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NUR 3226 – Adult Health Nursing II – Final
Exam Questions And Correct Answers (Verified
Answers) Plus Rationales 2025
- A client with COPD is receiving oxygen therapy at 4 L/min via nasal cannula. The nurse monitors for which complication? a. Pulmonary embolism b. Oxygen-induced hypoventilation c. Metabolic alkalosis d. Respiratory infection Excessive oxygen in COPD patients can suppress their hypoxic respiratory drive, leading to hypoventilation and respiratory acidosis.
- A client with heart failure has gained 5 pounds in 2 days. The nurse suspects: a. Increased muscle mass b. Fluid retention c. Increased appetite d. Decreased cardiac output Rapid weight gain indicates fluid accumulation, a key sign of worsening heart failure.
- A nurse is caring for a client with an abdominal aortic aneurysm. Which is the priority assessment? a. Abdominal or back pain
b. Bowel sounds c. Urinary output d. Skin turgor Pain may indicate impending rupture, which is a life-threatening emergency.
- A patient with acute pancreatitis should be monitored for: a. Hypoglycemia b. Hypocalcemia c. Hypertension d. Hypernatremia Pancreatitis can lead to fat necrosis, which binds calcium, causing hypocalcemia.
- What lab value confirms a diagnosis of myocardial infarction? a. CK-MB b. Myoglobin c. Troponin I d. BNP Troponin is the most specific and sensitive indicator of myocardial injury.
- A client with liver cirrhosis is at risk for: a. Hyperkalemia b. Hyperglycemia c. Bleeding tendencies d. Increased clotting
10.Which position should a nurse place a client in during a seizure? a. Supine with head elevated b. Prone with neck extended c. Side-lying to prevent aspiration d. Trendelenburg Side-lying helps maintain an open airway and reduces aspiration risk. 11.Which is an early sign of increased intracranial pressure (ICP)? a. Decreased level of consciousness b. Bradycardia c. Hypotension d. Fixed pupils Changes in LOC are early indicators of rising ICP. 12.What is the priority action for a patient with diabetic ketoacidosis? a. Administer long-acting insulin b. Initiate IV fluid replacement c. Administer potassium d. Provide a carbohydrate snack Fluid replacement is critical to treat dehydration and improve perfusion. 13.A client with Parkinson’s disease should be taught to: a. Use a walker with wheels b. Take medications at bedtime c. Avoid all dairy products d. Perform deep breathing exercises
A walker with wheels helps maintain balance and reduces fall risk in Parkinson’s disease. 14.Which lab value is most concerning in a client with chronic kidney disease? a. Potassium 6.2 mEq/L b. Hemoglobin 10 g/dL c. Creatinine 2.1 mg/dL d. BUN 24 mg/dL Hyperkalemia increases risk of life-threatening cardiac arrhythmias. 15.A client with multiple sclerosis reports blurred vision and fatigue. The nurse should: a. Restrict fluids b. Schedule rest periods during the day c. Provide a high-calorie diet d. Administer iron supplements Fatigue is a common symptom; energy conservation is essential. 16.Which assessment finding indicates peripheral arterial disease (PAD)? a. Edema and warmth b. Brown discoloration of skin c. Intermittent claudication d. Dull leg pain at rest PAD typically presents with pain during exertion that is relieved with rest. 17.Which diet is most appropriate for a patient with nephrotic syndrome? a. High protein, low fat b. High sodium, low potassium
d. Flush the catheter with heparin Central lines are high risk for infection; assess the site immediately. 21.A client with a history of GI bleeding is receiving NSAIDs for arthritis. Which action is most appropriate? a. Increase fluid intake b. Monitor for constipation c. Assess for signs of gastrointestinal bleeding d. Administer antacids before meals NSAIDs increase the risk of GI ulcers and bleeding, especially in high-risk patients. 22.A patient with chronic heart failure is prescribed furosemide. The nurse should monitor for: a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypertension Furosemide is a loop diuretic that can cause significant potassium loss. 23.Which ECG change is most concerning in a patient with hypokalemia? a. Prolonged PR interval b. Elevated ST segment c. Presence of U wave d. Sinus bradycardia
A U wave is a classic sign of hypokalemia and may lead to dangerous arrhythmias. 24.A nurse reviews lab results for a client with leukemia. Which finding should be reported immediately? a. WBC 4,000/mm³ b. Platelet count 20,000/mm³ c. Hematocrit 35% d. Hemoglobin 11.5 g/dL A low platelet count significantly increases the risk of spontaneous bleeding. 25.A client with Cushing’s syndrome may exhibit: a. Weight loss b. Hypoglycemia c. Moon face d. Hypotension Moon face is a common manifestation due to fat redistribution and cortisol excess. 26.What is a priority nursing diagnosis for a client post-lobectomy? a. Risk for constipation b. Disturbed body image c. Impaired gas exchange d. Ineffective coping Lung surgery impacts oxygenation, making impaired gas exchange a top priority.
