NUR 265 Exam 2 LATEST 2025 ACTUAL
EXAM WITH COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS (100%
VERIFIED ANSWERS) |ALREADY GRADED
A+| ||PROFESSOR VERIFIED||
||BRANDNEW!!!||
1. A postoperative patient has a respiratory rate of 8 breaths/min, O₂ saturation 88% on
room air, and is somnolent. Which action is highest priority?
A. Encourage incentive spirometry
B. Administer PRN opioid antagonist (naloxone)
C. Offer warm blankets
D. Reassess in 30 minutes
Explanation: Respiratory depression with low RR and low SpO₂ plus somnolence
suggests opioid-induced depression. Naloxone is first-line to reverse. Support
airway/oxygen while preparing and monitoring after administration.
2. A patient with CHF has sudden weight gain of 3 kg in 3 days, increased dyspnea, and
peripheral edema. Which nursing diagnosis is most appropriate?
A. Risk for falls
B. Excess fluid volume
C. Imbalanced nutrition: more than body requirements
D. Ineffective airway clearance
Explanation: Rapid weight gain and edema indicate fluid retention. Excess fluid volume
addresses pathophysiology and directs interventions like diuretics, sodium restriction,
and monitoring.
3. The nurse is teaching a patient started on warfarin. Which instruction is most important?
A. Avoid grapefruit juice
B. Maintain consistent vitamin K intake
C. Take with a full glass of water
D. Stop medication if minor bleeding occurs
, Explanation: Warfarin’s effect varies with vitamin K intake; consistent intake stabilizes
INR. Grapefruit interacts more with some meds, but vitamin K consistency is key. Never
stop without provider guidance.
4. A client with hyperkalemia (K⁺ 6.2 mEq/L) is being treated emergently. Which med is
given to stabilize cardiac membranes?
A. Sodium polystyrene sulfonate
B. Calcium gluconate
C. Insulin + glucose
D. Furosemide
Explanation: Calcium gluconate (or chloride) stabilizes myocardial cell membranes
immediately to reduce arrhythmia risk; insulin + glucose shifts K⁺ intracellularly but
doesn’t stabilize membranes.
5. A patient with COPD reports increased sputum and purulence. Which nursing action is
priority?
A. Teach pursed-lip breathing
B. Obtain sputum culture and notify provider
C. Provide high-flow oxygen at 10 L/min
D. Encourage bed rest
Explanation: Purulent sputum suggests infection; obtain culture to guide antibiotics.
High-flow O₂ may depress respiratory drive; assessment and targeted therapy come first.
6. The nurse notes new onset atrial fibrillation with rapid ventricular response (rate 150).
Immediate priority is to:
A. Begin heparin infusion
B. Obtain a 12-lead ECG and assess hemodynamics
C. Start amiodarone at home dose
D. Schedule cardioversion tomorrow
Explanation: Rapid assessment with 12-lead ECG and hemodynamic status informs
urgent treatment (rate control, cardioversion). Anticoagulation and antiarrhythmics
depend on findings and risks.
7. A patient on diabetic insulin therapy reports headache, diaphoresis, and confusion.
Which is most appropriate initial action?
A. Give 4 oz fruit juice or glucose gel
B. Call provider for glucagon order
C. Hold insulin dose next day
D. Recheck blood glucose in 2 hours
, Explanation: Symptoms suggest hypoglycemia — immediate fast-acting carbohydrate
(juice, glucose gel) is first. Reassess glucose after treatment and proceed as advised.
8. Which lab change is most consistent with dehydration?
A. Decreased hematocrit
B. Decreased BUN
C. Increased BUN-to-creatinine ratio
D. Decreased serum sodium
Explanation: Dehydration causes hemoconcentration and increased BUN/creatinine
ratio (>20:1). Sodium may be high or normal depending on losses; BUN increases rather
than decreases.
9. A patient receiving IV potassium chloride develops burning at the IV site and redness.
What should nurse do first?
A. Slowly push more KCl to finish infusion
B. Stop infusion and assess IV site
C. Call pharmacy for antihistamine
D. Apply warm compress and continue infusion
Explanation: Burning and redness suggest phlebitis or extravasation risk; stop infusion,
assess site, and notify provider. Do not push more KCl — it’s irritating to veins.
10. A client with acute pancreatitis is NPO and pain-managed. Which lab elevation is most
specific for pancreatitis?
A. ALT
B. Serum lipase
C. Creatinine
D. Troponin
Explanation: Serum lipase (and amylase) rise in pancreatitis; lipase is more specific and
remains elevated longer. ALT may suggest gallstone etiology if elevated.
