NUR 265 EXAM 4 Actual Exam
2026/2027 –Questions And Correct
Answers with Rationales| 100%
Verified – Pass Guaranteed – Already
Graded A+
1. Organ Transplant Rejection
The nurse is caring for a client who had a liver transplant 48 hours
ago. It is a priority for the nurse to notify the primary health care
provider (PHCP) if the client has which finding?
A. Scant amounts of serosanguinous drainage from the incision
B. A urine output that has decreased from 65 to 45 mL/hr since
surgery
C. An increase in blood pressure from 115/68 to 122/74
D. An increasing bilirubin level
Answer: D. An increasing bilirubin level
Rationale: An increasing bilirubin level is a key indicator of acute
graft rejection in a liver transplant recipient. Elevated liver enzymes
and right upper quadrant (RUQ) pain are also signs of rejection .
Other options may be expected post-operatively or are less specific.
2. Anaphylaxis and Emergency Management
, The nurse working in the emergency department (ED) is admitting
a client who presents with stridor, dyspnea, and bronchospasm
after being stung by a bee. After notifying the ED health care
provider, which of the following actions should the nurse take
next?
A. Administer an Albuterol nebulizer treatment.
B. Initiate oxygen via a nonrebreather mask.
C. Remove the bee sting from the site of the sting.
D. Prepare to administer a corticosteroid.
Answer: B. Initiate oxygen via a nonrebreather mask.
Rationale: The priority action is to ensure adequate oxygenation.
While all options may be part of the treatment plan, initiating
oxygen is the immediate, life-saving intervention to address
respiratory distress and hypoxia.
3. Systemic Lupus Erythematosus (SLE)
Which clinical manifestation would cause the nurse to suspect
that the client is diagnosed with systemic lupus erythematosus
(SLE)?
A. Joint edema and tenderness
B. Painless, symmetric pitting edema
C. Decreased skin elasticity
D. Dry, scaly skin patches
Answer: A. Joint edema and tenderness
Rationale: Joint pain, edema, and tenderness are common
manifestations of SLE. A butterfly rash (malar rash) is also a classic
, sign . The other options describe symptoms more consistent with
scleroderma .
4. HIV/AIDS and Opportunistic Infections
The nurse working in the emergency department (ED) has triaged
a client who presented with chest pain, shortness of breath, a
productive cough, and reports of night sweats. The client's health
history includes the presence of acquired immune deficiency
syndrome (AIDS) and recent laboratory results that reveal a low
CD4+ count. Which of the following actions should the nurse take
next?
A. Initiate airborne precautions.
B. Check the client's temperature.
C. Assess the client for shingles.
D. Obtain a throat culture.
Answer: A. Initiate airborne precautions.
Rationale: The client's symptoms and history of AIDS with a low
CD4+ count suggest a potential for tuberculosis (TB). Hallmark
signs of TB include night sweats, fever, and cough . TB requires
airborne isolation to prevent transmission.
5. Acute Kidney Injury (AKI)
A client with acute kidney injury has a potassium level of 6.8
mEq/L and peaked T waves on the ECG. What is the priority
nursing intervention?
A. Restrict potassium intake.
B. Administer insulin with dextrose.
, C. Encourage oral fluids.
D. Monitor urine output.
Answer: B. Administer insulin with dextrose.
Rationale: A potassium level of 6.8 mEq/L is a critical value that
indicates hyperkalemia. This can lead to life-threatening cardiac
dysrhythmias. Administering insulin with dextrose drives potassium
back into the cells, rapidly lowering serum levels and reducing
cardiac risk. While restricting potassium and monitoring urine
output are appropriate, they are not the immediate priority for a
critically high potassium level .
6. Liver and Kidney Transplant Candidate Selection
The nurse attended a conference about kidney transplantations.
Which of the following clients who have end-stage renal disease
(ESRD) does the nurse recognize as being a transplant candidate?
A. A 35-year-old client who is reporting burning with urination
and is receiving abdominal radiation.
B. A 42-year-old client who is sobbing after receiving a new
diagnosis of ovarian cancer.
C. A 24-year-old client who is receiving neck radiation and is
reporting xerostomia.
D. A 56-year-old client who is receiving chest radiation and has
developed changes in taste.
Answer: B. A 42-year-old client who is sobbing after receiving
a new diagnosis of ovarian cancer.
