NUR 265 Nursing Concepts II Exam Prep | Complete Question
Bank, Clinical Scenarios & Detailed Rationales 2026/2027
Question 1
A client with end-stage heart failure is being managed with a left
ventricular assist device (LVAD) as a bridge to transplantation. Which of
the following is a critical nursing assessment when evaluating this
client's perfusion status?
• A. Assessing the radial pulse using standard manual palpation to
determine heart rate.
• B. Auscultating for a traditional S1 and S2 heart sound pattern.
• C. Evaluating mean arterial pressure (MAP) using an automated
Doppler device, as continuous-flow LVADs often lack a palpable
pulse.
• D. Measuring blood pressure via a standard manual
sphygmomanometer cuff.
Correct Answer: C. Evaluating mean arterial pressure (MAP) using an
automated Doppler device, as continuous-flow LVADs often lack a
palpable pulse.
Detailed Rationale: Continuous-flow LVADs provide continuous blood
flow rather than pulsatile flow. Consequently, clients often do not have
a traditional palpable pulse or easily measurable auscultated blood
pressure. A Doppler ultrasound is required to determine the mean
arterial pressure (target typically between 70 and 80 mmHg).
,Question 2
A client is receiving mechanical ventilation in the intensive care unit. To
minimize the risk of ventilator-associated pneumonia (VAP), which of
the following evidence-based interventions should the nurse include in
the daily plan of care?
• A. Keep the head of the bed flat at 0 degrees to maximize cerebral
perfusion.
• B. Perform routine scheduled changes of ventilator circuits every
24 hours.
• C. Maintain the head of the bed elevated between 30 and 45
degrees and perform daily sedation vacations to assess readiness
to extubate.
• D. Administer routine prophylactic systemic broad-spectrum
antibiotics to all intubated clients.
Correct Answer: C. Maintain the head of the bed elevated between 30
and 45 degrees and perform daily sedation vacations to assess
readiness to extubate.
Detailed Rationale: Elevating the head of the bed (30 to 45 degrees)
prevents aspiration of gastric contents, a primary cause of VAP. Daily
sedation vacations and assessments of extubation readiness reduce the
duration of mechanical ventilation, thereby lowering infection risks.
Circuit changes are not done routinely every 24 hours, and prophylactic
antibiotics are avoided to prevent resistance.
Question 3
,A client with acute kidney injury is undergoing continuous renal
replacement therapy (CRRT). Which of the following nursing
responsibilities is of highest priority during this therapy?
• A. Monitoring hourly intake and output and checking the
extracorporeal circuit frequently for clotting.
• B. Rapidly infusing large volumes of replacement fluid every hour
to correct electrolyte imbalances.
• C. Discontinuing the blood flow every 2 hours to measure client
vital signs.
• D. Administering high-dose potassium supplements directly into
the CRRT return line.
Correct Answer: A. Monitoring hourly intake and output and checking
the extracorporeal circuit frequently for clotting.
Detailed Rationale: CRRT is a slow, continuous filtration process. Closely
monitoring hourly fluid balance ensures precise fluid removal or
replacement. Regular assessment of the blood circuit for clotting is
crucial to prevent blood loss and loss of access functionality.
Question 4
A client is admitted to the medical unit in thyroid storm (thyrotoxic
crisis). Which of the following manifestations should the nurse expect to
assess?
• A. Profound hypothermia, bradycardia, and lethargy.
• B. High fever, severe tachycardia, delirium, and heart failure.
• C. Hypoactive bowel sounds and dry, coarse skin.
, • D. Hypotension and profound hypoglycemia.
Correct Answer: B. High fever, severe tachycardia, delirium, and heart
failure.
Detailed Rationale: Thyroid storm is an extreme, life-threatening
manifestation of hyperthyroidism characterized by hyperpyrexia (>
105∘ F), marked tachycardia, high-output heart failure, gastrointestinal
distress, and central nervous system disturbances such as agitation or
delirium.
Question 5
A client with a traumatic brain injury has an intracranial pressure (ICP)
of 22 mmHg. The healthcare provider prescribes mannitol intravenous
infusion. The nurse understands that mannitol exerts its therapeutic
effect by:
• A. Increasing systemic blood pressure to promote cerebral
vasoconstriction.
• B. Drawing water from the brain tissue into the vascular space
through an osmotic gradient, thereby reducing ICP.
• C. Suppressing metabolic activity within the cerebral cortex.
• D. Directly blocking cerebrospinal fluid production in the choroid
plexus.
Correct Answer: B. Drawing water from the brain tissue into the
vascular space through an osmotic gradient, thereby reducing ICP.
