NU 185 Medical Surgical Nursing II Exam 3 Study
Guide Exam 3 Practice Questions & Rationa, Exams
of Nursing
1. A client with heart failure is prescribed furosemide 40 mg IV push. Which assessment
finding most urgently requires the nurse to hold the dose and notify the provider?
A. Serum potassium of 3.1 mEq/L
B. Serum sodium of 138 mEq/L
C. Blood pressure of 118/72 mm Hg
D. Urine output of 60 mL/hr
Answer: A
Rationale: Loop diuretics like furosemide cause potassium wasting; a K+ of 3.1 mEq/L places the
client at risk for dysrhythmias and should prompt holding the dose. Sodium, BP, and urine
output values are within acceptable parameters and do not contraindicate administration.
2. A client is admitted with an acute exacerbation of COPD. Which oxygen delivery
approach is most appropriate to prevent hypercapnia?
A. High-flow 100% non-rebreather at 15 L/min
B. Venturi mask titrated to SpO2 88-92%
C. Simple face mask at 10 L/min continuously
D. Nasal cannula at 6 L/min during sleep only
Answer: B
Rationale: COPD clients with chronic CO2 retention rely on hypoxic drive; targeting SpO2
88-92% via Venturi mask prevents oxygen-induced hypercapnia. High-flow 100% and 10 L/min
exceed safe limits, and intermittent nocturnal oxygen does not treat acute exacerbation.
3. A client with acute kidney injury has a serum potassium of 6.8 mEq/L and peaked T
waves on ECG. Which prescribed intervention should the nurse anticipate administering
first?
A. Oral sodium polystyrene sulfonate
B. IV calcium gluconate
C. Subcutaneous regular insulin
D. IV furosemide bolus
Answer: B
Rationale: IV calcium gluconate is the immediate cardioprotective measure for hyperkalemia
with ECG changes; it stabilizes cardiac membranes within minutes. Polystyrene, insulin, and
furosemide lower potassium but act too slowly to address acute dysrhythmia risk.
Page 1
,4. Which finding best indicates that a client with diabetic ketoacidosis is responding to
treatment?
A. Serum glucose decreased from 480 to 320 mg/dL
B. Serum bicarbonate increased from 10 to 16 mEq/L
C. Urine output decreased to 20 mL/hr
D. Respiratory rate increased to 32/min
Answer: B
Rationale: Resolution of ketoacidosis is reflected by rising bicarbonate and closing anion gap,
not glucose alone. Decreasing urine output and tachypnea suggest worsening status.
5. A client with a new ileostomy has liquid output of 1,800 mL/day. Which nursing action is
the priority?
A. Encourage a high-fiber diet to thicken stool
B. Monitor for signs of hypovolemia and electrolyte imbalance
C. Apply a convex wafer to prevent leakage
D. Irrigate the stoma with 500 mL warm water
Answer: B
Rationale: High-output ileostomies cause significant fluid and electrolyte losses; monitoring for
hypovolemia and hypokalemia/hyponatremia is priority. High-fiber diets are avoided early,
convex wafers are for retracted stomas, and ileostomies are not routinely irrigated.
6. A client with a traumatic brain injury has an ICP of 22 mm Hg. Which position should
the nurse maintain?
A. Flat supine with head neutral
B. Head of bed elevated 30 degrees with head midline
C. Trendelenburg with knees flexed
D. Prone with head turned to the side
Answer: B
Rationale: Elevating HOB 30 degrees with head midline promotes venous drainage and reduces
ICP. Flat, Trendelenburg, and prone positions impede venous return and raise ICP.
7. Which assessment finding is most concerning in a client receiving a blood transfusion 15
minutes after initiation?
A. Temperature 37.9°C (100.2°F)
B. Urticaria on the chest
C. Complaint of low back pain
D. Blood pressure 110/68 mm Hg
Answer: C
Rationale: Low back pain suggests an acute hemolytic transfusion reaction, requiring immediate
cessation of the transfusion. Low-grade fever and urticaria may indicate milder reactions; the
BP is normal.
