NUR 335 EXAM 3 | QUESTIONS AND ANSWERS | VERIFIED
ANSWERS PLUS RATIONALES | EXAM ALREADY GRADED
A+ | LATEST EXAM
1. Which nursing intervention is most appropriate for a patient experiencing acute pain?
A. Encourage deep breathing exercises
B. Administer prescribed analgesics
C. Ask the patient to ignore the pain
D. Delay intervention until the pain increases
Answer: B. Administer prescribed analgesics
Rationale: Administering prescribed analgesics provides immediate pain relief and improves
patient comfort, which is a primary nursing responsibility.
2. A patient with heart failure presents with dyspnea and edema. Which lab value would
the nurse expect to be elevated?
A. Sodium
B. B-type natriuretic peptide (BNP)
C. Potassium
D. Hemoglobin
Answer: B. B-type natriuretic peptide (BNP)
Rationale: BNP is released by the ventricles in response to volume expansion and pressure
overload, making it a key marker for heart failure.
3. Which medication is commonly prescribed for rapid atrial fibrillation rate control?
A. Amiodarone
B. Metoprolol
C. Furosemide
D. Digoxin
Answer: B. Metoprolol
Rationale: Metoprolol, a beta-blocker, slows AV conduction and reduces heart rate in atrial
fibrillation.
4. A patient receiving IV antibiotics develops a rash and wheezing. What is the nurse’s
priority action?
A. Notify the provider after completing the dose
B. Stop the infusion immediately
C. Document the reaction and continue infusion
D. Administer a PRN analgesic
Answer: B. Stop the infusion immediately
Rationale: Rash and wheezing indicate a possible allergic reaction, and stopping the infusion is
essential to prevent anaphylaxis.
,5. The nurse is teaching a patient with diabetes about hypoglycemia. Which symptom
should the patient be taught to recognize first?
A. Fruity breath
B. Shakiness and sweating
C. Polyuria
D. Blurred vision
Answer: B. Shakiness and sweating
Rationale: Shakiness, sweating, and palpitations are early signs of hypoglycemia and should
prompt immediate treatment.
6. Which nursing action is most appropriate when caring for a patient with a newly placed
chest tube?
A. Clamp the tube to assess drainage
B. Keep the drainage system below the chest level
C. Strip the tubing to prevent clots
D. Disconnect the tube for patient mobility
Answer: B. Keep the drainage system below the chest level
Rationale: Keeping the drainage system below chest level prevents backflow of fluid into the
pleural space.
7. A patient with chronic kidney disease is at risk for hyperkalemia. Which ECG change
indicates hyperkalemia?
A. Prolonged PR interval
B. Peaked T waves
C. ST-segment elevation
D. Inverted P waves
Answer: B. Peaked T waves
Rationale: Hyperkalemia often manifests as peaked T waves on ECG due to altered cardiac
repolarization.
8. A nurse is monitoring a patient receiving IV potassium. Which is the safest method of
administration?
A. Rapid IV push
B. Continuous IV infusion with cardiac monitoring
C. IM injection
D. Subcutaneous injection
Answer: B. Continuous IV infusion with cardiac monitoring
Rationale: Rapid IV administration of potassium can cause cardiac arrest; continuous infusion
with monitoring is safest.
9. Which patient is at highest risk for developing pressure ulcers?
A. Patient who is ambulatory but fatigued
B. Patient who is immobile and incontinent
C. Patient with mild eczema
D. Patient recovering from a cold
Answer: B. Patient who is immobile and incontinent
,Rationale: Immobility and moisture from incontinence are major risk factors for pressure ulcer
development.
10. A patient with COPD is using pursed-lip breathing. What is the primary purpose of this
technique?
A. Increase oxygen intake
B. Slow expiration and prevent airway collapse
C. Promote coughing
D. Reduce inhalation volume
Answer: B. Slow expiration and prevent airway collapse
Rationale: Pursed-lip breathing helps keep airways open longer during exhalation, reducing air
trapping.
11. Which electrolyte imbalance is most commonly associated with chronic diarrhea?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B. Hypokalemia
Rationale: Chronic diarrhea causes loss of potassium, leading to hypokalemia.
12. Which nursing intervention is most appropriate for a patient with hypovolemic shock?
A. Administer IV fluids rapidly
B. Provide high-fiber diet
C. Encourage ambulation
D. Limit oxygen therapy
Answer: A. Administer IV fluids rapidly
Rationale: Rapid fluid resuscitation is essential to restore circulating volume and perfusion in
hypovolemic shock.