Detailed Rationale: Mannitol is an osmotic diuretic. When infused
intravenously, it creates an osmotic gradient that draws fluid out of the
interstitial spaces of the brain tissue and into the intravascular
Bank, Clinical Scenarios & Detailed Rationales 2026/2027
Question 1
A client with end-stage heart failure is being managed with a left
ventricular assist device (LVAD) as a bridge to transplantation. Which of
the following is a critical nursing assessment when evaluating this
client's perfusion status?
• A. Assessing the radial pulse using standard manual palpation to
determine heart rate.
• B. Auscultating for a traditional S1 and S2 heart sound pattern.
• C. Evaluating mean arterial pressure (MAP) using an automated
Doppler device, as continuous-flow LVADs often lack a palpable
pulse.
• D. Measuring blood pressure via a standard manual
sphygmomanometer cuff.
Correct Answer: C. Evaluating mean arterial pressure (MAP) using an
automated Doppler device, as continuous-flow LVADs often lack a
palpable pulse.
Detailed Rationale: Continuous-flow LVADs provide continuous blood
flow rather than pulsatile flow. Consequently, clients often do not have
a traditional palpable pulse or easily measurable auscultated blood
pressure. A Doppler ultrasound is required to determine the mean
arterial pressure (target typically between 70 and 80 mmHg).
,Question 2
A client is receiving mechanical ventilation in the intensive care unit. To
minimize the risk of ventilator-associated pneumonia (VAP), which of
the following evidence-based interventions should the nurse include in
the daily plan of care?
• A. Keep the head of the bed flat at 0 degrees to maximize cerebral
perfusion.
• B. Perform routine scheduled changes of ventilator circuits every
24 hours.
• C. Maintain the head of the bed elevated between 30 and 45
degrees and perform daily sedation vacations to assess readiness
to extubate.
• D. Administer routine prophylactic systemic broad-spectrum
antibiotics to all intubated clients.
Correct Answer: C. Maintain the head of the bed elevated between 30
and 45 degrees and perform daily sedation vacations to assess
readiness to extubate.
Detailed Rationale: Elevating the head of the bed (30 to 45 degrees)
prevents aspiration of gastric contents, a primary cause of VAP. Daily
sedation vacations and assessments of extubation readiness reduce the
duration of mechanical ventilation, thereby lowering infection risks.
Circuit changes are not done routinely every 24 hours, and prophylactic
antibiotics are avoided to prevent resistance.
Question 3
,A client with acute kidney injury is undergoing continuous renal
replacement therapy (CRRT). Which of the following nursing
responsibilities is of highest priority during this therapy?
• A. Monitoring hourly intake and output and checking the
extracorporeal circuit frequently for clotting.
• B. Rapidly infusing large volumes of replacement fluid every hour
to correct electrolyte imbalances.
• C. Discontinuing the blood flow every 2 hours to measure client
vital signs.
• D. Administering high-dose potassium supplements directly into
the CRRT return line.
Correct Answer: A. Monitoring hourly intake and output and checking
the extracorporeal circuit frequently for clotting.
Detailed Rationale: CRRT is a slow, continuous filtration process. Closely
monitoring hourly fluid balance ensures precise fluid removal or
replacement. Regular assessment of the blood circuit for clotting is
crucial to prevent blood loss and loss of access functionality.
Question 4
A client is admitted to the medical unit in thyroid storm (thyrotoxic
crisis). Which of the following manifestations should the nurse expect to
assess?
• A. Profound hypothermia, bradycardia, and lethargy.
• B. High fever, severe tachycardia, delirium, and heart failure.
• C. Hypoactive bowel sounds and dry, coarse skin.
, • D. Hypotension and profound hypoglycemia.
Correct Answer: B. High fever, severe tachycardia, delirium, and heart
failure.
Detailed Rationale: Thyroid storm is an extreme, life-threatening
manifestation of hyperthyroidism characterized by hyperpyrexia (>
105∘ F), marked tachycardia, high-output heart failure, gastrointestinal
distress, and central nervous system disturbances such as agitation or
delirium.
Question 5
A client with a traumatic brain injury has an intracranial pressure (ICP)
of 22 mmHg. The healthcare provider prescribes mannitol intravenous
infusion. The nurse understands that mannitol exerts its therapeutic
effect by:
• A. Increasing systemic blood pressure to promote cerebral
vasoconstriction.
• B. Drawing water from the brain tissue into the vascular space
through an osmotic gradient, thereby reducing ICP.
• C. Suppressing metabolic activity within the cerebral cortex.
• D. Directly blocking cerebrospinal fluid production in the choroid
plexus.
Correct Answer: B. Drawing water from the brain tissue into the
vascular space through an osmotic gradient, thereby reducing ICP.
Detailed Rationale: Mannitol is an osmotic diuretic. When infused
intravenously, it creates an osmotic gradient that draws fluid out of the
interstitial spaces of the brain tissue and into the intravascular
