Adult Nursing II Exam Latest (2025/2026) – Questions with Detailed Answers and Rationale | Graded A+ | Guaranteed Pass

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Adult Nursing II Exam Latest (2025/2026) – Questions with
Detailed Answers and Rationale | Graded A+ | Guaranteed
Pass

Question 1
A patient with decompensated cirrhosis develops sudden confusion, asterixis, and elevated
serum ammonia levels. Which nursing intervention takes highest priority?

• A. Restrict protein intake completely

• B. Administer lactulose as prescribed

• C. Place the patient on seizure precautions

• D. Monitor for ascites and abdominal girth changes

Answer: B. Administer lactulose as prescribed
Rationale: Lactulose reduces serum ammonia by promoting its excretion in the stool. Restricting
protein can worsen malnutrition. Seizure precautions and ascites monitoring are important but
not priority for acute encephalopathy.



Question 2
A patient with myasthenia gravis is receiving pyridostigmine. Shortly after dosing, the patient
develops bradycardia, excessive salivation, and muscle weakness. The nurse should suspect:

• A. Myasthenic crisis

• B. Cholinergic crisis

• C. Exacerbation due to infection

• D. Normal expected response

Answer: B. Cholinergic crisis
Rationale: Overmedication with anticholinesterase drugs produces cholinergic crisis (SLUDGE
symptoms). Priority is to stop medication and support airway.

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Question 3
A client with diabetic ketoacidosis (DKA) is started on IV insulin. Which lab value requires the
most urgent intervention?

• A. Serum potassium 2.9 mEq/L

• B. Blood glucose 400 mg/dL

• C. pH 7.25

• D. Serum bicarbonate 18 mEq/L

Answer: A. Serum potassium 2.9 mEq/L
Rationale: Potassium <3.5 mEq/L is life-threatening, especially during insulin therapy which
drives K⁺ into cells. Correcting potassium takes precedence even over hyperglycemia.



Question 4
A patient on warfarin therapy reports tarry stools. PT/INR = 6.2. The nurse should anticipate
administering:

• A. Protamine sulfate

• B. Vitamin K

• C. Fresh frozen plasma

• D. Platelets

Answer: B. Vitamin K
Rationale: Vitamin K is the antidote for warfarin overdose. Protamine sulfate is for heparin. FFP
may be used in severe active bleeding, but first-line reversal is Vitamin K.



Question 5
A client with Guillain-Barré syndrome has rapidly ascending paralysis. Which assessment is
most critical?

• A. Deep tendon reflexes

• B. Bowel sounds

• C. Vital capacity and respiratory effort

• D. Cranial nerve function

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Answer: C. Vital capacity and respiratory effort
Rationale: The biggest threat in GBS is respiratory failure due to muscle paralysis. Monitoring
lung function is priority.



Question 6
A patient with chronic kidney disease (CKD) is prescribed epoetin alfa. Which lab value would
make the nurse hold the medication?

• A. Hemoglobin 12.2 g/dL

• B. Hemoglobin 11.5 g/dL

• C. Hemoglobin 10.0 g/dL

• D. Hematocrit 30%

Answer: A. Hemoglobin 12.2 g/dL
Rationale: Epoetin alfa is held when Hgb >11 due to increased risk of thromboembolic events.



Question 7
A patient with heart failure is on furosemide. Which finding indicates dangerous complication?

• A. BP 98/62 mmHg

• B. Potassium 2.8 mEq/L

• C. Urine output 1,200 mL in 24 hrs

• D. Weight loss of 2 lbs overnight

Answer: B. Potassium 2.8 mEq/L
Rationale: Severe hypokalemia can cause life-threatening arrhythmias.



Question 8
A client with multiple sclerosis is receiving high-dose IV methylprednisolone. Which assessment
is most important?

• A. Mood swings and irritability

• B. Blood glucose monitoring

• C. Skin turgor and dryness

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• D. Muscle strength

Answer: B. Blood glucose monitoring
Rationale: Corticosteroids can cause acute hyperglycemia, which is especially dangerous in
stressed or hospitalized patients.



Question 9
A patient with acute pancreatitis has severe epigastric pain radiating to the back. Which nursing
action is most effective for pain relief?

• A. Place in high-Fowler’s position

• B. Encourage ambulation

• C. Position the patient leaning forward while sitting

• D. Offer small frequent meals

Answer: C. Position the patient leaning forward while sitting
Rationale: Flexed, leaning-forward posture reduces tension on inflamed pancreas.



Question 10
A patient with COPD is receiving oxygen at 6 L/min via nasal cannula. The nurse notes
somnolence and a PaCO₂ of 68 mmHg. What is the priority action?

• A. Increase O₂ to 10 L/min

• B. Notify the HCP immediately

• C. Reduce O₂ to 2 L/min

• D. Prepare for endotracheal intubation

Answer: C. Reduce O₂ to 2 L/min
Rationale: High oxygen in COPD suppresses hypoxic drive, leading to CO₂ narcosis. Lower O₂
delivery while maintaining saturation.

Question 11
A patient with Addison’s disease is admitted with severe hypotension, dehydration, and
hyperkalemia. Which intervention takes priority?

• A. Administer IV hydrocortisone