NUR 265 Exam 3 | Medical-Surgical Nursing | Galen College of Nursing
GALEN COLLEGE OF NURSING
NUR 265 — Medical-Surgical Nursing
Exam 3 — Comprehensive Examination
Academic Year
Course: NUR 265 - Medical-Surgical Nursing Exam: Exam 3
Total Questions: 100 Multiple-Choice (4 options) Cognitive Mix: 30% Recall / 50% Application / 20% Analysis
Format: 80% Scenario-based, 20% Direct Recall Time Limit: 150 minutes
Passing Score: 75% (institutional standard) Materials: Pencil, calculator, scratch paper
EXAM CONTENT OVERVIEW
Section Topic Question Range
1 Renal and Urinary System Q1 - Q18 (18 questions)
2 Gastrointestinal System Q19 - Q36 (18 questions)
3 Hepatic and Biliary System Q37 - Q52 (16 questions)
4 Endocrine System Q53 - Q70 (18 questions)
5 Hematologic System Q71 - Q85 (15 questions)
6 Oncologic Nursing Q86 - Q100 (15 questions)
EXAM INSTRUCTIONS
1. This examination contains 100 multiple-choice questions across six content sections.
2. Each question has FOUR options (A, B, C, D). Select the SINGLE BEST answer.
3. The correct answer is marked [CORRECT] for self-study and review purposes.
4. A rationale with pathophysiologic reasoning and nursing interventions is provided for each question.
5. Apply clinical judgment, ABC prioritization, Maslow's hierarchy, and safety principles when evaluating scenarios.
6. Use this examination as an NCLEX-style preparation tool for the NUR 265 Exam 3 content.
Comprehensive Exam - 100 Questions Page 1
,NUR 265 Exam 3 | Medical-Surgical Nursing | Galen College of Nursing
Section 1: Renal and Urinary System
Acute Kidney Injury | Chronic Kidney Disease | Dialysis | UTIs | Benign Prostatic Hyperplasia (Q1 - Q18)
Q1. A 68-year-old male is admitted with severe dehydration secondary to gastroenteritis. His BUN is 58
mg/dL, serum creatinine is 1.9 mg/dL (BUN:Cr ratio 30:1), urine specific gravity is 1.030, and urine sodium is
12 mEq/L. The nurse identifies this presentation as which type of acute kidney injury (AKI)?
A. Intrarenal AKI due to acute tubular necrosis
B. Prerenal AKI due to decreased renal perfusion [CORRECT]
C. Postrenal AKI due to urinary tract obstruction
D. Intrinsic AKI due to glomerulonephritis
Correct Answer: B
Rationale: The BUN:Cr ratio > 20:1, urine specific gravity > 1.020, and urine sodium < 20 mEq/L are classic
laboratory markers of prerenal AKI, which results from decreased renal perfusion (hypovolemia, hemorrhage, heart
failure, sepsis). The kidneys are structurally intact and respond avidly to conserve sodium and water. Intrarenal AKI
would present with BUN:Cr < 15:1, urine sodium > 40 mEq/L, and muddy brown casts; postrenal AKI requires
evidence of obstruction (e.g., BPH, stones, tumor).
Q2. The nurse is caring for a patient in the oliguric phase of acute kidney injury. Which assessment finding
requires the most immediate intervention?
A. Serum potassium of 6.8 mEq/L with peaked T waves on ECG [CORRECT]
B. Serum creatinine of 4.2 mg/dL trending upward over 48 hours
C. Urine output of 180 mL over the past 12 hours
D. BUN of 65 mg/dL with mild confusion
Correct Answer: A
Rationale: Hyperkalemia with ECG changes (peaked T waves, widened QRS) is a life-threatening complication of AKI
that can progress to ventricular fibrillation and cardiac arrest within minutes, requiring immediate intervention with
IV calcium gluconate (membrane stabilizer), insulin/glucose, and possibly emergent dialysis. While elevated
creatinine, oliguria, and uremic confusion all require management, they do not pose the same immediate threat to life
as hyperkalemia with cardiac conduction changes.
Q3. A patient was started on IV gentamicin 6 days ago for a Gram-negative bloodstream infection. Today the
patient's creatinine has risen from 0.9 to 2.6 mg/dL and the urinalysis shows muddy brown casts. The nurse
recognizes this as which phase and type of AKI?