13. Which assessment finding is most concerning for a patient on anticoagulant therapy?
A. Mild bruising on arms
B. Gum bleeding while brushing
C. Nosebleed lasting 15 minutes
D. Occasional headaches
Answer: C. Nosebleed lasting 15 minutes
Rationale: Prolonged bleeding may indicate excessive anticoagulation and requires immediate
attention.
14. A patient with asthma is prescribed albuterol. Which is the expected effect?
A. Bronchoconstriction
B. Bronchodilation
C. Increased mucus production
D. Sedation
, Answer: B. Bronchodilation
Rationale: Albuterol is a beta-2 agonist that relaxes bronchial smooth muscle to relieve airway
obstruction.
15. Which action should the nurse take first for a patient with suspected sepsis?
A. Obtain blood cultures
B. Administer IV antibiotics
C. Monitor vital signs
D. Start a low-sodium diet
Answer: A. Obtain blood cultures
Rationale: Blood cultures should be obtained before antibiotics to identify the causative
organism.
16. Which sign indicates worsening heart failure in a patient?
A. Weight loss of 2 lbs in 1 week
B. Increased shortness of breath
C. Decreased heart rate
D. Improved exercise tolerance
Answer: B. Increased shortness of breath
Rationale: Dyspnea is a hallmark of worsening fluid overload in heart failure.
17. A patient with diabetes is scheduled for surgery. Which action should the nurse take
regarding insulin?
A. Hold all insulin
B. Adjust according to blood glucose levels
C. Double the dose pre-op
D. Stop monitoring glucose
Answer: B. Adjust according to blood glucose levels
Rationale: Insulin doses must be carefully adjusted perioperatively to prevent hypo- or
hyperglycemia.
18. Which precaution is essential for a patient with neutropenia?
A. Strict hand hygiene and infection prevention
B. Encourage large crowds for social support
C. Limit fluid intake
D. Avoid pain medications
Answer: A. Strict hand hygiene and infection prevention
Rationale: Neutropenic patients are highly susceptible to infection; strict precautions reduce
risk.
19. A patient with cirrhosis develops ascites. Which nursing intervention is appropriate?
A. Encourage high-sodium diet
B. Monitor abdominal girth daily
C. Limit ambulation
D. Restrict fluids to 500 mL/day
Answer: B. Monitor abdominal girth daily
ANSWERS PLUS RATIONALES | EXAM ALREADY GRADED
A+ | LATEST EXAM
1. Which nursing intervention is most appropriate for a patient experiencing acute pain?
A. Encourage deep breathing exercises
B. Administer prescribed analgesics
C. Ask the patient to ignore the pain
D. Delay intervention until the pain increases
Answer: B. Administer prescribed analgesics
Rationale: Administering prescribed analgesics provides immediate pain relief and improves
patient comfort, which is a primary nursing responsibility.
2. A patient with heart failure presents with dyspnea and edema. Which lab value would
the nurse expect to be elevated?
A. Sodium
B. B-type natriuretic peptide (BNP)
C. Potassium
D. Hemoglobin
Answer: B. B-type natriuretic peptide (BNP)
Rationale: BNP is released by the ventricles in response to volume expansion and pressure
overload, making it a key marker for heart failure.
3. Which medication is commonly prescribed for rapid atrial fibrillation rate control?
A. Amiodarone
B. Metoprolol
C. Furosemide
D. Digoxin
Answer: B. Metoprolol
Rationale: Metoprolol, a beta-blocker, slows AV conduction and reduces heart rate in atrial
fibrillation.
4. A patient receiving IV antibiotics develops a rash and wheezing. What is the nurse’s
priority action?
A. Notify the provider after completing the dose
B. Stop the infusion immediately
C. Document the reaction and continue infusion
D. Administer a PRN analgesic
Answer: B. Stop the infusion immediately
Rationale: Rash and wheezing indicate a possible allergic reaction, and stopping the infusion is
essential to prevent anaphylaxis.
,5. The nurse is teaching a patient with diabetes about hypoglycemia. Which symptom
should the patient be taught to recognize first?
A. Fruity breath
B. Shakiness and sweating
C. Polyuria
D. Blurred vision
Answer: B. Shakiness and sweating
Rationale: Shakiness, sweating, and palpitations are early signs of hypoglycemia and should
prompt immediate treatment.
6. Which nursing action is most appropriate when caring for a patient with a newly placed
chest tube?