11. A patient with hypothyroidism is started on levothyroxine. Which teaching point is
essential?
A. Take medication at bedtime
B. Take on an empty stomach in the morning
C. Avoid sunlight exposure
D. Stop once symptoms improve
Explanation: Levothyroxine is best absorbed on an empty stomach in the morning, 30–
60 min before food. Dosage is lifelong for many; stopping can cause relapse.
, 12. Which position promotes drainage and reduces aspiration risk for a patient with stroke
and dysphagia?
A. Supine
B. High Fowler’s with chin tuck
C. Trendelenburg
D. Side-lying with head flat
Explanation: High Fowler’s and chin-tuck helps swallow mechanics and reduces
aspiration. Side-lying may be used for secretions, but upright position is best for oral
intake.
13. A patient is receiving IV vancomycin. Nurse notes sudden flushing, hypotension, and
erythema of the neck. Action?
A. Slow the infusion and notify provider
B. Give IV furosemide
C. Stop vancomycin and document only
D. Increase infusion rate to finish faster
Explanation: Red man syndrome from rapid infusion causes flushing and hypotension.
Stop or slow infusion, administer antihistamine as ordered, and notify provider. Do not
speed up.
14. A patient with DKA presents with K⁺ 3.2 mEq/L. Which is correct?
A. Start insulin infusion immediately without K⁺ replacement
B. Hold potassium replacement because insulin will lower K⁺ more
C. Replace potassium before insulin is started
D. Give sodium bicarbonate immediately
Explanation: If K⁺ low (<3.3), replace potassium BEFORE insulin to avoid life-threatening
hypokalemia due to insulin-driven intracellular shift.
15. A nurse is planning discharge teaching for a patient with a new ostomy. Which statement
by patient indicates need for more teaching?
A. “I will empty the pouch when it is one-third to half full.”
B. “I can swim with my pouch secured.”
C. “I will measure output the same as before surgery.”
D. “I will watch the stoma color for changes.”
Explanation: Output measurement differs and depends on ostomy type; patient
expecting pre-op patterns may be incorrect. Emptying pouch when one-third to half full
and monitoring stoma color are correct.
16. During blood transfusion the patient develops chills, fever, and flank pain. Nurse should:
A. Slow infusion and observe for 30 minutes
EXAM WITH COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS (100%
VERIFIED ANSWERS) |ALREADY GRADED
A+| ||PROFESSOR VERIFIED||
||BRANDNEW!!!||
1. A postoperative patient has a respiratory rate of 8 breaths/min, O₂ saturation 88% on
room air, and is somnolent. Which action is highest priority?
A. Encourage incentive spirometry
B. Administer PRN opioid antagonist (naloxone)
C. Offer warm blankets
D. Reassess in 30 minutes
Explanation: Respiratory depression with low RR and low SpO₂ plus somnolence
suggests opioid-induced depression. Naloxone is first-line to reverse. Support
airway/oxygen while preparing and monitoring after administration.
2. A patient with CHF has sudden weight gain of 3 kg in 3 days, increased dyspnea, and
peripheral edema. Which nursing diagnosis is most appropriate?
A. Risk for falls
B. Excess fluid volume
C. Imbalanced nutrition: more than body requirements
D. Ineffective airway clearance
Explanation: Rapid weight gain and edema indicate fluid retention. Excess fluid volume
addresses pathophysiology and directs interventions like diuretics, sodium restriction,
and monitoring.
3. The nurse is teaching a patient started on warfarin. Which instruction is most important?
A. Avoid grapefruit juice
B. Maintain consistent vitamin K intake
C. Take with a full glass of water
D. Stop medication if minor bleeding occurs
, Explanation: Warfarin’s effect varies with vitamin K intake; consistent intake stabilizes
INR. Grapefruit interacts more with some meds, but vitamin K consistency is key. Never
stop without provider guidance.
4. A client with hyperkalemia (K⁺ 6.2 mEq/L) is being treated emergently. Which med is
given to stabilize cardiac membranes?
A. Sodium polystyrene sulfonate
B. Calcium gluconate
C. Insulin + glucose
D. Furosemide
Explanation: Calcium gluconate (or chloride) stabilizes myocardial cell membranes
immediately to reduce arrhythmia risk; insulin + glucose shifts K⁺ intracellularly but
doesn’t stabilize membranes.
5. A patient with COPD reports increased sputum and purulence. Which nursing action is
priority?