A. Prerenal azotemia caused by hypoperfusion
B. Intrarenal AKI caused by acute tubular necrosis from nephrotoxicity [CORRECT]
C. Postrenal AKI caused by bilateral ureteral obstruction
D. Recovery phase of AKI with diuresis
Correct Answer: B
Rationale: Aminoglycosides (gentamicin, tobramycin, amikacin) are direct nephrotoxins that accumulate in proximal
tubular cells, causing acute tubular necrosis (ATN), the most common form of intrinsic (intrarenal) AKI. Muddy brown
casts are the hallmark urinalysis finding of ATN. The rising creatinine after sustained gentamicin exposure, in the
Comprehensive Exam - 100 Questions Page 2
,NUR 265 Exam 3 | Medical-Surgical Nursing | Galen College of Nursing
absence of hypoperfusion or obstruction, confirms nephrotoxic intrarenal injury. Recovery phase is characterized by
diuresis and falling creatinine, not rising values.
Q4. A patient with chronic kidney disease (CKD) has a GFR of 22 mL/min. According to the KDIGO
classification, which stage of CKD is this patient in?
A. Stage 2 (mild, GFR 60-89 mL/min)
B. Stage 3a (mild-moderate, GFR 45-59 mL/min)
C. Stage 4 (severe, GFR 15-29 mL/min) [CORRECT]
D. Stage 5 (kidney failure, GFR < 15 mL/min or dialysis)
Correct Answer: C
Rationale: KDIGO staging of CKD is based on GFR: Stage 1 (GFR >= 90 with kidney damage), Stage 2 (60-89),
Stage 3a (45-59), Stage 3b (30-44), Stage 4 (15-29, severe reduction), and Stage 5 (< 15 or dialysis). A GFR of 22
mL/min falls within Stage 4. Patients in Stage 4 require preparation for renal replacement therapy, aggressive
management of complications (anemia, bone mineral disorder, fluid overload), and referral to nephrology for vascular
access planning.
Q5. A patient with stage 5 CKD on hemodialysis has a serum potassium of 6.5 mEq/L. Which of the following
is the priority nursing action?
A. Administer a phosphate binder with the next meal
B. Administer kayexalate (sodium polystyrene sulfonate) orally
C. Assess for muscle weakness and obtain a 12-lead ECG [CORRECT]
D. Encourage the patient to drink additional fluids to flush potassium
Correct Answer: C
Rationale: Hyperkalemia in CKD can rapidly cause life-threatening cardiac dysrhythmias. The priority action is to
assess for clinical manifestations (muscle weakness, paresthesias, cardiac arrhythmias) and obtain an ECG to
evaluate for peaked T waves, prolonged PR interval, or widened QRS. Phosphate binders address hyperphosphatemia,
not potassium. Kayexalate is a slow-acting exchange resin and is not appropriate for acute severe hyperkalemia.
Additional fluid intake is contraindicated in a dialysis-dependent patient with limited urine output.
Q6. A patient receiving hemodialysis three times weekly has gained 4.5 kg since the last treatment two days
ago. Which assessment finding would the nurse anticipate as a direct result of this fluid overload?
A. Crackles in the lung bases and jugular venous distention [CORRECT]
B. Sunken eyeballs and flat jugular veins
C. Hypotension and weak peripheral pulses
D. Decreased urine output and hypernatremia
Correct Answer: A
Rationale: Interdialytic weight gain of 4.5 kg represents approximately 4.5 liters of retained fluid, which causes
hypervolemia manifested by bibasilar crackles, jugular venous distention, peripheral edema, hypertension, and
possibly pulmonary edema. The nurse should anticipate adjusting the ultrafiltration goal for this treatment and
reinforce fluid restriction education (typically 1,000 mL/day plus urine output). Hypotension, flat jugular veins, and
sunken eyes suggest hypovolemia, the opposite of this patient's presentation.
Comprehensive Exam - 100 Questions Page 3
, NUR 265 Exam 3 | Medical-Surgical Nursing | Galen College of Nursing
Q7. A patient with a newly created left brachiocephalic AV fistula is being discharged. Which statement by
the patient indicates a need for further teaching?
A. I will check for a thrill and bruit over the fistula every day
B. I should avoid taking blood pressures or drawing blood from my left arm
C. I can sleep on my left arm to protect the fistula during the night [CORRECT]
D. I will perform hand exercises such as squeezing a soft ball to mature the fistula
Correct Answer: C
Rationale: Sleeping on or compressing the access arm can occlude blood flow and cause fistula thrombosis, the most
common complication of AV fistulas. The patient should never place pressure on the access arm, including avoiding
blood pressure measurements, venipunctures, IV insertion, or restrictive clothing/jewelry on that arm. Daily
assessment for thrill (palpable vibration) and bruit (audible swoosh) confirms patency. Hand exercises promote
venous dilation and fistula maturation (typically 6 weeks before first cannulation).
