NU 185 Exam 3 Advanced Medical Surgical Nursing
II Exam 3 Practice Questions & Rationales, Exams of
Nursing
1. The nurse is assigned to care for an infant with physiologic jaundice. Which action by
the nurse would facilitate elimination of bilirubin?
A. Expose the infant to direct sunlight for 30 minutes each day
B. Increase the infant's fluid intake
C. Withhold breastfeeding until the bilirubin level decreases
D. Administer a prescribed opioid analgesic to the infant
Answer: B
Rationale: Bilirubin is excreted through the kidneys, thus the need for increased fluids.
Maintaining the body temp is important but will not assist in eliminating bilirubin.
2. A client receiving a cleansing enema complains of pain and cramping. Which corrective
action should the nurse take?
A. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.
B. Discontinue the enema immediately and document the client's intolerance.
C. Remove the enema tubing, encourage the client to expel the solution, and then restart the enema.
D. Raise the enema container higher to increase the flow rate and finish the procedure quickly.
Answer: A
Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain,
the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the
likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in
the remaining options are incorrect.
3. When did the patient's lower back pain begin?
A. Gradually over the past several weeks without a specific injury
B. After a long car ride earlier that day
C. After lifting boxes at home
D. After a sudden twisting movement while getting out of bed
Answer: C
Rationale: The correct answer identifies the onset of the patient's lower back pain as occurring
after lifting boxes at home, which is the key historical detail. The other options describe different
onset mechanisms or timelines that are not supported by the patient's report. Accurate
identification of the precipitating event is essential for assessing musculoskeletal pain and
guiding appropriate care.
Page 1
,4. The nurse has been teaching the client improved airflow techniques, but the client
continues to experience restrictive breathing problems. Which finding is the best indicator
that the teaching has been successful?
A. Client states that breathing feels easier when sitting upright
B. Respiratory rate of 22 breaths/min while at rest
C. Peak expiratory flow rate of 300 L/min before using the inhaler
D. SpO2 level of 92% after ambulating 50 feet
Answer: D
Rationale: Maintaining a baseline Spo2 of 92% after ambulating 50 feet is an excellent indicator
that the client has achieved better airflow, and that the nurse's teaching has been effective.
5. The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has
repositioned the client's head in a flexed-forward position. The client has been asked to
begin swallowing, and the nurse slowly advances the NG tube with each swallow. The client
then begins to cough, gag, and choke. Which actions should the nurse take to ensure proper
tube insertion and promote client relaxation? Select all that apply.
A. Continue advancing the tube firmly despite the client's coughing and gagging.
B. Pull the tube back slightly.
C. Remove the tube completely and reinsert it through the other nostril without pausing.
D. Instruct the client to hyperextend the neck and take deep breaths through the mouth.
Answer: B
Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which
may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the
nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and
obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the
tube back slightly will remove it from the larynx; advancing the tube might position it in the
trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the
esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse
should check the back of the client's throat to note whether the tube has coiled. The tube may be
advanced after the client relaxes.
6. Which acid-base disturbance should the nurse anticipate in a client with morbid obesity?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: Respiratory acidosis is related to CO2 retention secondary to respiratory depression,
inadequate chest expansion, airway obstruction, and reduced alveolar-capillary diffusion,
common in the morbidly obese, who experience inadequate chest expansion owing to their size
and work of breathing.
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, 7. A client with a recent diagnosis of myocardial infarction and impaired renal function is
recuperating on the step-down cardiac unit. The client's blood pressure has been borderline
low, and IV fluids have been infusing at 100 mL/hr via a central line catheter in the right
internal jugular for approximately 24 hours to increase renal output and maintain blood
pressure. Upon entering the client's room, the nurse notes that the client is breathing
rapidly and is coughing. The nurse determines that the client is most likely experiencing
which complication of IV therapy?
A. Circulatory overload
B. Pneumothorax
C. Air embolism
D. Catheter-related bloodstream infection
Answer: A
Rationale: The client has received a large volume of IV fluids over 24 hours and has impaired
renal function, which increases the risk of fluid retention. Rapid breathing and coughing are
classic signs of circulatory overload (pulmonary edema) due to excess intravascular fluid. The
other options are less likely given the subacute presentation and the absence of sudden
cardiovascular collapse, fever, or pleuritic chest pain.
8. A client has been advanced to a solid diet after undergoing a subtotal gastrectomy.
Which nursing intervention is appropriate to prevent dumping syndrome?
A. Offer a diet high in simple carbohydrates to meet energy needs.
B. Encourage the client to drink fluids with meals to aid digestion.
C. Remove fluids from the meal tray.
D. Position the client supine immediately after meals.
Answer: C
Rationale: Factors to minimize dumping syndrome after gastric surgery include having the client
lie down for at least 30 minutes after eating; giving small, frequent meals; having the client
maintain a low Fowler's position while eating, if possible; avoiding liquids with meals; and
avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as
needed to delay gastric emptying.
9. True or False: Voice messages can be automatically deleted once they reach a specified
age in days.
A. False - voice messages can only be deleted manually, one at a time
B. False - automatic deletion applies only to text messages, not voice messages
C. True
D. False - voice messages are retained indefinitely and cannot be deleted automatically
Answer: C
Rationale: Most messaging and voicemail systems allow users to set an automatic deletion period
for voice messages, such as 30 days, so the statement is true. The other choices are distractors
that do not accurately complete the statement.
