Galen College of Nursing NUR 265 Final Exam Practice
1. A client with acute heart failure develops severe dyspnea, crackles, and an oxygen
saturation of 84%. Which action should the nurse take first?
A. Place the client flat
B. Encourage oral fluids
C. Place the client in high-Fowler position and administer oxygen as prescribed
D. Encourage ambulation
Answer: C
Rationale: Upright positioning improves lung expansion and oxygenation. Supplemental
oxygen should be administered according to the client's condition and prescription.
2. Which finding is most characteristic of left-sided heart failure?
A. Pulmonary crackles and dyspnea
B. Ascites only
C. Enlarged liver without respiratory symptoms
D. Dependent edema without pulmonary symptoms
Answer: A
Rationale: Left-sided heart failure causes pulmonary congestion, producing dyspnea and
crackles.
3. A client with heart failure gains 4 lb in 3 days. What does this finding most likely indicate?
A. Improved cardiac function
B. Fluid retention
C. Dehydration
D. Loss of adipose tissue
Answer: B
Rationale: Rapid weight gain is an important indicator of fluid accumulation in clients with
heart failure.
4. Which instruction should the nurse provide to a client with chronic heart failure?
A. Weigh yourself daily at approximately the same time
B. Weigh yourself only once a month
C. Increase sodium intake
D. Report weight changes only when severe edema occurs
,Answer: A
Rationale: Daily weights can identify fluid retention early, allowing treatment before severe
symptoms develop.
5. A client reports crushing chest pain radiating to the left arm and becomes diaphoretic.
What is the priority nursing action?
A. Initiate immediate assessment and the facility's acute coronary syndrome protocol
B. Encourage the client to walk
C. Offer a meal
D. Wait until the next scheduled vital signs
Answer: A
Rationale: These findings are concerning for acute coronary syndrome and require
immediate assessment and intervention.
6. Which laboratory marker is commonly used to evaluate myocardial injury?
A. Lipase
B. Bilirubin
C. Troponin
D. Creatinine only
Answer: C
Rationale: Cardiac troponins are sensitive and specific markers of myocardial injury.
7. A client with atrial fibrillation is at increased risk for which complication?
A. Embolic stroke
B. Pneumothorax
C. Appendicitis
D. Hypothyroidism
Answer: A
Rationale: Atrial fibrillation promotes blood stasis and thrombus formation, increasing the
risk of embolic stroke.
8. Which new finding in a client with atrial fibrillation requires immediate intervention?
A. Sudden facial drooping and difficulty speaking
B. Mild fatigue
C. Irregular pulse without other symptoms
D. Heart rate of 82/min
, Answer: A
Rationale: Sudden neurologic deficits may indicate an acute stroke and require emergency
evaluation.
9. A client taking digoxin reports nausea, blurred or yellow vision, and palpitations. What
should the nurse suspect?
A. Hyperthyroidism
B. Therapeutic response
C. Improved cardiac output
D. Digoxin toxicity
Answer: D
Rationale: Gastrointestinal symptoms, visual disturbances, and dysrhythmias are possible
manifestations of digoxin toxicity.
10. Which electrolyte abnormality increases the risk of digoxin toxicity?
A. Hypermagnesemia
B. Hypernatremia
C. Hyperchloremia
D. Hypokalemia
Answer: D
Rationale: Low potassium levels increase myocardial sensitivity to digoxin and increase
toxicity risk.
11. A client with COPD is experiencing dyspnea. Which position can help improve
breathing?
A. Tripod position
B. Flat supine position
C. Trendelenburg position
D. Head-down position
Answer: A
Rationale: The tripod position can improve accessory muscle use and respiratory mechanics.
12. Which breathing technique should the nurse teach a client with COPD?
A. Pursed-lip breathing
B. Rapid shallow breathing
C. Prolonged breath holding
D. Complete suppression of coughing
1. A client with acute heart failure develops severe dyspnea, crackles, and an oxygen
saturation of 84%. Which action should the nurse take first?
A. Place the client flat
B. Encourage oral fluids
C. Place the client in high-Fowler position and administer oxygen as prescribed
D. Encourage ambulation
Answer: C
Rationale: Upright positioning improves lung expansion and oxygenation. Supplemental
oxygen should be administered according to the client's condition and prescription.
2. Which finding is most characteristic of left-sided heart failure?
A. Pulmonary crackles and dyspnea
B. Ascites only
C. Enlarged liver without respiratory symptoms
D. Dependent edema without pulmonary symptoms
Answer: A
Rationale: Left-sided heart failure causes pulmonary congestion, producing dyspnea and
crackles.
3. A client with heart failure gains 4 lb in 3 days. What does this finding most likely indicate?
A. Improved cardiac function
B. Fluid retention
C. Dehydration
D. Loss of adipose tissue
Answer: B
Rationale: Rapid weight gain is an important indicator of fluid accumulation in clients with
heart failure.
4. Which instruction should the nurse provide to a client with chronic heart failure?
A. Weigh yourself daily at approximately the same time
B. Weigh yourself only once a month
C. Increase sodium intake
D. Report weight changes only when severe edema occurs
,Answer: A
Rationale: Daily weights can identify fluid retention early, allowing treatment before severe
symptoms develop.
5. A client reports crushing chest pain radiating to the left arm and becomes diaphoretic.
What is the priority nursing action?
A. Initiate immediate assessment and the facility's acute coronary syndrome protocol
B. Encourage the client to walk
C. Offer a meal
D. Wait until the next scheduled vital signs
Answer: A
Rationale: These findings are concerning for acute coronary syndrome and require
immediate assessment and intervention.
6. Which laboratory marker is commonly used to evaluate myocardial injury?
A. Lipase
B. Bilirubin
C. Troponin
D. Creatinine only
Answer: C
Rationale: Cardiac troponins are sensitive and specific markers of myocardial injury.
7. A client with atrial fibrillation is at increased risk for which complication?
A. Embolic stroke
B. Pneumothorax
C. Appendicitis
D. Hypothyroidism
Answer: A
Rationale: Atrial fibrillation promotes blood stasis and thrombus formation, increasing the
risk of embolic stroke.
8. Which new finding in a client with atrial fibrillation requires immediate intervention?
A. Sudden facial drooping and difficulty speaking
B. Mild fatigue
C. Irregular pulse without other symptoms
D. Heart rate of 82/min
, Answer: A
Rationale: Sudden neurologic deficits may indicate an acute stroke and require emergency
evaluation.
9. A client taking digoxin reports nausea, blurred or yellow vision, and palpitations. What
should the nurse suspect?
A. Hyperthyroidism
B. Therapeutic response
C. Improved cardiac output
D. Digoxin toxicity
Answer: D
Rationale: Gastrointestinal symptoms, visual disturbances, and dysrhythmias are possible
manifestations of digoxin toxicity.
10. Which electrolyte abnormality increases the risk of digoxin toxicity?
A. Hypermagnesemia
B. Hypernatremia
C. Hyperchloremia
D. Hypokalemia
Answer: D
Rationale: Low potassium levels increase myocardial sensitivity to digoxin and increase
toxicity risk.
11. A client with COPD is experiencing dyspnea. Which position can help improve
breathing?
A. Tripod position
B. Flat supine position
C. Trendelenburg position
D. Head-down position
Answer: A
Rationale: The tripod position can improve accessory muscle use and respiratory mechanics.
12. Which breathing technique should the nurse teach a client with COPD?
A. Pursed-lip breathing
B. Rapid shallow breathing
C. Prolonged breath holding
D. Complete suppression of coughing