Q8. A patient performing continuous ambulatory peritoneal dialysis (CAPD) calls the clinic reporting that the
effluent appears cloudy and has a faint odor. The patient also reports mild abdominal discomfort. What is the
most appropriate nursing response?
A. Instruct the patient to drain the abdomen immediately and proceed to the ED
B. Tell the patient this is a normal finding and to continue the next exchange as scheduled
C. Have the patient save a sample of the effluent and come to the clinic for evaluation of peritonitis
[CORRECT]
D. Recommend the patient take an oral antibiotic and continue dialysis at home
Correct Answer: C
Rationale: Cloudy effluent with abdominal pain is the cardinal sign of peritonitis, the most common complication of
peritoneal dialysis. The patient must be evaluated promptly, the effluent cultured, and empiric intraperitoneal
antibiotics initiated. Peritonitis can progress rapidly and may lead to catheter removal or even fatal sepsis. Simply
draining the abdomen without further workup misses the diagnosis; reassuring the patient or treating empirically
without culture is unsafe practice.
Q9. A 24-year-old female presents with dysuria, urinary frequency, and urgency. She has no fever or flank
pain. Urinalysis shows positive leukocyte esterase and nitrites. Which organism is most likely responsible for
this patient's infection?
A. Escherichia coli [CORRECT]
B. Streptococcus pyogenes
C. Pseudomonas aeruginosa
D. Candida albicans
Correct Answer: A
Rationale: Escherichia coli causes 80-85% of uncomplicated lower urinary tract infections (cystitis), particularly in
young women due to urethral anatomy and ascending infection from the perineal flora. Positive leukocyte esterase
indicates pyuria (WBCs in urine) and nitrites suggest the presence of Enterobacteriaceae that convert nitrates to
nitrites. Streptococcus pyogenes typically causes pharyngitis and skin infections; Pseudomonas and Candida are more
common in catheter-associated or hospital-acquired UTIs.
Comprehensive Exam - 100 Questions Page 4
GALEN COLLEGE OF NURSING
NUR 265 — Medical-Surgical Nursing
Exam 3 — Comprehensive Examination
Academic Year
Course: NUR 265 - Medical-Surgical Nursing Exam: Exam 3
Total Questions: 100 Multiple-Choice (4 options) Cognitive Mix: 30% Recall / 50% Application / 20% Analysis
Format: 80% Scenario-based, 20% Direct Recall Time Limit: 150 minutes
Passing Score: 75% (institutional standard) Materials: Pencil, calculator, scratch paper
EXAM CONTENT OVERVIEW
Section Topic Question Range
1 Renal and Urinary System Q1 - Q18 (18 questions)
2 Gastrointestinal System Q19 - Q36 (18 questions)
3 Hepatic and Biliary System Q37 - Q52 (16 questions)
4 Endocrine System Q53 - Q70 (18 questions)
5 Hematologic System Q71 - Q85 (15 questions)
6 Oncologic Nursing Q86 - Q100 (15 questions)
EXAM INSTRUCTIONS
1. This examination contains 100 multiple-choice questions across six content sections.
2. Each question has FOUR options (A, B, C, D). Select the SINGLE BEST answer.
3. The correct answer is marked [CORRECT] for self-study and review purposes.
4. A rationale with pathophysiologic reasoning and nursing interventions is provided for each question.
5. Apply clinical judgment, ABC prioritization, Maslow's hierarchy, and safety principles when evaluating scenarios.
6. Use this examination as an NCLEX-style preparation tool for the NUR 265 Exam 3 content.
Comprehensive Exam - 100 Questions Page 1
,NUR 265 Exam 3 | Medical-Surgical Nursing | Galen College of Nursing
Section 1: Renal and Urinary System
Acute Kidney Injury | Chronic Kidney Disease | Dialysis | UTIs | Benign Prostatic Hyperplasia (Q1 - Q18)
Q1. A 68-year-old male is admitted with severe dehydration secondary to gastroenteritis. His BUN is 58
mg/dL, serum creatinine is 1.9 mg/dL (BUN:Cr ratio 30:1), urine specific gravity is 1.030, and urine sodium is
12 mEq/L. The nurse identifies this presentation as which type of acute kidney injury (AKI)?
