NUR 231 EXAM 3 – ADULT NURSING II
(2026) ACTUAL QUESTIONS & VERIFIED
ANSWERS ILLINOIS STATE UNIVERSITY
GUARANTEE PASS
1.
A client with COPD has a PaCO₂ of 58 mmHg and pH of 7.32. Which interpretation is correct?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Answer: B
Rationale: Elevated PaCO₂ with a low pH indicates respiratory acidosis caused by hypoventilation.
2.
A nurse is caring for a client with heart failure. Which finding requires the most immediate attention?
A. 1+ ankle edema
B. Fatigue after walking
C. Crackles with severe dyspnea
D. Weight gain of 1 lb in a week
Answer: C
Rationale: Severe dyspnea and crackles can indicate acute pulmonary edema and impaired oxygenation.
3.
A client receiving chemotherapy has an absolute neutrophil count of 400/mm³. Which finding should the nurse
report immediately?
A. Temperature of 38.3°C (100.9°F)
B. Mild nausea
C. Alopecia
D. Fatigue
Answer: A
,Rationale: Severe neutropenia places the client at high risk for life-threatening infection. Fever requires immediate
evaluation.
4.
Which assessment finding is expected in a client with left-sided heart failure?
A. Ascites
B. Jugular venous distention
C. Pulmonary crackles
D. Dependent peripheral edema only
Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion, producing crackles and dyspnea.
5.
A client with suspected pulmonary embolism suddenly develops dyspnea and chest pain. What is the nurse's
priority?
A. Encourage ambulation
B. Apply oxygen
C. Massage the affected leg
D. Place the client flat
Answer: B
Rationale: Oxygenation is the immediate priority for acute respiratory compromise.
6.
A client with diabetes is awake, confused, diaphoretic, and has a blood glucose of 48 mg/dL. What should the
nurse do?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Restrict oral intake
D. Administer long-acting insulin
Answer: B
Rationale: A conscious client with hypoglycemia should receive approximately 15 g of rapid-acting carbohydrate,
followed by reassessment.
7.
Which finding is most characteristic of diabetic ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
,C. Severe hypothermia
D. Metabolic alkalosis
Answer: B
Rationale: DKA causes metabolic acidosis. The body compensates with deep, rapid Kussmaul respirations.
8.
A client with hyperkalemia has which ECG change?
A. Peaked T waves
B. Prolonged QT interval only
C. U waves
D. ST elevation in every lead
Answer: A
Rationale: Tall, peaked T waves are a classic early ECG manifestation of hyperkalemia.
9.
A client with severe hyponatremia develops a seizure. Which intervention is the priority?
A. Encourage oral fluids
B. Maintain airway and protect from injury
C. Place the client in Trendelenburg position
D. Encourage ambulation
Answer: B
Rationale: Severe hyponatremia can cause cerebral edema and seizures. Airway protection and injury prevention
are priorities.
10.
Which assessment finding is most concerning in a client with a new colostomy?
A. Pink, moist stoma
B. Small amount of edema
C. Dusky or black stoma
D. Mild tenderness around the site
Answer: C
Rationale: A dusky, purple, or black stoma may indicate impaired blood supply and requires immediate evaluation.
11.
A client with pancreatitis reports severe epigastric pain radiating to the back. Which laboratory value would the
nurse expect to be elevated?
, A. Lipase
B. Hemoglobin A1c only
C. Troponin
D. INR only
Answer: A
Rationale: Pancreatic inflammation commonly causes elevated serum lipase.
12.
Which intervention is appropriate for a client with acute pancreatitis?
A. Encourage a high-fat diet
B. Monitor fluid and electrolyte status
C. Encourage alcohol intake
D. Administer laxatives routinely
Answer: B
Rationale: Pancreatitis can cause significant third spacing, dehydration, electrolyte abnormalities, and systemic
complications.
13.
A client with appendicitis asks for a laxative because of constipation. What is the best response?
A. “A laxative will relieve the inflammation.”
B. “Laxatives should be avoided because they may increase the risk of perforation.”
C. “Take twice the recommended dose.”
D. “Use an enema instead.”
Answer: B
Rationale: Laxatives and enemas are generally avoided when appendicitis is suspected because increased
intestinal activity may increase perforation risk.
14.
Which finding is most consistent with Crohn's disease?
A. Continuous inflammation limited to the rectum
B. Transmural inflammation with skip lesions
C. Disease affecting only the stomach
D. Absence of diarrhea
Answer: B
Rationale: Crohn's disease can affect any part of the GI tract and is characterized by transmural inflammation and
skip lesions.