Clients with low neutrophils are at increased risk of infection; isolation precautions are essential. 31.Which finding indicates an adverse effect of enalapril? a. Constipation b. Weight gain c. Dry cough d. Bradycardia ACE inhibitors commonly cause a persistent dry cough. 32.A client is diagnosed with Guillain-Barré syndrome. The nurse monitors for: a. Hypertension b. Respiratory failure c. Increased reflexes d. Bradykinesia Ascending paralysis may impair respiratory muscles and require ventilatory support. 33.A patient receiving chemotherapy reports mouth sores. The nurse recommends: a. Rinsing mouth with saline solution b. Using commercial mouthwash c. Eating spicy foods d. Using hydrogen peroxide Saline rinses are gentle and promote oral healing during mucositis. 34.The nurse identifies jugular vein distension and crackles in a client with MI. What complication is developing?
a. Pneumonia b. Left-sided heart failure c. Cardiac tamponade d. Hypertensive crisis Crackles and JVD suggest fluid overload due to left heart dysfunction. 35.A patient with a mechanical valve is on warfarin. What INR value indicates therapeutic anticoagulation? a. 1. b. 3. c. 0. d. 1. Mechanical valves require a higher INR target, typically 2.5–3.5. 36.A nurse is caring for a patient post-stroke with right-sided hemiplegia. Which is a priority intervention? a. Place items on the left side b. Use restraints c. Feed from the right side d. Turn every 6 hours Placing objects on the unaffected side promotes independence and reduces frustration. 37.In diabetic retinopathy, the nurse expects which visual change? a. Blurred or patchy vision b. Eye pain c. Halos around lights
d. Eat grapefruit Methotrexate suppresses the immune system, increasing infection risk. 41.Which statement indicates a need for further teaching in a client with a colostomy? a. "I will clean around the stoma with mild soap and water." b. "I will apply lotion to the stoma to prevent irritation." c. "I will empty the pouch when it's one-third full." d. "I will check the stoma color regularly." Lotion can interfere with the adhesive seal of the colostomy appliance. 42.Which dietary teaching is appropriate for a client with hepatic encephalopathy? a. High-protein diet b. Low-protein diet c. High-sodium diet d. Gluten-free diet Reducing protein intake helps decrease ammonia levels, which worsen encephalopathy. 43.The nurse is caring for a client with tuberculosis. What precaution is necessary? a. Contact precautions b. Airborne precautions c. Droplet precautions d. Standard precautions only
TB spreads via airborne particles; N95 masks and negative-pressure rooms are required. 44.A nurse observes a client’s chest tube drainage of 150 mL/hour. The priority action is to: a. Clamp the chest tube b. Notify the healthcare provider immediately c. Encourage coughing d. Change the drainage system Sudden increased drainage suggests possible hemorrhage. 45.A client with asthma is prescribed albuterol. Which indicates a therapeutic effect? a. Clear lung sounds b. Tachycardia c. Tremors d. Decreased sputum production Albuterol is a bronchodilator that should improve airway clearance. 46.What is the best indicator of adequate fluid resuscitation in a burn client? a. Blood pressure b. Urine output c. Heart rate d. Mental status Urine output (0.5–1 mL/kg/hr) is a reliable sign of organ perfusion in burn patients.
b. Cloudy dialysate output c. Blood-tinged fluid d. Weight gain of 1 lb Cloudy effluent suggests peritonitis, a serious complication.
