NUR 265 Exam 3 V2 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 3) | Galen
1. Mr. Henderson, a 58-year-old patient with a history of alcohol-induced cirrhosis, is
admitted with a sudden onset of hematemesis and hypotension. The nurse suspects bleeding
esophageal varices. What is the priority nursing intervention?
A. Insert a large-bore nasogastric tube for gastric lavage.
B. Establish patent airway and prepare for possible intubation.
C. Administer Vitamin K intramuscularly to facilitate clotting.
D. Initiate a rapid infusion of normal saline to maintain blood pressure.
Correct Answer: B
Explanation: In patients with active esophageal variceal bleeding, the risk of aspiration is
extremely high due to hematemesis and potential altered consciousness. Protecting the
airway is the first priority in the ABC (Airway, Breathing, Circulation) framework. Once the
airway is secured, volume resuscitation and pharmacological management can be
addressed.
2. A patient with acute liver failure is exhibiting stage 3 hepatic encephalopathy. The nurse
notes the patient has significant flapping tremors of the hands. How should the nurse
document this finding?
A. Presence of positive Babinski sign.
,B. Evidence of decerebrate posturing.
C. Clinical indication of myoclonus.
D. Observation of asterixis.
Correct Answer: D
Explanation: Asterixis, also known as ‘liver flap,’ is a classic sign of worsening hepatic
encephalopathy caused by the accumulation of ammonia and other toxins. The nurse
assesses this by asking the patient to extend their arms and dorsiflex their wrists.
Documentation of this finding helps track the progression or resolution of metabolic
encephalopathy.
3. Mrs. Garcia, diagnosed with decompensated cirrhosis, presents with massive ascites and
respiratory distress. The physician performs a paracentesis, removing 5 liters of fluid. Which
complication should the nurse monitor for most closely during the post-procedure period?
A. Hypovolemic shock.
B. Hypervolemic crisis.
C. Metabolic alkalosis.
D. Acute renal failure due to hydronephrosis.
Correct Answer: A
Explanation: Rapid removal of large amounts of ascitic fluid (large-volume paracentesis)
causes a fluid shift from the intravascular space into the abdominal cavity to replace the
, removed fluid. This can lead to decreased circulating volume, hypotension, and
hypovolemic shock. Monitoring vital signs and administering intravenous albumin are
essential interventions to prevent this complication.
4. A nurse is caring for a client with acute kidney injury (AKI) who has a serum potassium level
of 6.8 mEq/L. The nurse observes peaked T-waves on the cardiac monitor. Which order
should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Start a nebulized albuterol treatment.
C. Administer 10 units of regular insulin with 50 mL of 50% dextrose IV.
D. Obtain a prescription for emergency hemodialysis.
Correct Answer: C
Explanation: A potassium level of 6.8 mEq/L with EKG changes represents a medical
emergency. Intravenous insulin with dextrose works quickly to shift potassium from the
extracellular fluid into the intracellular space. While Kayexalate and dialysis are effective,
they take much longer to lower potassium levels compared to the rapid shift induced by
insulin.
5. A patient is receiving Continuous Renal Replacement Therapy (CRRT). The nurse notices
that the ‘filter pressure’ alarm is sounding and the filter appears dark and clotted. What
action should the nurse take?
A. Stop the pump and return the blood to the patient if possible, then change the circuit.
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 3) | Galen
1. Mr. Henderson, a 58-year-old patient with a history of alcohol-induced cirrhosis, is
admitted with a sudden onset of hematemesis and hypotension. The nurse suspects bleeding
esophageal varices. What is the priority nursing intervention?
A. Insert a large-bore nasogastric tube for gastric lavage.
B. Establish patent airway and prepare for possible intubation.
C. Administer Vitamin K intramuscularly to facilitate clotting.
D. Initiate a rapid infusion of normal saline to maintain blood pressure.
Correct Answer: B
Explanation: In patients with active esophageal variceal bleeding, the risk of aspiration is
extremely high due to hematemesis and potential altered consciousness. Protecting the
airway is the first priority in the ABC (Airway, Breathing, Circulation) framework. Once the
airway is secured, volume resuscitation and pharmacological management can be
addressed.
2. A patient with acute liver failure is exhibiting stage 3 hepatic encephalopathy. The nurse
notes the patient has significant flapping tremors of the hands. How should the nurse
document this finding?
A. Presence of positive Babinski sign.
,B. Evidence of decerebrate posturing.
C. Clinical indication of myoclonus.
D. Observation of asterixis.
Correct Answer: D
Explanation: Asterixis, also known as ‘liver flap,’ is a classic sign of worsening hepatic
encephalopathy caused by the accumulation of ammonia and other toxins. The nurse
assesses this by asking the patient to extend their arms and dorsiflex their wrists.
Documentation of this finding helps track the progression or resolution of metabolic
encephalopathy.
3. Mrs. Garcia, diagnosed with decompensated cirrhosis, presents with massive ascites and
respiratory distress. The physician performs a paracentesis, removing 5 liters of fluid. Which
complication should the nurse monitor for most closely during the post-procedure period?
A. Hypovolemic shock.
B. Hypervolemic crisis.
C. Metabolic alkalosis.
D. Acute renal failure due to hydronephrosis.
Correct Answer: A
Explanation: Rapid removal of large amounts of ascitic fluid (large-volume paracentesis)
causes a fluid shift from the intravascular space into the abdominal cavity to replace the
, removed fluid. This can lead to decreased circulating volume, hypotension, and
hypovolemic shock. Monitoring vital signs and administering intravenous albumin are
essential interventions to prevent this complication.
4. A nurse is caring for a client with acute kidney injury (AKI) who has a serum potassium level
of 6.8 mEq/L. The nurse observes peaked T-waves on the cardiac monitor. Which order
should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Start a nebulized albuterol treatment.
C. Administer 10 units of regular insulin with 50 mL of 50% dextrose IV.
D. Obtain a prescription for emergency hemodialysis.
Correct Answer: C
Explanation: A potassium level of 6.8 mEq/L with EKG changes represents a medical
emergency. Intravenous insulin with dextrose works quickly to shift potassium from the
extracellular fluid into the intracellular space. While Kayexalate and dialysis are effective,
they take much longer to lower potassium levels compared to the rapid shift induced by
insulin.
5. A patient is receiving Continuous Renal Replacement Therapy (CRRT). The nurse notices
that the ‘filter pressure’ alarm is sounding and the filter appears dark and clotted. What
action should the nurse take?
A. Stop the pump and return the blood to the patient if possible, then change the circuit.