Page 2
, 8. A client with cirrhosis has ascites and is prescribed spironolactone. Which parameter
best evaluates therapeutic effectiveness?
A. Serum potassium level
B. Daily weight and abdominal girth
C. Serum albumin level
D. Urine specific gravity
Answer: B
Rationale: Daily weight and abdominal girth directly reflect mobilization of ascitic fluid, the
therapeutic goal of diuresis in cirrhosis. Potassium and albumin are monitored for safety but do
not measure diuretic effect.
9. Which client is at highest risk for developing a venous thromboembolism
postoperatively?
A. Client who had a laparoscopic cholecystectomy and ambulated within 4 hours
B. Client who had a total hip arthroplasty and is on bed rest
C. Client who had cataract surgery and is using eye drops
D. Client who had a colonoscopy and is tolerating a clear diet
Answer: B
Rationale: Major orthopedic surgery plus immobility creates Virchow's triad, placing the client
at highest VTE risk. The other clients have low-risk procedures and early mobility.
10. A patient with acute decompensated heart failure is receiving IV furosemide. Which
assessment finding best indicates the medication is producing the intended 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. Heart rate decreases from 110 to 88 beats/min
D. Bilateral crackles become more diffuse on auscultation
Answer: B
Rationale: Loop diuretics reduce preload by promoting diuresis; the therapeutic endpoint is
increased urine output with decreased venous congestion (falling JVP, reduced edema, weight
loss). Rising potassium reflects the opposite of expected loop-diuretic effect, slowing heart rate
is not the direct target, and more diffuse crackles signal worsening pulmonary congestion.
11. Which arterial blood gas pattern is most consistent with a patient experiencing an acute
exacerbation of COPD with CO2 retention?
A. pH 7.48, PaCO2 30 mm Hg, HCO3 22 mEq/L
B. pH 7.30, PaCO2 58 mm Hg, HCO3 27 mEq/L
C. pH 7.50, PaCO2 40 mm Hg, HCO3 32 mEq/L
D. pH 7.36, PaCO2 40 mm Hg, HCO3 24 mEq/L
Page 3
Guide Exam 3 Practice Questions & Rationa, Exams
of Nursing
1. A client with heart failure is prescribed furosemide 40 mg IV push. Which assessment
finding most urgently requires the nurse to hold the dose and notify the provider?
A. Serum potassium of 3.1 mEq/L
B. Serum sodium of 138 mEq/L
C. Blood pressure of 118/72 mm Hg
D. Urine output of 60 mL/hr
Answer: A
Rationale: Loop diuretics like furosemide cause potassium wasting; a K+ of 3.1 mEq/L places the
client at risk for dysrhythmias and should prompt holding the dose. Sodium, BP, and urine
output values are within acceptable parameters and do not contraindicate administration.
2. A client is admitted with an acute exacerbation of COPD. Which oxygen delivery
approach is most appropriate to prevent hypercapnia?
A. High-flow 100% non-rebreather at 15 L/min
B. Venturi mask titrated to SpO2 88-92%
C. Simple face mask at 10 L/min continuously
D. Nasal cannula at 6 L/min during sleep only
Answer: B
Rationale: COPD clients with chronic CO2 retention rely on hypoxic drive; targeting SpO2
88-92% via Venturi mask prevents oxygen-induced hypercapnia. High-flow 100% and 10 L/min
exceed safe limits, and intermittent nocturnal oxygen does not treat acute exacerbation.
3. A client with acute kidney injury has a serum potassium of 6.8 mEq/L and peaked T
waves on ECG. Which prescribed intervention should the nurse anticipate administering
first?
A. Oral sodium polystyrene sulfonate
B. IV calcium gluconate
C. Subcutaneous regular insulin
D. IV furosemide bolus
Answer: B
Rationale: IV calcium gluconate is the immediate cardioprotective measure for hyperkalemia
with ECG changes; it stabilizes cardiac membranes within minutes. Polystyrene, insulin, and
furosemide lower potassium but act too slowly to address acute dysrhythmia risk.
Page 1
,4. Which finding best indicates that a client with diabetic ketoacidosis is responding to
treatment?