A. Intrarenal AKI due to acute tubular necrosis
B. Prerenal AKI due to decreased renal perfusion [CORRECT]
C. Postrenal AKI due to urinary tract obstruction
D. Intrinsic AKI due to glomerulonephritis
Correct Answer: B
Rationale: The BUN:Cr ratio > 20:1, urine specific gravity > 1.020, and urine sodium < 20 mEq/L are classic
laboratory markers of prerenal AKI, which results from decreased renal perfusion (hypovolemia, hemorrhage, heart
failure, sepsis). The kidneys are structurally intact and respond avidly to conserve sodium and water. Intrarenal AKI
would present with BUN:Cr < 15:1, urine sodium > 40 mEq/L, and muddy brown casts; postrenal AKI requires
evidence of obstruction (e.g., BPH, stones, tumor).
Q2. The nurse is caring for a patient in the oliguric phase of acute kidney injury. Which assessment finding
requires the most immediate intervention?
A. Serum potassium of 6.8 mEq/L with peaked T waves on ECG [CORRECT]
B. Serum creatinine of 4.2 mg/dL trending upward over 48 hours
C. Urine output of 180 mL over the past 12 hours
D. BUN of 65 mg/dL with mild confusion
Correct Answer: A
Rationale: Hyperkalemia with ECG changes (peaked T waves, widened QRS) is a life-threatening complication of AKI
that can progress to ventricular fibrillation and cardiac arrest within minutes, requiring immediate intervention with
IV calcium gluconate (membrane stabilizer), insulin/glucose, and possibly emergent dialysis. While elevated
creatinine, oliguria, and uremic confusion all require management, they do not pose the same immediate threat to life
as hyperkalemia with cardiac conduction changes.
Q3. A patient was started on IV gentamicin 6 days ago for a Gram-negative bloodstream infection. Today the
patient's creatinine has risen from 0.9 to 2.6 mg/dL and the urinalysis shows muddy brown casts. The nurse
recognizes this as which phase and type of AKI?
A. Prerenal azotemia caused by hypoperfusion
B. Intrarenal AKI caused by acute tubular necrosis from nephrotoxicity [CORRECT]
C. Postrenal AKI caused by bilateral ureteral obstruction
D. Recovery phase of AKI with diuresis
Correct Answer: B
Rationale: Aminoglycosides (gentamicin, tobramycin, amikacin) are direct nephrotoxins that accumulate in proximal
tubular cells, causing acute tubular necrosis (ATN), the most common form of intrinsic (intrarenal) AKI. Muddy brown
casts are the hallmark urinalysis finding of ATN. The rising creatinine after sustained gentamicin exposure, in the
Comprehensive Exam - 100 Questions Page 2
,NUR 265 Exam 3 | Medical-Surgical Nursing | Galen College of Nursing
absence of hypoperfusion or obstruction, confirms nephrotoxic intrarenal injury. Recovery phase is characterized by
diuresis and falling creatinine, not rising values.
Q4. A patient with chronic kidney disease (CKD) has a GFR of 22 mL/min. According to the KDIGO
classification, which stage of CKD is this patient in?
A. Stage 2 (mild, GFR 60-89 mL/min)
B. Stage 3a (mild-moderate, GFR 45-59 mL/min)
C. Stage 4 (severe, GFR 15-29 mL/min) [CORRECT]
D. Stage 5 (kidney failure, GFR < 15 mL/min or dialysis)
Correct Answer: C
Rationale: KDIGO staging of CKD is based on GFR: Stage 1 (GFR >= 90 with kidney damage), Stage 2 (60-89),
Stage 3a (45-59), Stage 3b (30-44), Stage 4 (15-29, severe reduction), and Stage 5 (< 15 or dialysis). A GFR of 22
mL/min falls within Stage 4. Patients in Stage 4 require preparation for renal replacement therapy, aggressive
management of complications (anemia, bone mineral disorder, fluid overload), and referral to nephrology for vascular
access planning.
Q5. A patient with stage 5 CKD on hemodialysis has a serum potassium of 6.5 mEq/L. Which of the following
is the priority nursing action?
