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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
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.
,2|Page
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
,3|Page
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
, 4|Page
• 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
