NU 185 Medical Surgical Nursing II Exam 3 Practice
Exam 3 Practice Questions & Rationales, Exams of
Nursing
1. A patient with heart failure is prescribed sacubitril/valsartan. Which assessment finding
requires immediate follow-up before administration?
A. Potassium 4.2 mEq/L
B. History of angioedema with lisinopril
C. Blood pressure 118/72 mm Hg
D. Heart rate 88 beats/min
Answer: B
Rationale: Sacubitril/valsartan is contraindicated in patients with a history of angioedema
related to ACE inhibitors due to the risk of life-threatening angioedema. Potassium, blood
pressure, and heart rate values are within acceptable ranges and do not preclude
administration.
2. Which laboratory result is most concerning for a patient receiving heparin infusion for
venous thromboembolism?
A. aPTT 45 seconds
B. Platelets 85,000/mm³
C. Hemoglobin 11.8 g/dL
D. INR 1.1
Answer: B
Rationale: A platelet count below 100,000/mm³ may indicate heparin-induced thrombocytopenia
(HIT), a serious immune-mediated complication requiring immediate discontinuation of heparin.
The other values are not directly associated with heparin therapy complications.
3. Which finding in a patient with chronic kidney disease indicates the need for immediate
intervention?
A. Serum creatinine 2.8 mg/dL
B. Potassium 6.2 mEq/L
C. Hemoglobin 10.2 g/dL
D. Blood urea nitrogen 35 mg/dL
Answer: B
Rationale: Hyperkalemia (potassium >6.0 mEq/L) can cause lethal cardiac dysrhythmias and
requires immediate treatment. The other values are consistent with chronic kidney disease but
are not immediately life-threatening.
Page 1
,4. A patient with type 1 diabetes is found unresponsive with a blood glucose of 42 mg/dL.
After administering IV dextrose, which action is priority?
A. Recheck blood glucose in 15 minutes
B. Administer long-acting insulin
C. Give oral glucose gel
D. Start a new IV line
Answer: A
Rationale: After treating hypoglycemia, the priority is to recheck blood glucose within 15 minutes
to ensure improvement and prevent recurrence. Insulin is contraindicated, and oral glucose is
unsafe in an unresponsive patient.
5. Which statement by a patient with a new ileostomy indicates correct understanding of
dietary management?
A. I should eat foods that are high in fiber to thicken output.
B. I should avoid drinking fluids with meals to prevent diarrhea.
C. I should chew food thoroughly and avoid high-fiber foods initially.
D. I should take laxatives daily to regulate output.
Answer: C
Rationale: Initially after ileostomy, high-fiber foods can cause obstruction; thorough chewing
and a low-fiber diet are recommended. Fluid avoidance and laxatives are inappropriate and can
lead to dehydration or complications.
6. Which assessment finding in a patient with a casted extremity suggests compartment
syndrome?
A. Capillary refill of 2 seconds
B. Severe pain unrelieved by opioids
C. Mild swelling at the cast edges
D. Complaint of itching under the cast
Answer: B
Rationale: Severe, unrelieved pain is the earliest and most sensitive sign of compartment
syndrome, requiring immediate notification of the provider. The other findings are expected or
less urgent.
7. A patient with an acute exacerbation of multiple sclerosis is prescribed
methylprednisolone. Which nursing action is most important during therapy?
A. Monitor blood glucose and assess for infection
B. Restrict fluids to prevent edema
C. Administer live vaccines concurrently
D. Encourage a high-sodium diet
Answer: A
Page 2
, Rationale: High-dose corticosteroids can cause hyperglycemia and immunosuppression, so monitoring glucose and
infection is essential. Fluid restriction, live vaccines, and high sodium are inappropriate and potentially harmful.
8. Which intervention is priority for a patient with a new tracheostomy who is coughing
and has copious secretions?
A. Suction the tracheostomy
B. Administer a cough suppressant
C. Increase humidification
D. Deflate the cuff
Answer: A
Rationale: Suctioning is indicated when the patient has copious secretions and an ineffective
cough to maintain a patent airway. Cough suppressants and deflating the cuff can worsen
airway clearance and safety.
9. Which finding in a patient receiving chemotherapy requires immediate notification of
the provider?
A. Temperature 100.4°F (38°C)
B. Mild fatigue
C. Alopecia
D. Nausea controlled with antiemetics
Answer: A
Rationale: A temperature of 100.4°F or higher in a neutropenic patient after chemotherapy
indicates possible neutropenic fever, a medical emergency requiring immediate intervention. The
other findings are expected side effects.
10. A patient with acute decompensated heart failure is started on intravenous furosemide.
Which assessment finding best indicates the medication is producing the desired
therapeutic effect?
A. Serum potassium rises from 3.4 to 4.2 mEq/L
B. Urine output increases with a corresponding drop in jugular venous pressure
C. Blood pressure decreases from 138/84 to 112/70 mm Hg
D. Heart rate decreases from 118 to 92 beats/min
Answer: B
Rationale: Loop diuretics relieve congestion in heart failure; the therapeutic endpoint is diuresis
with reduced preload, reflected by falling jugular venous pressure and improved oxygenation.
Rising potassium is not expected with furosemide (it causes hypokalemia), and BP/HR changes
are secondary hemodynamic effects rather than the primary decongestion goal.
11. Which laboratory trend most strongly suggests the onset of tumor lysis syndrome in a
patient receiving chemotherapy for a rapidly growing malignancy?