15.
(2026) ACTUAL QUESTIONS & VERIFIED
ANSWERS ILLINOIS STATE UNIVERSITY
GUARANTEE PASS
1.
A client with COPD has a PaCO₂ of 58 mmHg and pH of 7.32. Which interpretation is correct?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Answer: B
Rationale: Elevated PaCO₂ with a low pH indicates respiratory acidosis caused by hypoventilation.
2.
A nurse is caring for a client with heart failure. Which finding requires the most immediate attention?
A. 1+ ankle edema
B. Fatigue after walking
C. Crackles with severe dyspnea
D. Weight gain of 1 lb in a week
Answer: C
Rationale: Severe dyspnea and crackles can indicate acute pulmonary edema and impaired oxygenation.
3.
A client receiving chemotherapy has an absolute neutrophil count of 400/mm³. Which finding should the nurse
report immediately?
A. Temperature of 38.3°C (100.9°F)
B. Mild nausea
C. Alopecia
D. Fatigue
Answer: A
,Rationale: Severe neutropenia places the client at high risk for life-threatening infection. Fever requires immediate
evaluation.
4.
Which assessment finding is expected in a client with left-sided heart failure?
A. Ascites
B. Jugular venous distention
C. Pulmonary crackles
D. Dependent peripheral edema only
Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion, producing crackles and dyspnea.
5.
A client with suspected pulmonary embolism suddenly develops dyspnea and chest pain. What is the nurse's
priority?
A. Encourage ambulation
B. Apply oxygen
C. Massage the affected leg
D. Place the client flat
Answer: B
Rationale: Oxygenation is the immediate priority for acute respiratory compromise.
6.
A client with diabetes is awake, confused, diaphoretic, and has a blood glucose of 48 mg/dL. What should the
nurse do?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Restrict oral intake
D. Administer long-acting insulin
Answer: B
Rationale: A conscious client with hypoglycemia should receive approximately 15 g of rapid-acting carbohydrate,
followed by reassessment.
7.
Which finding is most characteristic of diabetic ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
,C. Severe hypothermia
D. Metabolic alkalosis
Answer: B
Rationale: DKA causes metabolic acidosis. The body compensates with deep, rapid Kussmaul respirations.
8.
A client with hyperkalemia has which ECG change?
A. Peaked T waves
B. Prolonged QT interval only
C. U waves
D. ST elevation in every lead
Answer: A
Rationale: Tall, peaked T waves are a classic early ECG manifestation of hyperkalemia.
9.
A client with severe hyponatremia develops a seizure. Which intervention is the priority?
A. Encourage oral fluids
B. Maintain airway and protect from injury
C. Place the client in Trendelenburg position
D. Encourage ambulation
Answer: B
Rationale: Severe hyponatremia can cause cerebral edema and seizures. Airway protection and injury prevention
are priorities.
10.
Which assessment finding is most concerning in a client with a new colostomy?
A. Pink, moist stoma
B. Small amount of edema
C. Dusky or black stoma
D. Mild tenderness around the site
Answer: C
Rationale: A dusky, purple, or black stoma may indicate impaired blood supply and requires immediate evaluation.
11.
A client with pancreatitis reports severe epigastric pain radiating to the back. Which laboratory value would the
nurse expect to be elevated?
, A. Lipase
B. Hemoglobin A1c only
C. Troponin
D. INR only
Answer: A
Rationale: Pancreatic inflammation commonly causes elevated serum lipase.
12.
Which intervention is appropriate for a client with acute pancreatitis?
A. Encourage a high-fat diet
B. Monitor fluid and electrolyte status
C. Encourage alcohol intake
D. Administer laxatives routinely
Answer: B
Rationale: Pancreatitis can cause significant third spacing, dehydration, electrolyte abnormalities, and systemic
complications.
13.
A client with appendicitis asks for a laxative because of constipation. What is the best response?
A. “A laxative will relieve the inflammation.”
B. “Laxatives should be avoided because they may increase the risk of perforation.”
C. “Take twice the recommended dose.”
D. “Use an enema instead.”
Answer: B
Rationale: Laxatives and enemas are generally avoided when appendicitis is suspected because increased
intestinal activity may increase perforation risk.
14.
Which finding is most consistent with Crohn's disease?
A. Continuous inflammation limited to the rectum
B. Transmural inflammation with skip lesions
C. Disease affecting only the stomach
D. Absence of diarrhea
Answer: B
Rationale: Crohn's disease can affect any part of the GI tract and is characterized by transmural inflammation and
skip lesions.
15.