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II Exam 3 Practice Questions & Rationales, Exams of
Nursing
1. The nurse is assigned to care for an infant with physiologic jaundice. Which action by
the nurse would facilitate elimination of bilirubin?
A. Expose the infant to direct sunlight for 30 minutes each day
B. Increase the infant's fluid intake
C. Withhold breastfeeding until the bilirubin level decreases
D. Administer a prescribed opioid analgesic to the infant
Answer: B
Rationale: Bilirubin is excreted through the kidneys, thus the need for increased fluids.
Maintaining the body temp is important but will not assist in eliminating bilirubin.
2. A client receiving a cleansing enema complains of pain and cramping. Which corrective
action should the nurse take?
A. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.
B. Discontinue the enema immediately and document the client's intolerance.
C. Remove the enema tubing, encourage the client to expel the solution, and then restart the enema.
D. Raise the enema container higher to increase the flow rate and finish the procedure quickly.
Answer: A
Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain,
the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the
likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in
the remaining options are incorrect.
3. When did the patient's lower back pain begin?
A. Gradually over the past several weeks without a specific injury
B. After a long car ride earlier that day
C. After lifting boxes at home
D. After a sudden twisting movement while getting out of bed
Answer: C
Rationale: The correct answer identifies the onset of the patient's lower back pain as occurring
after lifting boxes at home, which is the key historical detail. The other options describe different
onset mechanisms or timelines that are not supported by the patient's report. Accurate
identification of the precipitating event is essential for assessing musculoskeletal pain and
guiding appropriate care.
Page 1
,4. The nurse has been teaching the client improved airflow techniques, but the client
continues to experience restrictive breathing problems. Which finding is the best indicator
that the teaching has been successful?
A. Client states that breathing feels easier when sitting upright
B. Respiratory rate of 22 breaths/min while at rest
C. Peak expiratory flow rate of 300 L/min before using the inhaler
D. SpO2 level of 92% after ambulating 50 feet
Answer: D
Rationale: Maintaining a baseline Spo2 of 92% after ambulating 50 feet is an excellent indicator
that the client has achieved better airflow, and that the nurse's teaching has been effective.
5. The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has
repositioned the client's head in a flexed-forward position. The client has been asked to
begin swallowing, and the nurse slowly advances the NG tube with each swallow. The client
then begins to cough, gag, and choke. Which actions should the nurse take to ensure proper
tube insertion and promote client relaxation? Select all that apply.
A. Continue advancing the tube firmly despite the client's coughing and gagging.
B. Pull the tube back slightly.
C. Remove the tube completely and reinsert it through the other nostril without pausing.
D. Instruct the client to hyperextend the neck and take deep breaths through the mouth.
Answer: B
Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which
may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the
nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and
obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the
tube back slightly will remove it from the larynx; advancing the tube might position it in the
trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the
esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse
should check the back of the client's throat to note whether the tube has coiled. The tube may be
advanced after the client relaxes.
6. Which acid-base disturbance should the nurse anticipate in a client with morbid obesity?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: Respiratory acidosis is related to CO2 retention secondary to respiratory depression,
inadequate chest expansion, airway obstruction, and reduced alveolar-capillary diffusion,
common in the morbidly obese, who experience inadequate chest expansion owing to their size
and work of breathing.
Page 2
, 7. A client with a recent diagnosis of myocardial infarction and impaired renal function is
recuperating on the step-down cardiac unit. The client's blood pressure has been borderline
low, and IV fluids have been infusing at 100 mL/hr via a central line catheter in the right
internal jugular for approximately 24 hours to increase renal output and maintain blood
pressure. Upon entering the client's room, the nurse notes that the client is breathing
rapidly and is coughing. The nurse determines that the client is most likely experiencing
which complication of IV therapy?
A. Circulatory overload
B. Pneumothorax
C. Air embolism
D. Catheter-related bloodstream infection
Answer: A
Rationale: The client has received a large volume of IV fluids over 24 hours and has impaired
renal function, which increases the risk of fluid retention. Rapid breathing and coughing are
classic signs of circulatory overload (pulmonary edema) due to excess intravascular fluid. The
other options are less likely given the subacute presentation and the absence of sudden
cardiovascular collapse, fever, or pleuritic chest pain.
8. A client has been advanced to a solid diet after undergoing a subtotal gastrectomy.
Which nursing intervention is appropriate to prevent dumping syndrome?
A. Offer a diet high in simple carbohydrates to meet energy needs.
B. Encourage the client to drink fluids with meals to aid digestion.
C. Remove fluids from the meal tray.
D. Position the client supine immediately after meals.
Answer: C
Rationale: Factors to minimize dumping syndrome after gastric surgery include having the client
lie down for at least 30 minutes after eating; giving small, frequent meals; having the client
maintain a low Fowler's position while eating, if possible; avoiding liquids with meals; and
avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as
needed to delay gastric emptying.
9. True or False: Voice messages can be automatically deleted once they reach a specified
age in days.
A. False - voice messages can only be deleted manually, one at a time
B. False - automatic deletion applies only to text messages, not voice messages
C. True
D. False - voice messages are retained indefinitely and cannot be deleted automatically
Answer: C
Rationale: Most messaging and voicemail systems allow users to set an automatic deletion period
for voice messages, such as 30 days, so the statement is true. The other choices are distractors
that do not accurately complete the statement.
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