Page 3
Exam 3 Practice Questions & Rationales, Exams of
Nursing
1. A patient with heart failure is prescribed sacubitril/valsartan. Which assessment finding
requires immediate follow-up before administration?
A. Potassium 4.2 mEq/L
B. History of angioedema with lisinopril
C. Blood pressure 118/72 mm Hg
D. Heart rate 88 beats/min
Answer: B
Rationale: Sacubitril/valsartan is contraindicated in patients with a history of angioedema
related to ACE inhibitors due to the risk of life-threatening angioedema. Potassium, blood
pressure, and heart rate values are within acceptable ranges and do not preclude
administration.
2. Which laboratory result is most concerning for a patient receiving heparin infusion for
venous thromboembolism?
A. aPTT 45 seconds
B. Platelets 85,000/mm³
C. Hemoglobin 11.8 g/dL
D. INR 1.1
Answer: B
Rationale: A platelet count below 100,000/mm³ may indicate heparin-induced thrombocytopenia
(HIT), a serious immune-mediated complication requiring immediate discontinuation of heparin.
The other values are not directly associated with heparin therapy complications.
3. Which finding in a patient with chronic kidney disease indicates the need for immediate
intervention?
A. Serum creatinine 2.8 mg/dL
B. Potassium 6.2 mEq/L
C. Hemoglobin 10.2 g/dL
D. Blood urea nitrogen 35 mg/dL
Answer: B
Rationale: Hyperkalemia (potassium >6.0 mEq/L) can cause lethal cardiac dysrhythmias and
requires immediate treatment. The other values are consistent with chronic kidney disease but
are not immediately life-threatening.
Page 1
,4. A patient with type 1 diabetes is found unresponsive with a blood glucose of 42 mg/dL.
After administering IV dextrose, which action is priority?
A. Recheck blood glucose in 15 minutes
B. Administer long-acting insulin
C. Give oral glucose gel
D. Start a new IV line
Answer: A
Rationale: After treating hypoglycemia, the priority is to recheck blood glucose within 15 minutes
to ensure improvement and prevent recurrence. Insulin is contraindicated, and oral glucose is
unsafe in an unresponsive patient.
5. Which statement by a patient with a new ileostomy indicates correct understanding of
dietary management?
A. I should eat foods that are high in fiber to thicken output.
B. I should avoid drinking fluids with meals to prevent diarrhea.
C. I should chew food thoroughly and avoid high-fiber foods initially.
D. I should take laxatives daily to regulate output.
Answer: C
Rationale: Initially after ileostomy, high-fiber foods can cause obstruction; thorough chewing
and a low-fiber diet are recommended. Fluid avoidance and laxatives are inappropriate and can
lead to dehydration or complications.
6. Which assessment finding in a patient with a casted extremity suggests compartment
syndrome?
A. Capillary refill of 2 seconds
B. Severe pain unrelieved by opioids
C. Mild swelling at the cast edges
D. Complaint of itching under the cast
Answer: B
Rationale: Severe, unrelieved pain is the earliest and most sensitive sign of compartment
syndrome, requiring immediate notification of the provider. The other findings are expected or
less urgent.
7. A patient with an acute exacerbation of multiple sclerosis is prescribed
methylprednisolone. Which nursing action is most important during therapy?
A. Monitor blood glucose and assess for infection
B. Restrict fluids to prevent edema
C. Administer live vaccines concurrently
D. Encourage a high-sodium diet
Answer: A
Page 2
, Rationale: High-dose corticosteroids can cause hyperglycemia and immunosuppression, so monitoring glucose and
infection is essential. Fluid restriction, live vaccines, and high sodium are inappropriate and potentially harmful.
8. Which intervention is priority for a patient with a new tracheostomy who is coughing
and has copious secretions?
A. Suction the tracheostomy
B. Administer a cough suppressant
C. Increase humidification
D. Deflate the cuff
Answer: A
Rationale: Suctioning is indicated when the patient has copious secretions and an ineffective
cough to maintain a patent airway. Cough suppressants and deflating the cuff can worsen
airway clearance and safety.
9. Which finding in a patient receiving chemotherapy requires immediate notification of
the provider?
A. Temperature 100.4°F (38°C)
B. Mild fatigue
C. Alopecia
D. Nausea controlled with antiemetics
Answer: A
Rationale: A temperature of 100.4°F or higher in a neutropenic patient after chemotherapy
indicates possible neutropenic fever, a medical emergency requiring immediate intervention. The
other findings are expected side effects.
10. A patient with acute decompensated heart failure is started on intravenous furosemide.
Which assessment finding best indicates the medication is producing the desired
therapeutic effect?
A. Serum potassium rises from 3.4 to 4.2 mEq/L
B. Urine output increases with a corresponding drop in jugular venous pressure
C. Blood pressure decreases from 138/84 to 112/70 mm Hg
D. Heart rate decreases from 118 to 92 beats/min
Answer: B
Rationale: Loop diuretics relieve congestion in heart failure; the therapeutic endpoint is diuresis
with reduced preload, reflected by falling jugular venous pressure and improved oxygenation.
Rising potassium is not expected with furosemide (it causes hypokalemia), and BP/HR changes
are secondary hemodynamic effects rather than the primary decongestion goal.
11. Which laboratory trend most strongly suggests the onset of tumor lysis syndrome in a
patient receiving chemotherapy for a rapidly growing malignancy?
Page 3