Rationale: For a client to be a transplant candidate, they should be
free of active infection or malignancy. A new diagnosis of ovarian
2026/2027 –Questions And Correct
Answers with Rationales| 100%
Verified – Pass Guaranteed – Already
Graded A+
1. Organ Transplant Rejection
The nurse is caring for a client who had a liver transplant 48 hours
ago. It is a priority for the nurse to notify the primary health care
provider (PHCP) if the client has which finding?
A. Scant amounts of serosanguinous drainage from the incision
B. A urine output that has decreased from 65 to 45 mL/hr since
surgery
C. An increase in blood pressure from 115/68 to 122/74
D. An increasing bilirubin level
Answer: D. An increasing bilirubin level
Rationale: An increasing bilirubin level is a key indicator of acute
graft rejection in a liver transplant recipient. Elevated liver enzymes
and right upper quadrant (RUQ) pain are also signs of rejection .
Other options may be expected post-operatively or are less specific.
2. Anaphylaxis and Emergency Management
, The nurse working in the emergency department (ED) is admitting
a client who presents with stridor, dyspnea, and bronchospasm
after being stung by a bee. After notifying the ED health care
provider, which of the following actions should the nurse take
next?
A. Administer an Albuterol nebulizer treatment.
B. Initiate oxygen via a nonrebreather mask.
C. Remove the bee sting from the site of the sting.
D. Prepare to administer a corticosteroid.
Answer: B. Initiate oxygen via a nonrebreather mask.
Rationale: The priority action is to ensure adequate oxygenation.
While all options may be part of the treatment plan, initiating
oxygen is the immediate, life-saving intervention to address
respiratory distress and hypoxia.
3. Systemic Lupus Erythematosus (SLE)
Which clinical manifestation would cause the nurse to suspect
that the client is diagnosed with systemic lupus erythematosus
(SLE)?
A. Joint edema and tenderness
B. Painless, symmetric pitting edema
C. Decreased skin elasticity
D. Dry, scaly skin patches
Answer: A. Joint edema and tenderness
Rationale: Joint pain, edema, and tenderness are common
manifestations of SLE. A butterfly rash (malar rash) is also a classic
, sign . The other options describe symptoms more consistent with
scleroderma .
4. HIV/AIDS and Opportunistic Infections
The nurse working in the emergency department (ED) has triaged
a client who presented with chest pain, shortness of breath, a
productive cough, and reports of night sweats. The client's health
history includes the presence of acquired immune deficiency
syndrome (AIDS) and recent laboratory results that reveal a low
CD4+ count. Which of the following actions should the nurse take
next?
A. Initiate airborne precautions.
B. Check the client's temperature.
C. Assess the client for shingles.
D. Obtain a throat culture.
Answer: A. Initiate airborne precautions.
Rationale: The client's symptoms and history of AIDS with a low
CD4+ count suggest a potential for tuberculosis (TB). Hallmark
signs of TB include night sweats, fever, and cough . TB requires
airborne isolation to prevent transmission.
5. Acute Kidney Injury (AKI)
A client with acute kidney injury has a potassium level of 6.8
mEq/L and peaked T waves on the ECG. What is the priority
nursing intervention?
A. Restrict potassium intake.
B. Administer insulin with dextrose.
, C. Encourage oral fluids.
D. Monitor urine output.
Answer: B. Administer insulin with dextrose.
Rationale: A potassium level of 6.8 mEq/L is a critical value that
indicates hyperkalemia. This can lead to life-threatening cardiac
dysrhythmias. Administering insulin with dextrose drives potassium
back into the cells, rapidly lowering serum levels and reducing
cardiac risk. While restricting potassium and monitoring urine
output are appropriate, they are not the immediate priority for a
critically high potassium level .
6. Liver and Kidney Transplant Candidate Selection
The nurse attended a conference about kidney transplantations.
Which of the following clients who have end-stage renal disease
(ESRD) does the nurse recognize as being a transplant candidate?
A. A 35-year-old client who is reporting burning with urination
and is receiving abdominal radiation.
B. A 42-year-old client who is sobbing after receiving a new
diagnosis of ovarian cancer.
C. A 24-year-old client who is receiving neck radiation and is
reporting xerostomia.
D. A 56-year-old client who is receiving chest radiation and has
developed changes in taste.
Answer: B. A 42-year-old client who is sobbing after receiving
a new diagnosis of ovarian cancer.
Rationale: For a client to be a transplant candidate, they should be
free of active infection or malignancy. A new diagnosis of ovarian
