NUR 245 Exam 3 Concepts of Nursing Care of the Adult II –
Questions, Answers & Rationales
TABLE OF CONTENTS
1. Cardiovascular Disorders
2. Respiratory Disorders
3. Neurologic Disorders
4. Renal and Urinary Disorders
5. Endocrine Disorders
6. Gastrointestinal and Hepatic Disorders
7. Musculoskeletal Disorders
8. Hematologic and Immune Disorders
9. Oncology and Cancer Care
10.Emergency, Critical Care & Multisystem Concepts
11.Integrated Adult Nursing Care
SECTION I — CARDIOVASCULAR DISORDERS
1. A client with left-sided heart failure develops dyspnea and crackles. Which
pathophysiologic process is primarily responsible?
A. Systemic venous congestion
B. Pulmonary fluid accumulation
C. Decreased systemic vascular resistance
D. Increased renal perfusion
Answer: B. Pulmonary fluid accumulation
Rationale: Left-sided heart failure causes blood to back up into the pulmonary
circulation, increasing pulmonary capillary pressure and causing pulmonary
edema, crackles, and dyspnea.
,2. Which assessment finding is most concerning in a client with acute
pulmonary edema?
A. Mild ankle edema
B. Pink, frothy sputum
C. Heart rate of 88/min
D. Mild fatigue
Answer: B. Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of severe pulmonary edema
and requires immediate intervention.
3. Which position is most appropriate for a client experiencing acute dyspnea
related to heart failure?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and decreases
venous return to the heart, helping reduce pulmonary congestion.
4. A client taking digoxin reports nausea, anorexia, and seeing yellow halos
around lights. What should the nurse suspect?
A. Hyperglycemia
B. Digoxin toxicity
C. Hypocalcemia
D. Dehydration
Answer: B. Digoxin toxicity
Rationale: Gastrointestinal symptoms and visual disturbances such as yellow
or blurred vision are characteristic findings of digoxin toxicity.
,5. Which laboratory value is especially important when monitoring a client
receiving warfarin?
A. aPTT
B. INR
C. Troponin
D. Hemoglobin A1c
Answer: B. INR
Rationale: The international normalized ratio (INR) is used to monitor the
therapeutic effect of warfarin and assess bleeding risk.
6. A client taking furosemide is at greatest risk for which electrolyte
imbalance?
A. Hyperkalemia
B. Hypokalemia
C. Hypermagnesemia
D. Hypernatremia
Answer: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary potassium
excretion.
7. Which symptom is most characteristic of stable angina?
A. Chest pain occurring predictably with exertion
B. Chest pain lasting several hours at rest
C. Sudden unilateral leg swelling
D. Severe abdominal pain
Answer: A. Chest pain occurring predictably with exertion
Rationale: Stable angina commonly occurs with exertion or stress and
improves with rest or prescribed nitroglycerin.
8. Which medication is commonly administered sublingually for an acute
angina episode?
, A. Furosemide
B. Nitroglycerin
C. Warfarin
D. Digoxin
Answer: B. Nitroglycerin
Rationale: Sublingual nitroglycerin rapidly dilates coronary and systemic
vessels and is used for acute angina.
9. A client with suspected myocardial infarction reports crushing substernal
chest pain. Which laboratory test is most specific for myocardial injury?
A. Troponin
B. Sodium
C. Creatinine
D. Albumin
Answer: A. Troponin
Rationale: Cardiac troponins are highly sensitive and specific markers of
myocardial injury.
10. Which finding after a myocardial infarction requires immediate attention?
A. Mild fatigue
B. Occasional anxiety
C. New-onset ventricular dysrhythmia
D. Decreased appetite
Answer: C. New-onset ventricular dysrhythmia
Rationale: Ventricular dysrhythmias can rapidly become life-threatening and
may occur after myocardial injury.
11. Which assessment finding is commonly associated with right-sided heart
failure?