A. Teach pursed-lip breathing
B. Obtain sputum culture and notify provider
C. Provide high-flow oxygen at 10 L/min
D. Encourage bed rest
Explanation: Purulent sputum suggests infection; obtain culture to guide antibiotics.
High-flow O₂ may depress respiratory drive; assessment and targeted therapy come first.
6. The nurse notes new onset atrial fibrillation with rapid ventricular response (rate 150).
Immediate priority is to:
A. Begin heparin infusion
B. Obtain a 12-lead ECG and assess hemodynamics
C. Start amiodarone at home dose
D. Schedule cardioversion tomorrow
Explanation: Rapid assessment with 12-lead ECG and hemodynamic status informs
urgent treatment (rate control, cardioversion). Anticoagulation and antiarrhythmics
depend on findings and risks.
7. A patient on diabetic insulin therapy reports headache, diaphoresis, and confusion.
Which is most appropriate initial action?
A. Give 4 oz fruit juice or glucose gel
B. Call provider for glucagon order
C. Hold insulin dose next day
D. Recheck blood glucose in 2 hours
, Explanation: Symptoms suggest hypoglycemia — immediate fast-acting carbohydrate
(juice, glucose gel) is first. Reassess glucose after treatment and proceed as advised.
8. Which lab change is most consistent with dehydration?
A. Decreased hematocrit
B. Decreased BUN
C. Increased BUN-to-creatinine ratio
D. Decreased serum sodium
Explanation: Dehydration causes hemoconcentration and increased BUN/creatinine
ratio (>20:1). Sodium may be high or normal depending on losses; BUN increases rather
than decreases.
9. A patient receiving IV potassium chloride develops burning at the IV site and redness.
What should nurse do first?
A. Slowly push more KCl to finish infusion
B. Stop infusion and assess IV site
C. Call pharmacy for antihistamine
D. Apply warm compress and continue infusion
Explanation: Burning and redness suggest phlebitis or extravasation risk; stop infusion,
assess site, and notify provider. Do not push more KCl — it’s irritating to veins.
10. A client with acute pancreatitis is NPO and pain-managed. Which lab elevation is most
specific for pancreatitis?
A. ALT
B. Serum lipase
C. Creatinine
D. Troponin
Explanation: Serum lipase (and amylase) rise in pancreatitis; lipase is more specific and
remains elevated longer. ALT may suggest gallstone etiology if elevated.
11. A patient with hypothyroidism is started on levothyroxine. Which teaching point is
essential?
A. Take medication at bedtime
B. Take on an empty stomach in the morning
C. Avoid sunlight exposure
D. Stop once symptoms improve
Explanation: Levothyroxine is best absorbed on an empty stomach in the morning, 30–
60 min before food. Dosage is lifelong for many; stopping can cause relapse.
, 12. Which position promotes drainage and reduces aspiration risk for a patient with stroke
and dysphagia?
A. Supine
B. High Fowler’s with chin tuck
C. Trendelenburg
D. Side-lying with head flat
Explanation: High Fowler’s and chin-tuck helps swallow mechanics and reduces
aspiration. Side-lying may be used for secretions, but upright position is best for oral
intake.
13. A patient is receiving IV vancomycin. Nurse notes sudden flushing, hypotension, and
erythema of the neck. Action?
A. Slow the infusion and notify provider
B. Give IV furosemide
C. Stop vancomycin and document only
D. Increase infusion rate to finish faster
Explanation: Red man syndrome from rapid infusion causes flushing and hypotension.
Stop or slow infusion, administer antihistamine as ordered, and notify provider. Do not
speed up.
14. A patient with DKA presents with K⁺ 3.2 mEq/L. Which is correct?
A. Start insulin infusion immediately without K⁺ replacement
B. Hold potassium replacement because insulin will lower K⁺ more
C. Replace potassium before insulin is started
D. Give sodium bicarbonate immediately
Explanation: If K⁺ low (<3.3), replace potassium BEFORE insulin to avoid life-threatening
hypokalemia due to insulin-driven intracellular shift.
15. A nurse is planning discharge teaching for a patient with a new ostomy. Which statement
by patient indicates need for more teaching?
A. “I will empty the pouch when it is one-third to half full.”
B. “I can swim with my pouch secured.”
C. “I will measure output the same as before surgery.”
D. “I will watch the stoma color for changes.”
Explanation: Output measurement differs and depends on ostomy type; patient
expecting pre-op patterns may be incorrect. Emptying pouch when one-third to half full
and monitoring stoma color are correct.
16. During blood transfusion the patient develops chills, fever, and flank pain. Nurse should:
A. Slow infusion and observe for 30 minutes
