NEWEST NUR 265 EXAM 1 ADVANCED CONCEPT IN
MEDICAL SURGICAL NURSING EXAM ACTUAL EXAM
2026 COMPLETE EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS A NEW UPDATED VERSION LATEST
2026-2027 MOST RECENT EXAM/NUR 265 EXAM 1
(VERIFIED ANSWERS) ALREADY GRADED A+
A postoperative patient is confused, restless, and has a blood pressure of 88/52
mmHg. What is the priority nursing action?
A. Reorient the patient to time and place.
B. Assess for hypovolemic shock and notify the healthcare provider.
C. Encourage the patient to increase oral fluid intake.
D. Document the findings in the patient's chart.
Answer: B.
Hypotension with confusion and restlessness are classic signs of hypovolemic
shock. The priority is to assess the patient's hemodynamic status and notify the
provider to prevent further deterioration. Reorientation and documentation are
secondary to stabilizing the patient's condition .
A patient on furosemide complains of muscle weakness and heart palpitations.
Which laboratory result should the nurse review first?
A. Serum potassium of 2.7 mEq/L.
B. Serum sodium of 140 mEq/L.
,C. Serum glucose of 100 mg/dL.
D. Serum calcium of 9 mg/dL.
Answer: A.
Furosemide is a loop diuretic that causes significant potassium loss.
Hypokalemia (K+ < 3.5 mEq/L) can cause muscle weakness and life-
threatening cardiac dysrhythmias. This is the most critical finding requiring
immediate action .
A patient reports sudden onset of chest pain and shortness of breath. What is
the nurse's first action?
A. Encourage the patient to rest and calm down.
B. Assess the patient's airway, breathing, and circulation (ABCs).
C. Offer the patient a glass of water.
D. Document the patient's symptoms.
Answer: B.
The ABCs are always the priority in any acute symptom presentation. The
airway, breathing, and circulation must be assessed first to identify any life-
threatening conditions .
A patient with diabetes reports feeling shaky and sweating profusely after
taking insulin. What is the priority nursing action?
A. Administer a dose of rapid-acting insulin.
B. Encourage the patient to rest.
C. Check the patient's blood glucose level immediately.
D. Document the symptoms in the chart.
Answer: C.
, Shakiness and diaphoresis are classic symptoms of hypoglycemia. An
immediate blood glucose check is needed to confirm the diagnosis and guide
appropriate treatment. Giving insulin would worsen the condition .
A patient on warfarin presents with new bruising and nosebleeds. What should
the nurse do first?
A. Check the patient's INR and notify the healthcare provider.
B. Continue the warfarin as prescribed.
C. Encourage the patient to increase fluid intake.
D. Administer vitamin K immediately.
Answer: A. Bruising and bleeding indicate an elevated INR, suggesting the
patient is over-anticoagulated. The nurse should assess the INR and notify the
provider. Vitamin K should not be administered without a provider's order .
A patient receiving oxygen via nasal cannula at 2 L/min has an SpO₂ of 85%
and is dyspneic. What is the nurse's priority action?
A. Apply oxygen as prescribed and assess the patient's respiratory effort.
B. Immediately increase the oxygen to 6 L/min without an order.
C. Remove the nasal cannula to reassess the patient's breathing.
D. Document the findings and continue to monitor.
Answer: A.
Oxygen should be titrated as prescribed while assessing respiratory effort and
effectiveness. Increasing oxygen without an order or removing the cannula is
unsafe and could harm the patient .
A patient on a continuous heparin infusion has an aPTT of 90 seconds. What
should the nurse do?
, A. Hold the heparin infusion and notify the healthcare provider.
B. Continue the infusion as it is at a therapeutic level.
C. Encourage the patient to ambulate.
D. Document the finding only.
Answer: A.
An aPTT of 90 seconds is significantly above the therapeutic range (typically
60-80 seconds). This places the patient at high risk for bleeding. The heparin
should be held and the provider notified for a dose adjustment .
A patient reports dizziness after taking their antihypertensive medication.
What is the first action?
A. Reassure the patient that this is a normal side effect.
B. Assess the patient's blood pressure.
C. Encourage the patient to drink more fluids.
D. Document the patient's complaint.
Answer: B.
Dizziness after taking antihypertensives often indicates hypotension. The
priority is to assess the patient's blood pressure to determine the severity and
appropriate intervention .
A patient with heart failure has dyspnea and crackles in the lungs. Which
intervention is a priority?
