NUR265 EXAM / NUR 265 EXAM 1, EXAM 2, EXAM 3 & STUDY
GUIDE COMPLETE ACCURATE EXAM APPROVED
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES (100% CORRECT VERIFIED ANSWERS)
LATEST UPDATED VERSION 2026 EDITION |GUARANTEED
PASS A+ (BRAND NEW!) FULL REVISED NUR 265 MEDICAL
SURGICAL EXAM 2026 /2027
NUR 265 EXAM 1
Question 1
A nurse is caring for a client with heart failure who is receiving furosemide. Which
assessment finding requires immediate intervention?
A. Urinary output of 200 mL over 4 hours
B. Serum potassium level of 3.2 me/L
C. Blood pressure of 110/70 mm Hg
D. Mild pedal edema
CORRECT ANSWER: B. Serum potassium level of 3.2 me/L
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A serum
potassium level of 3.2 me/L indicates hypokalemia, which increases the risk of
cardiac dysrhythmias, especially in clients with heart failure who may also be
taking digoxin. This requires immediate intervention. Urinary output of 200 mL
over 4 hours (50 mL/hr.) is adequate. BP 110/70 is acceptable. Mild pedal
edema is expected in heart failure but not urgent.
Question 2
,A client with chronic obstructive pulmonary disease (COPD) has a pulse oximetry
reading of 88% on room air. Which action should the nurse take first?
A. Administer oxygen at 2 L/min via nasal cannula
B. Encourage deep breathing and coughing exercises
C. Position the client in High-Fowler’s position
D. Obtain an arterial blood gas sample
CORRECT ANSWER: A. Administer oxygen at 2 L/min via nasal cannula
Rationale: In COPD, oxygen saturation below 88-90% indicates hypoxemia
requiring supplementation. Low-flow oxygen (2 L/min) is the initial intervention
to prevent oxygen-induced hypercapnia while improving oxygenation.
Positioning and breathing exercises are supportive but not the priority. ABG may
be obtained later but not first.
Question 3
A nurse is assessing a client with diabetes mellitus who reports blurred vision and
a headache. The client’s blood glucose level is 220 mg/ld. Which additional finding
would indicate hyperglycemic hyperosmolar state (HHS)?
A. Deep, rapid respirations
B. Serum osmolality of 320 mom/kg
C. Positive urine ketones
D. Blood pH of 7.32
CORRECT ANSWER: B. Serum osmolality of 320 mom/kg
,Rationale: HHS is characterized by severe hyperglycemia (often >600 mg/ld., but
can be lower in some cases), marked hyper osmolality (>320 mom/kg), and
minimal ketosis. A serum osmolality of 320 mom/kg supports HHS. Deep rapid
respirations (Kussmaul) and low pH indicate DKA. Positive urine ketones are
typical of DKA, not HHS.
Question 4
A client post–myocardial infarction is receiving thrombolytic therapy. The nurse
notes bleeding at the IV insertion site. Which priority action should the nurse
take?
A. Apply pressure to the site for 10 minutes
B. Stop the thrombolytic infusion immediately
C. Administer vitamin K intramuscularly
D. Increase the infusion rate to flush the line
CORRECT ANSWER: A. Apply pressure to the site for 10 minutes
Rationale: Bleeding is a known complication of thrombolytic. The first action is
to apply pressure to achieve hemostasis. Stopping the infusion without
physician order is not advised unless severe bleeding. Vitamin K is for warfarin
reversal, not thrombolytic. Increasing rate would worsen bleeding.
Question 5
A nurse is teaching a client with chronic kidney disease (CKD) about dietary
restrictions. Which statement by the client indicates understanding?
A. “I should eat bananas and oranges daily for potassium.”
, B. “I can use salt substitutes freely to season my food.”
C. “I will limit my intake of dairy products to control phosphorus.”
D. “I need to increase protein to build muscle strength.”
CORRECT ANSWER: C. “I will limit my intake of dairy products to control
phosphorus.”
Rationale: In CKD, phosphorus is restricted to prevent hyperphosphatemia and
bone disease. Dairy products are high in phosphorus. Bananas/oranges are high
potassium – should be limited. Salt substitutes contain potassium chloride,
dangerous in CKD. Protein is typically restricted, not increased, in later-stage
CKD.
Question 6
A client with cirrhosis develops asterisks and lethargy. Which laboratory finding is
most consistent with hepatic encephalopathy?
A. Elevated serum albumin
B. Decreased ammonia level
C. Elevated ammonia level
D. Increased platelet count
CORRECT ANSWER: C. Elevated ammonia level
Rationale: Hepatic encephalopathy is associated with elevated ammonia due to
the liver’s inability to convert ammonia to urea. Asterisks (liver flap) and
lethargy are clinical signs. Serum albumin is low in cirrhosis. Ammonia is
increased, not decreased. Platelets are decreased due to splenomegaly.