A. Clamp the tube to assess drainage
B. Keep the drainage system below the chest level
C. Strip the tubing to prevent clots
D. Disconnect the tube for patient mobility
Answer: B. Keep the drainage system below the chest level
Rationale: Keeping the drainage system below chest level prevents backflow of fluid into the
pleural space.
7. A patient with chronic kidney disease is at risk for hyperkalemia. Which ECG change
indicates hyperkalemia?
A. Prolonged PR interval
B. Peaked T waves
C. ST-segment elevation
D. Inverted P waves
Answer: B. Peaked T waves
Rationale: Hyperkalemia often manifests as peaked T waves on ECG due to altered cardiac
repolarization.
8. A nurse is monitoring a patient receiving IV potassium. Which is the safest method of
administration?
A. Rapid IV push
B. Continuous IV infusion with cardiac monitoring
C. IM injection
D. Subcutaneous injection
Answer: B. Continuous IV infusion with cardiac monitoring
Rationale: Rapid IV administration of potassium can cause cardiac arrest; continuous infusion
with monitoring is safest.
9. Which patient is at highest risk for developing pressure ulcers?
A. Patient who is ambulatory but fatigued
B. Patient who is immobile and incontinent
C. Patient with mild eczema
D. Patient recovering from a cold
Answer: B. Patient who is immobile and incontinent
,Rationale: Immobility and moisture from incontinence are major risk factors for pressure ulcer
development.
10. A patient with COPD is using pursed-lip breathing. What is the primary purpose of this
technique?
A. Increase oxygen intake
B. Slow expiration and prevent airway collapse
C. Promote coughing
D. Reduce inhalation volume
Answer: B. Slow expiration and prevent airway collapse
Rationale: Pursed-lip breathing helps keep airways open longer during exhalation, reducing air
trapping.
11. Which electrolyte imbalance is most commonly associated with chronic diarrhea?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B. Hypokalemia
Rationale: Chronic diarrhea causes loss of potassium, leading to hypokalemia.
12. Which nursing intervention is most appropriate for a patient with hypovolemic shock?
A. Administer IV fluids rapidly
B. Provide high-fiber diet
C. Encourage ambulation
D. Limit oxygen therapy
Answer: A. Administer IV fluids rapidly
Rationale: Rapid fluid resuscitation is essential to restore circulating volume and perfusion in
hypovolemic shock.
13. Which assessment finding is most concerning for a patient on anticoagulant therapy?
A. Mild bruising on arms
B. Gum bleeding while brushing
C. Nosebleed lasting 15 minutes
D. Occasional headaches
Answer: C. Nosebleed lasting 15 minutes
Rationale: Prolonged bleeding may indicate excessive anticoagulation and requires immediate
attention.
14. A patient with asthma is prescribed albuterol. Which is the expected effect?
A. Bronchoconstriction
B. Bronchodilation
C. Increased mucus production
D. Sedation
, Answer: B. Bronchodilation
Rationale: Albuterol is a beta-2 agonist that relaxes bronchial smooth muscle to relieve airway
obstruction.
15. Which action should the nurse take first for a patient with suspected sepsis?
A. Obtain blood cultures
B. Administer IV antibiotics
C. Monitor vital signs
D. Start a low-sodium diet
Answer: A. Obtain blood cultures
Rationale: Blood cultures should be obtained before antibiotics to identify the causative
organism.
16. Which sign indicates worsening heart failure in a patient?
A. Weight loss of 2 lbs in 1 week
B. Increased shortness of breath
C. Decreased heart rate
D. Improved exercise tolerance
Answer: B. Increased shortness of breath
Rationale: Dyspnea is a hallmark of worsening fluid overload in heart failure.
17. A patient with diabetes is scheduled for surgery. Which action should the nurse take
regarding insulin?
A. Hold all insulin
B. Adjust according to blood glucose levels
C. Double the dose pre-op
D. Stop monitoring glucose
Answer: B. Adjust according to blood glucose levels
Rationale: Insulin doses must be carefully adjusted perioperatively to prevent hypo- or
hyperglycemia.
18. Which precaution is essential for a patient with neutropenia?
A. Strict hand hygiene and infection prevention
B. Encourage large crowds for social support
C. Limit fluid intake
D. Avoid pain medications
Answer: A. Strict hand hygiene and infection prevention
Rationale: Neutropenic patients are highly susceptible to infection; strict precautions reduce
risk.
19. A patient with cirrhosis develops ascites. Which nursing intervention is appropriate?
A. Encourage high-sodium diet
B. Monitor abdominal girth daily
C. Limit ambulation
D. Restrict fluids to 500 mL/day
Answer: B. Monitor abdominal girth daily
