor daily weight under consistent conditions
B. Weigh only when symptoms become severe
