,South College NSG 2610 Exam 3 | Adult Health
Nursing II (2026) Q&A
1. A client with congestive heart failure is prescribed furosemide. What is the priority
nursing assessment?
A) Monitor serum sodium levels
B) Monitor serum potassium levels
C) Monitor serum calcium levels
D) Monitor serum magnesium levels
Correct Answer: Monitor serum potassium levels
Rationale: Furosemide is a loop diuretic that promotes excretion of potassium,
which can lead to hypokalemia. Hypokalemia increases the risk of cardiac
arrhythmias, especially in clients taking digitalis preparations. Potassium levels should
be monitored closely during therapy.
2. A client with chronic kidney disease has a GFR of 18 mL/min. Which stage of CKD
is this?
A) Stage 2
B) Stage 3
C) Stage 4
D) Stage 5
Correct Answer: Stage 4
,Rationale: A GFR between 15-29 mL/min indicates Stage 4 chronic kidney disease.
Stage 5 (ESRD) is a GFR <15 mL/min. Accurate staging is essential for determining
the appropriate level of intervention and monitoring for complications.
3. Which laboratory value is most critical to monitor for a client on warfarin therapy?
A) aPTT
B) INR
C) Platelet count
D) Serum creatinine
Correct Answer: INR
Rationale: INR (International Normalized Ratio) guides warfarin dosing and monitors
therapeutic range to prevent bleeding or clotting complications. The therapeutic goal
is typically 2-3 for most indications. aPTT is used to monitor heparin therapy.
4. A postoperative patient has absent bowel sounds. What is the most appropriate
nursing action?
A) Advance the diet to clear liquids
B) Encourage ambulation
C) Continue NPO and document findings
D) Administer a laxative
Correct Answer: Continue NPO and document findings
Rationale: Absent bowel sounds may indicate paralytic ileus, a common
postoperative complication. Continuing NPO prevents complications like vomiting or
aspiration until bowel function returns. The findings should be documented and
reported to the provider.
, 5. A client with COPD is receiving oxygen at 4 L/min via nasal cannula. What is the
priority concern?
A) Oxygen toxicity
B) Oxygen-induced hypoventilation
C) Nasal dryness
D) Carbon dioxide narcosis
Correct Answer: Oxygen-induced hypoventilation
Rationale: High-flow oxygen can blunt the respiratory drive in COPD patients who
rely on hypoxic stimulus to breathe, leading to CO₂ retention and respiratory
acidosis. Oxygen should be titrated to maintain SpO₂ of 88-92%.
6. Which sign is most specific for deep vein thrombosis (DVT)?
A) Bilateral leg swelling
B) Unilateral calf swelling
C) Cool, pale extremity
D) Diminished pedal pulses
Correct Answer: Unilateral calf swelling
Rationale: Unilateral leg swelling, warmth, and tenderness are hallmark signs of DVT.
Bilateral edema suggests systemic causes like heart failure. Cool, pale extremities and
diminished pulses suggest arterial insufficiency.
7. Which intervention is the priority for a client in the emergency department with
suspected hyperglycemic hyperosmolar state (HHS)?
Nursing II (2026) Q&A
1. A client with congestive heart failure is prescribed furosemide. What is the priority
nursing assessment?
A) Monitor serum sodium levels
B) Monitor serum potassium levels
C) Monitor serum calcium levels
D) Monitor serum magnesium levels
Correct Answer: Monitor serum potassium levels
Rationale: Furosemide is a loop diuretic that promotes excretion of potassium,
which can lead to hypokalemia. Hypokalemia increases the risk of cardiac
arrhythmias, especially in clients taking digitalis preparations. Potassium levels should
be monitored closely during therapy.
2. A client with chronic kidney disease has a GFR of 18 mL/min. Which stage of CKD
is this?
A) Stage 2
B) Stage 3
C) Stage 4
D) Stage 5
Correct Answer: Stage 4
,Rationale: A GFR between 15-29 mL/min indicates Stage 4 chronic kidney disease.
Stage 5 (ESRD) is a GFR <15 mL/min. Accurate staging is essential for determining
the appropriate level of intervention and monitoring for complications.
3. Which laboratory value is most critical to monitor for a client on warfarin therapy?
A) aPTT
B) INR
C) Platelet count
D) Serum creatinine
Correct Answer: INR
Rationale: INR (International Normalized Ratio) guides warfarin dosing and monitors
therapeutic range to prevent bleeding or clotting complications. The therapeutic goal
is typically 2-3 for most indications. aPTT is used to monitor heparin therapy.
4. A postoperative patient has absent bowel sounds. What is the most appropriate
nursing action?
A) Advance the diet to clear liquids
B) Encourage ambulation
C) Continue NPO and document findings
D) Administer a laxative
Correct Answer: Continue NPO and document findings
Rationale: Absent bowel sounds may indicate paralytic ileus, a common
postoperative complication. Continuing NPO prevents complications like vomiting or
aspiration until bowel function returns. The findings should be documented and
reported to the provider.
, 5. A client with COPD is receiving oxygen at 4 L/min via nasal cannula. What is the
priority concern?
A) Oxygen toxicity
B) Oxygen-induced hypoventilation
C) Nasal dryness
D) Carbon dioxide narcosis
Correct Answer: Oxygen-induced hypoventilation
Rationale: High-flow oxygen can blunt the respiratory drive in COPD patients who
rely on hypoxic stimulus to breathe, leading to CO₂ retention and respiratory
acidosis. Oxygen should be titrated to maintain SpO₂ of 88-92%.
6. Which sign is most specific for deep vein thrombosis (DVT)?
A) Bilateral leg swelling
B) Unilateral calf swelling
C) Cool, pale extremity
D) Diminished pedal pulses
Correct Answer: Unilateral calf swelling
Rationale: Unilateral leg swelling, warmth, and tenderness are hallmark signs of DVT.
Bilateral edema suggests systemic causes like heart failure. Cool, pale extremities and
diminished pulses suggest arterial insufficiency.
7. Which intervention is the priority for a client in the emergency department with
suspected hyperglycemic hyperosmolar state (HHS)?