A. Pulmonary crackles only
B. Jugular venous distention
Questions, Answers & Rationales
TABLE OF CONTENTS
1. Cardiovascular Disorders
2. Respiratory Disorders
3. Neurologic Disorders
4. Renal and Urinary Disorders
5. Endocrine Disorders
6. Gastrointestinal and Hepatic Disorders
7. Musculoskeletal Disorders
8. Hematologic and Immune Disorders
9. Oncology and Cancer Care
10.Emergency, Critical Care & Multisystem Concepts
11.Integrated Adult Nursing Care
SECTION I — CARDIOVASCULAR DISORDERS
1. A client with left-sided heart failure develops dyspnea and crackles. Which
pathophysiologic process is primarily responsible?
A. Systemic venous congestion
B. Pulmonary fluid accumulation
C. Decreased systemic vascular resistance
D. Increased renal perfusion
Answer: B. Pulmonary fluid accumulation
Rationale: Left-sided heart failure causes blood to back up into the pulmonary
circulation, increasing pulmonary capillary pressure and causing pulmonary
edema, crackles, and dyspnea.
,2. Which assessment finding is most concerning in a client with acute
pulmonary edema?
A. Mild ankle edema
B. Pink, frothy sputum
C. Heart rate of 88/min
D. Mild fatigue
Answer: B. Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of severe pulmonary edema
and requires immediate intervention.
3. Which position is most appropriate for a client experiencing acute dyspnea
related to heart failure?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and decreases
venous return to the heart, helping reduce pulmonary congestion.
4. A client taking digoxin reports nausea, anorexia, and seeing yellow halos
around lights. What should the nurse suspect?
A. Hyperglycemia
B. Digoxin toxicity
C. Hypocalcemia
D. Dehydration
Answer: B. Digoxin toxicity
Rationale: Gastrointestinal symptoms and visual disturbances such as yellow
or blurred vision are characteristic findings of digoxin toxicity.
,5. Which laboratory value is especially important when monitoring a client
receiving warfarin?
A. aPTT
B. INR
C. Troponin
D. Hemoglobin A1c
Answer: B. INR
Rationale: The international normalized ratio (INR) is used to monitor the
therapeutic effect of warfarin and assess bleeding risk.
6. A client taking furosemide is at greatest risk for which electrolyte
imbalance?
A. Hyperkalemia
B. Hypokalemia
C. Hypermagnesemia
D. Hypernatremia
Answer: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary potassium
excretion.
7. Which symptom is most characteristic of stable angina?
A. Chest pain occurring predictably with exertion
B. Chest pain lasting several hours at rest
C. Sudden unilateral leg swelling
D. Severe abdominal pain
Answer: A. Chest pain occurring predictably with exertion
Rationale: Stable angina commonly occurs with exertion or stress and
improves with rest or prescribed nitroglycerin.
8. Which medication is commonly administered sublingually for an acute
angina episode?
, A. Furosemide
B. Nitroglycerin
C. Warfarin
D. Digoxin
Answer: B. Nitroglycerin
Rationale: Sublingual nitroglycerin rapidly dilates coronary and systemic
vessels and is used for acute angina.
9. A client with suspected myocardial infarction reports crushing substernal
chest pain. Which laboratory test is most specific for myocardial injury?
A. Troponin
B. Sodium
C. Creatinine
D. Albumin
Answer: A. Troponin
Rationale: Cardiac troponins are highly sensitive and specific markers of
myocardial injury.
10. Which finding after a myocardial infarction requires immediate attention?
A. Mild fatigue
B. Occasional anxiety
C. New-onset ventricular dysrhythmia
D. Decreased appetite
Answer: C. New-onset ventricular dysrhythmia
Rationale: Ventricular dysrhythmias can rapidly become life-threatening and
may occur after myocardial injury.
11. Which assessment finding is commonly associated with right-sided heart
failure?
A. Pulmonary crackles only
B. Jugular venous distention