GUIDE COMPLETE ACCURATE EXAM APPROVED
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES (100% CORRECT VERIFIED ANSWERS)
LATEST UPDATED VERSION 2026 EDITION |GUARANTEED
PASS A+ (BRAND NEW!) FULL REVISED NUR 265 MEDICAL
SURGICAL EXAM 2026 /2027
NUR 265 EXAM 1
Question 1
A nurse is caring for a client with heart failure who is receiving furosemide. Which
assessment finding requires immediate intervention?
A. Urinary output of 200 mL over 4 hours
B. Serum potassium level of 3.2 me/L
C. Blood pressure of 110/70 mm Hg
D. Mild pedal edema
CORRECT ANSWER: B. Serum potassium level of 3.2 me/L
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A serum
potassium level of 3.2 me/L indicates hypokalemia, which increases the risk of
cardiac dysrhythmias, especially in clients with heart failure who may also be
taking digoxin. This requires immediate intervention. Urinary output of 200 mL
over 4 hours (50 mL/hr.) is adequate. BP 110/70 is acceptable. Mild pedal
edema is expected in heart failure but not urgent.
Question 2
,A client with chronic obstructive pulmonary disease (COPD) has a pulse oximetry
reading of 88% on room air. Which action should the nurse take first?
A. Administer oxygen at 2 L/min via nasal cannula
B. Encourage deep breathing and coughing exercises
C. Position the client in High-Fowler’s position
D. Obtain an arterial blood gas sample
CORRECT ANSWER: A. Administer oxygen at 2 L/min via nasal cannula
Rationale: In COPD, oxygen saturation below 88-90% indicates hypoxemia
requiring supplementation. Low-flow oxygen (2 L/min) is the initial intervention
to prevent oxygen-induced hypercapnia while improving oxygenation.
Positioning and breathing exercises are supportive but not the priority. ABG may
be obtained later but not first.
Question 3
A nurse is assessing a client with diabetes mellitus who reports blurred vision and
a headache. The client’s blood glucose level is 220 mg/ld. Which additional finding
would indicate hyperglycemic hyperosmolar state (HHS)?
A. Deep, rapid respirations
B. Serum osmolality of 320 mom/kg
C. Positive urine ketones
D. Blood pH of 7.32
CORRECT ANSWER: B. Serum osmolality of 320 mom/kg
,Rationale: HHS is characterized by severe hyperglycemia (often >600 mg/ld., but
can be lower in some cases), marked hyper osmolality (>320 mom/kg), and
minimal ketosis. A serum osmolality of 320 mom/kg supports HHS. Deep rapid
respirations (Kussmaul) and low pH indicate DKA. Positive urine ketones are
typical of DKA, not HHS.
Question 4
A client post–myocardial infarction is receiving thrombolytic therapy. The nurse
notes bleeding at the IV insertion site. Which priority action should the nurse
take?
A. Apply pressure to the site for 10 minutes
B. Stop the thrombolytic infusion immediately
C. Administer vitamin K intramuscularly
D. Increase the infusion rate to flush the line
CORRECT ANSWER: A. Apply pressure to the site for 10 minutes
Rationale: Bleeding is a known complication of thrombolytic. The first action is
to apply pressure to achieve hemostasis. Stopping the infusion without
physician order is not advised unless severe bleeding. Vitamin K is for warfarin
reversal, not thrombolytic. Increasing rate would worsen bleeding.
Question 5
A nurse is teaching a client with chronic kidney disease (CKD) about dietary
restrictions. Which statement by the client indicates understanding?
A. “I should eat bananas and oranges daily for potassium.”
, B. “I can use salt substitutes freely to season my food.”
C. “I will limit my intake of dairy products to control phosphorus.”
D. “I need to increase protein to build muscle strength.”
CORRECT ANSWER: C. “I will limit my intake of dairy products to control
phosphorus.”
Rationale: In CKD, phosphorus is restricted to prevent hyperphosphatemia and
bone disease. Dairy products are high in phosphorus. Bananas/oranges are high
potassium – should be limited. Salt substitutes contain potassium chloride,
dangerous in CKD. Protein is typically restricted, not increased, in later-stage
CKD.
Question 6
A client with cirrhosis develops asterisks and lethargy. Which laboratory finding is
most consistent with hepatic encephalopathy?
A. Elevated serum albumin
B. Decreased ammonia level
C. Elevated ammonia level
D. Increased platelet count
CORRECT ANSWER: C. Elevated ammonia level
Rationale: Hepatic encephalopathy is associated with elevated ammonia due to
the liver’s inability to convert ammonia to urea. Asterisks (liver flap) and
lethargy are clinical signs. Serum albumin is low in cirrhosis. Ammonia is
increased, not decreased. Platelets are decreased due to splenomegaly.