A. Assess the patient's oxygen saturation and notify the healthcare provider.
B. Provide a warm blanket for comfort.
C. Encourage the patient to ambulate in the hallway.
D. Document the findings.
MEDICAL SURGICAL NURSING EXAM ACTUAL EXAM
2026 COMPLETE EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS A NEW UPDATED VERSION LATEST
2026-2027 MOST RECENT EXAM/NUR 265 EXAM 1
(VERIFIED ANSWERS) ALREADY GRADED A+
A postoperative patient is confused, restless, and has a blood pressure of 88/52
mmHg. What is the priority nursing action?
A. Reorient the patient to time and place.
B. Assess for hypovolemic shock and notify the healthcare provider.
C. Encourage the patient to increase oral fluid intake.
D. Document the findings in the patient's chart.
Answer: B.
Hypotension with confusion and restlessness are classic signs of hypovolemic
shock. The priority is to assess the patient's hemodynamic status and notify the
provider to prevent further deterioration. Reorientation and documentation are
secondary to stabilizing the patient's condition .
A patient on furosemide complains of muscle weakness and heart palpitations.
Which laboratory result should the nurse review first?
A. Serum potassium of 2.7 mEq/L.
B. Serum sodium of 140 mEq/L.
,C. Serum glucose of 100 mg/dL.
D. Serum calcium of 9 mg/dL.
Answer: A.
Furosemide is a loop diuretic that causes significant potassium loss.
Hypokalemia (K+ < 3.5 mEq/L) can cause muscle weakness and life-
threatening cardiac dysrhythmias. This is the most critical finding requiring
immediate action .
A patient reports sudden onset of chest pain and shortness of breath. What is
the nurse's first action?
A. Encourage the patient to rest and calm down.
B. Assess the patient's airway, breathing, and circulation (ABCs).
C. Offer the patient a glass of water.
D. Document the patient's symptoms.
Answer: B.
The ABCs are always the priority in any acute symptom presentation. The
airway, breathing, and circulation must be assessed first to identify any life-
threatening conditions .
A patient with diabetes reports feeling shaky and sweating profusely after
taking insulin. What is the priority nursing action?
A. Administer a dose of rapid-acting insulin.
B. Encourage the patient to rest.
C. Check the patient's blood glucose level immediately.
D. Document the symptoms in the chart.
Answer: C.
, Shakiness and diaphoresis are classic symptoms of hypoglycemia. An
immediate blood glucose check is needed to confirm the diagnosis and guide
appropriate treatment. Giving insulin would worsen the condition .
A patient on warfarin presents with new bruising and nosebleeds. What should
the nurse do first?
A. Check the patient's INR and notify the healthcare provider.
B. Continue the warfarin as prescribed.
C. Encourage the patient to increase fluid intake.
D. Administer vitamin K immediately.
Answer: A. Bruising and bleeding indicate an elevated INR, suggesting the
patient is over-anticoagulated. The nurse should assess the INR and notify the
provider. Vitamin K should not be administered without a provider's order .
A patient receiving oxygen via nasal cannula at 2 L/min has an SpO₂ of 85%
and is dyspneic. What is the nurse's priority action?
A. Apply oxygen as prescribed and assess the patient's respiratory effort.
B. Immediately increase the oxygen to 6 L/min without an order.
C. Remove the nasal cannula to reassess the patient's breathing.
D. Document the findings and continue to monitor.
Answer: A.
Oxygen should be titrated as prescribed while assessing respiratory effort and
effectiveness. Increasing oxygen without an order or removing the cannula is
unsafe and could harm the patient .
A patient on a continuous heparin infusion has an aPTT of 90 seconds. What
should the nurse do?
, A. Hold the heparin infusion and notify the healthcare provider.
B. Continue the infusion as it is at a therapeutic level.
C. Encourage the patient to ambulate.
D. Document the finding only.
Answer: A.
An aPTT of 90 seconds is significantly above the therapeutic range (typically
60-80 seconds). This places the patient at high risk for bleeding. The heparin
should be held and the provider notified for a dose adjustment .
A patient reports dizziness after taking their antihypertensive medication.
What is the first action?
A. Reassure the patient that this is a normal side effect.
B. Assess the patient's blood pressure.
C. Encourage the patient to drink more fluids.
D. Document the patient's complaint.
Answer: B.
Dizziness after taking antihypertensives often indicates hypotension. The
priority is to assess the patient's blood pressure to determine the severity and
appropriate intervention .
A patient with heart failure has dyspnea and crackles in the lungs. Which
intervention is a priority?
A. Assess the patient's oxygen saturation and notify the healthcare provider.
B. Provide a warm blanket for comfort.
C. Encourage the patient to ambulate in the hallway.
D. Document the findings.