A. Serum glucose decreased from 480 to 320 mg/dL
B. Serum bicarbonate increased from 10 to 16 mEq/L
C. Urine output decreased to 20 mL/hr
D. Respiratory rate increased to 32/min
Answer: B
Rationale: Resolution of ketoacidosis is reflected by rising bicarbonate and closing anion gap,
not glucose alone. Decreasing urine output and tachypnea suggest worsening status.
5. A client with a new ileostomy has liquid output of 1,800 mL/day. Which nursing action is
the priority?
A. Encourage a high-fiber diet to thicken stool
B. Monitor for signs of hypovolemia and electrolyte imbalance
C. Apply a convex wafer to prevent leakage
D. Irrigate the stoma with 500 mL warm water
Answer: B
Rationale: High-output ileostomies cause significant fluid and electrolyte losses; monitoring for
hypovolemia and hypokalemia/hyponatremia is priority. High-fiber diets are avoided early,
convex wafers are for retracted stomas, and ileostomies are not routinely irrigated.
6. A client with a traumatic brain injury has an ICP of 22 mm Hg. Which position should
the nurse maintain?
A. Flat supine with head neutral
B. Head of bed elevated 30 degrees with head midline
C. Trendelenburg with knees flexed
D. Prone with head turned to the side
Answer: B
Rationale: Elevating HOB 30 degrees with head midline promotes venous drainage and reduces
ICP. Flat, Trendelenburg, and prone positions impede venous return and raise ICP.
7. Which assessment finding is most concerning in a client receiving a blood transfusion 15
minutes after initiation?
A. Temperature 37.9°C (100.2°F)
B. Urticaria on the chest
C. Complaint of low back pain
D. Blood pressure 110/68 mm Hg
Answer: C
Rationale: Low back pain suggests an acute hemolytic transfusion reaction, requiring immediate
cessation of the transfusion. Low-grade fever and urticaria may indicate milder reactions; the
BP is normal.
Page 2
, 8. A client with cirrhosis has ascites and is prescribed spironolactone. Which parameter
best evaluates therapeutic effectiveness?
A. Serum potassium level
B. Daily weight and abdominal girth
C. Serum albumin level
D. Urine specific gravity
Answer: B
Rationale: Daily weight and abdominal girth directly reflect mobilization of ascitic fluid, the
therapeutic goal of diuresis in cirrhosis. Potassium and albumin are monitored for safety but do
not measure diuretic effect.
9. Which client is at highest risk for developing a venous thromboembolism
postoperatively?
A. Client who had a laparoscopic cholecystectomy and ambulated within 4 hours
B. Client who had a total hip arthroplasty and is on bed rest
C. Client who had cataract surgery and is using eye drops
D. Client who had a colonoscopy and is tolerating a clear diet
Answer: B
Rationale: Major orthopedic surgery plus immobility creates Virchow's triad, placing the client
at highest VTE risk. The other clients have low-risk procedures and early mobility.
10. A patient with acute decompensated heart failure is receiving IV furosemide. Which
assessment finding best indicates the medication is producing the intended 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. Heart rate decreases from 110 to 88 beats/min
D. Bilateral crackles become more diffuse on auscultation
Answer: B
Rationale: Loop diuretics reduce preload by promoting diuresis; the therapeutic endpoint is
increased urine output with decreased venous congestion (falling JVP, reduced edema, weight
loss). Rising potassium reflects the opposite of expected loop-diuretic effect, slowing heart rate
is not the direct target, and more diffuse crackles signal worsening pulmonary congestion.
11. Which arterial blood gas pattern is most consistent with a patient experiencing an acute
exacerbation of COPD with CO2 retention?
A. pH 7.48, PaCO2 30 mm Hg, HCO3 22 mEq/L
B. pH 7.30, PaCO2 58 mm Hg, HCO3 27 mEq/L
C. pH 7.50, PaCO2 40 mm Hg, HCO3 32 mEq/L
D. pH 7.36, PaCO2 40 mm Hg, HCO3 24 mEq/L
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