NUR 265 Exam 3 Medical-Surgical Nursing
(2026/2027) PDF | Nursing | Galen College
1. A patient with chronic heart failure has jugular venous
distention, 3+ pitting edema in the lower extremities, and
an S3 heart sound. Which nursing diagnosis is the priority?
A) Activity Intolerance
B) Excess Fluid Volume
C) Risk for Impaired Skin Integrity
D) Anxiety
Correct Answer: B
Rationale: JVD, edema, and S3 indicate fluid volume
overload, which can lead to pulmonary edema. Excess
fluid volume is the priority over activity intolerance, skin
integrity, or anxiety.
2. A nurse is administering digoxin to a patient with heart
failure. Which finding requires immediate action?
A) Apical pulse of 58 beats/min
1
,B) Serum potassium level of 3.2 mEq/L
C) Nausea and yellow halos around lights
D) Blood pressure 110/70 mm Hg
Correct Answer: C
Rationale: Nausea and yellow halos (xanthopsia) are
classic signs of digoxin toxicity, which can cause life-
threatening dysrhythmias. Hypokalemia increases risk but
the presence of symptoms is more urgent.
3. A patient with COPD has an SpO₂ of 88% on 2
L/min oxygen via nasal cannula. Which action should the
nurse take first?
A) Increase oxygen to 4 L/min
B) Auscultate lung sounds
C) Encourage deep breathing and coughing
D) Document the finding as expected
Correct Answer: B
Rationale: Target SpO₂ for COPD is 88–92%, so this
2
,value is acceptable. The nurse should first complete a
respiratory assessment before making changes. Increasing
oxygen blindly could cause hypoventilation in CO₂
retainers.
4. A patient with COPD is being discharged. Which
statement by the patient indicates a need for further
teaching?
A) “I will use my bronchodilator before my steroid inhaler.”
B) “I should rest before meals to conserve energy.”
C) “I will limit fluids to avoid fluid buildup in my lungs.”
D) “I will report increased green sputum to my doctor.”
Correct Answer: C
Rationale: COPD patients need adequate hydration (2–3
L/day) to thin mucus. Fluid restriction is not indicated and
could worsen secretion retention. The other statements are
correct.
3
, 5. A patient with acute kidney injury (AKI) in the oliguric
phase has a serum potassium of 6.8 mEq/L. Which
intervention is priority?
A) Administer IV calcium gluconate
B) Give sodium polystyrene sulfonate (Kayexalate)
C) Prepare for emergent hemodialysis
D) Restrict dietary potassium
Correct Answer: A
Rationale: Severe hyperkalemia (>6.5) requires
immediate IV calcium to stabilize cardiac membranes.
Kayexalate works slowly, hemodialysis requires setup
time, and dietary restriction is not emergent.
6. Which patient is most at risk for developing prerenal
AKI?
A) Patient with bladder outlet obstruction from BPH
B) Patient receiving IV vancomycin
4
(2026/2027) PDF | Nursing | Galen College
1. A patient with chronic heart failure has jugular venous
distention, 3+ pitting edema in the lower extremities, and
an S3 heart sound. Which nursing diagnosis is the priority?
A) Activity Intolerance
B) Excess Fluid Volume
C) Risk for Impaired Skin Integrity
D) Anxiety
Correct Answer: B
Rationale: JVD, edema, and S3 indicate fluid volume
overload, which can lead to pulmonary edema. Excess
fluid volume is the priority over activity intolerance, skin
integrity, or anxiety.
2. A nurse is administering digoxin to a patient with heart
failure. Which finding requires immediate action?
A) Apical pulse of 58 beats/min
1
,B) Serum potassium level of 3.2 mEq/L
C) Nausea and yellow halos around lights
D) Blood pressure 110/70 mm Hg
Correct Answer: C
Rationale: Nausea and yellow halos (xanthopsia) are
classic signs of digoxin toxicity, which can cause life-
threatening dysrhythmias. Hypokalemia increases risk but
the presence of symptoms is more urgent.
3. A patient with COPD has an SpO₂ of 88% on 2
L/min oxygen via nasal cannula. Which action should the
nurse take first?
A) Increase oxygen to 4 L/min
B) Auscultate lung sounds
C) Encourage deep breathing and coughing
D) Document the finding as expected
Correct Answer: B
Rationale: Target SpO₂ for COPD is 88–92%, so this
2
,value is acceptable. The nurse should first complete a
respiratory assessment before making changes. Increasing
oxygen blindly could cause hypoventilation in CO₂
retainers.
4. A patient with COPD is being discharged. Which
statement by the patient indicates a need for further
teaching?
A) “I will use my bronchodilator before my steroid inhaler.”
B) “I should rest before meals to conserve energy.”
C) “I will limit fluids to avoid fluid buildup in my lungs.”
D) “I will report increased green sputum to my doctor.”
Correct Answer: C
Rationale: COPD patients need adequate hydration (2–3
L/day) to thin mucus. Fluid restriction is not indicated and
could worsen secretion retention. The other statements are
correct.
3
, 5. A patient with acute kidney injury (AKI) in the oliguric
phase has a serum potassium of 6.8 mEq/L. Which
intervention is priority?
A) Administer IV calcium gluconate
B) Give sodium polystyrene sulfonate (Kayexalate)
C) Prepare for emergent hemodialysis
D) Restrict dietary potassium
Correct Answer: A
Rationale: Severe hyperkalemia (>6.5) requires
immediate IV calcium to stabilize cardiac membranes.
Kayexalate works slowly, hemodialysis requires setup
time, and dietary restriction is not emergent.
6. Which patient is most at risk for developing prerenal
AKI?
A) Patient with bladder outlet obstruction from BPH
B) Patient receiving IV vancomycin
4