A. Administer a phosphate binder with the next meal
B. Administer kayexalate (sodium polystyrene sulfonate) orally
C. Assess for muscle weakness and obtain a 12-lead ECG [CORRECT]
D. Encourage the patient to drink additional fluids to flush potassium
Correct Answer: C
Rationale: Hyperkalemia in CKD can rapidly cause life-threatening cardiac dysrhythmias. The priority action is to
assess for clinical manifestations (muscle weakness, paresthesias, cardiac arrhythmias) and obtain an ECG to
evaluate for peaked T waves, prolonged PR interval, or widened QRS. Phosphate binders address hyperphosphatemia,
not potassium. Kayexalate is a slow-acting exchange resin and is not appropriate for acute severe hyperkalemia.
Additional fluid intake is contraindicated in a dialysis-dependent patient with limited urine output.
Q6. A patient receiving hemodialysis three times weekly has gained 4.5 kg since the last treatment two days
ago. Which assessment finding would the nurse anticipate as a direct result of this fluid overload?
A. Crackles in the lung bases and jugular venous distention [CORRECT]
B. Sunken eyeballs and flat jugular veins
C. Hypotension and weak peripheral pulses
D. Decreased urine output and hypernatremia
Correct Answer: A
Rationale: Interdialytic weight gain of 4.5 kg represents approximately 4.5 liters of retained fluid, which causes
hypervolemia manifested by bibasilar crackles, jugular venous distention, peripheral edema, hypertension, and
possibly pulmonary edema. The nurse should anticipate adjusting the ultrafiltration goal for this treatment and
reinforce fluid restriction education (typically 1,000 mL/day plus urine output). Hypotension, flat jugular veins, and
sunken eyes suggest hypovolemia, the opposite of this patient's presentation.
Comprehensive Exam - 100 Questions Page 3
, NUR 265 Exam 3 | Medical-Surgical Nursing | Galen College of Nursing
Q7. A patient with a newly created left brachiocephalic AV fistula is being discharged. Which statement by
the patient indicates a need for further teaching?
A. I will check for a thrill and bruit over the fistula every day
B. I should avoid taking blood pressures or drawing blood from my left arm
C. I can sleep on my left arm to protect the fistula during the night [CORRECT]
D. I will perform hand exercises such as squeezing a soft ball to mature the fistula
Correct Answer: C
Rationale: Sleeping on or compressing the access arm can occlude blood flow and cause fistula thrombosis, the most
common complication of AV fistulas. The patient should never place pressure on the access arm, including avoiding
blood pressure measurements, venipunctures, IV insertion, or restrictive clothing/jewelry on that arm. Daily
assessment for thrill (palpable vibration) and bruit (audible swoosh) confirms patency. Hand exercises promote
venous dilation and fistula maturation (typically 6 weeks before first cannulation).
Q8. A patient performing continuous ambulatory peritoneal dialysis (CAPD) calls the clinic reporting that the
effluent appears cloudy and has a faint odor. The patient also reports mild abdominal discomfort. What is the
most appropriate nursing response?
A. Instruct the patient to drain the abdomen immediately and proceed to the ED
B. Tell the patient this is a normal finding and to continue the next exchange as scheduled
C. Have the patient save a sample of the effluent and come to the clinic for evaluation of peritonitis
[CORRECT]
D. Recommend the patient take an oral antibiotic and continue dialysis at home
Correct Answer: C
Rationale: Cloudy effluent with abdominal pain is the cardinal sign of peritonitis, the most common complication of
peritoneal dialysis. The patient must be evaluated promptly, the effluent cultured, and empiric intraperitoneal
antibiotics initiated. Peritonitis can progress rapidly and may lead to catheter removal or even fatal sepsis. Simply
draining the abdomen without further workup misses the diagnosis; reassuring the patient or treating empirically
without culture is unsafe practice.
Q9. A 24-year-old female presents with dysuria, urinary frequency, and urgency. She has no fever or flank
pain. Urinalysis shows positive leukocyte esterase and nitrites. Which organism is most likely responsible for
this patient's infection?
A. Escherichia coli [CORRECT]
B. Streptococcus pyogenes
C. Pseudomonas aeruginosa
D. Candida albicans
Correct Answer: A
Rationale: Escherichia coli causes 80-85% of uncomplicated lower urinary tract infections (cystitis), particularly in
young women due to urethral anatomy and ascending infection from the perineal flora. Positive leukocyte esterase
indicates pyuria (WBCs in urine) and nitrites suggest the presence of Enterobacteriaceae that convert nitrates to
nitrites. Streptococcus pyogenes typically causes pharyngitis and skin infections; Pseudomonas and Candida are more
common in catheter-associated or hospital-acquired UTIs.
Comprehensive Exam - 100 Questions Page 4
