Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm

Question 5

Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm. The nurse is caring for a patient who is intubated and on mechanical ventilation with a PEEP of 10 cm H₂O. Which finding suggests the patient is developing a complication that needs immediate intervention?

• Respiratory rate of 20 breaths per minute
• PaO₂ of 85
• Blood pressure of 75/40
• PaCO₂ of 40

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Question 6

A patient is ordered to start an IV Dopamine drip at 5 mcg/kg/min. The patient weighs 57 kg. You have a bag of Dopamine that reads 400mg/250 mL. Calculate the rate in mL/hr.

• 12 mL/hr
• 10.7 mL/hr
• 0.2 mL/hr
• 20.5 mL/hr

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Question 7

The nurse is assessing a client with shortness of breath and sudden chest pain. Which characteristic suggests the chest pain is likely respiratory rather than cardiac?

• Pain radiates to the left arm and jaw
• Pain worsens with deep breathing or coughing
• Pain is unaffected by position changes
• Pain is relieved by rest or nitroglycerin

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Question 8

A nurse is assisting in the resuscitation of a patient experiencing cardiac arrest. Waveform capnography is being used to monitor the patient’s status. Which of the following best describes the primary purpose of waveform capnography during cardiac arrest?

• To continuously monitor oxygen saturation in the blood Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm
• To assess respiratory rate and acidosis imbalance
• To measure blood pressure and cardiac output in real-time
• To assess end-tidal carbon dioxide for feedback on ventilation and circulation

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Question 9

The client has just returned from coronary artery bypass graft (CABG) surgery. The nurse must monitor for complications that can occur immediately after surgery. Which nursing assessment is the highest priority to ensure the patient’s heart is pumping enough blood to the body?

• Monitoring tidal volume and PEEP
• Assessing blood pressure and peripheral perfusion
• Teaching the patient chest splinting with coughing
• Assessing core body temperature

Question 10

A nurse is caring for a client in the emergency department who reports dizziness, weakness, and lightheadedness. The nurse places the client on a cardiac monitor and observes the following rhythm. The client’s heart rate is 42 beats per minute, blood pressure is 88/54 mm Hg, and they have cool, clammy skin. Which of the following is the nurse’s priority action?

• Administer atropine per provider order
• Monitor the client’s vital signs every 15 minutes
• Position the client flat with legs elevated
• Apply oxygen at 2 L/min via nasal cannula

Question 11

A client with an acute myocardial infarction has received three nitroglycerin tablets, supplemental oxygen via nasal cannula, and aspirin but is still reporting severe crushing chest pain with a rating of 8/10. What is the nurse’s priority?

• Administer ordered intravenous morphine.
• Administer ordered intravenous nonsteroidal anti-inflammatory.
• Administer ordered intravenous benzodiazepine.
• Use anxiety reduction measures.

Question 12

A nurse is caring for a patient in the intensive care unit with acute respiratory distress syndrome (ARDS) who has been placed in the prone position. The patient’s family asks why the patient needs to be positioned on their stomach. What is the nurse’s best response?

• “Prone positioning helps prevent the patient from choking.”
• “Prone positioning increases oxygen levels by allowing the patient to breathe more deeply.”
• “Prone positioning redistributes blood flow to healthier lung tissue, which improves oxygenation.”
• “Prone positioning prevents the patient from coughing too much.”

Question 13

A client is admitted to the hospital with a diagnosis of acute pericarditis. Which assessment finding should the nurse expect in this client?

• Chest pain that worsens when lying flat
• Diminished breath sounds in the lower lobes
• Pitting edema in the lower extremities
• Cyanosis and clubbing of the fingers

Question 14

A client has been admitted with hypertensive crisis and is experiencing headache, visual disturbances, confusion, nausea, and oliguria. The client has been started on an intravenous vasodilator to lower the blood pressure. What is the priority nursing assessment?

• Assess the client’s level of consciousness every 5 minutes
• Continuous blood pressure monitoring by arterial catheter
• Evaluate the effectiveness of pain management
• Assess the abdomen for distention and increased nausea

Question 15

The nurse is preparing to transfer a client who has recovered from a myocardial infarction to cardiac rehabilitation. When questioned by the client why this is necessary, what is the best response from the nurse?

• This program has been ordered by the health care provider and is required.
• Participation has been shown to decrease the risk of subsequent coronary events.
• The program includes mandatory exercise and risk-reduction counseling.
• Participation will improve quality of life, but is unlikely to affect emotional stability.

Question 16

The nurse is assessing a client in the emergency department with a history of rheumatic heart disease who presents with fever and malaise. During the assessment, the nurse notes the presence of small, reddish-brown streaks under the client’s fingernails. What do these findings indicate?

• The client may have nail trauma from frequent manicures.
• The client has normal findings related to poor nail hygiene.
• The client is exhibiting petechiae due to clotting abnormalities.
• The client has splinter hemorrhages, which are a sign of infective endocarditis.

Question 17

The nurse is caring for a patient receiving IV 0.9% NS at 80 mL/hr. The 1000mL bag was hung at 1400. When will the next bag need to be hung?

• 12:30 (0030) (Note: Calculation 1000 mL / 80 mL/hr = 12.5 hours. 1400 + 12 hours 30 minutes = 0230. Based on the options provided, 0230 is the correct duration).
• 2200
• 0030
• 0230

Question 18

A client with anginal chest pain is given a low-dose chewable aspirin tablet. In explaining the rationale for this medication to the client and family, what information does the nurse include?

• Aspirin will help control the pain.
• Reduction of low-grade fever is important.
• Antiplatelet effects will reduce clot formation.
• Aspirin is less toxic to the liver than acetaminophen.

Question 19

The nurse is educating a client newly diagnosed with heart failure about appropriate types of exercise. Which type of exercise chosen by the client indicates a correct understanding of the nurse’s teaching?

• Weightlifting to build muscle strength
• Running on a treadmill for 45 minutes daily
• High-intensity interval training (HIIT) to improve cardiovascular fitness
• Walking at a moderate pace for 30 minutes, five times a week

Question 20

A client with lung cancer is receiving chemotherapy and has a low neutrophil count. The nurse is teaching the patient ways to prevent infections. Which statement by the patient shows that the teaching was successful?

• “I should eat fresh fruits and salads to stay healthy.”
• “I will wash my hands often, especially before eating or after using the bathroom.”
• “I’ll go to crowded places only if I wear a mask.”
• “I can take a break from my antibiotics if I feel better.”

Question 21

A nurse is educating a 32-year-old female client on risk factors for pulmonary embolism (PE). Which of the following factors places this client at increased risk for PE?

• Regular aerobic exercise
• Following a high-sodium diet
• Drinking herbal teas
• Using oral contraceptives

Question 22

The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which of the following findings should the nurse expect to assess?

• Low cardiac output and symptoms of heart failure
• Increased peripheral pulses and stable blood pressure
• Bradycardia and improved cardiac output.
• Increased urine output and decreased jugular vein distention

Question 23

A nurse is admitting a patient with drug-induced idiopathic thrombocytopenic purpura (ITP) and a platelet count of 85,000. What is the priority assessment the nurse should perform during admission?

• Evaluating the patient’s medical history for other conditions
• Obtaining a STAT CBC and administering platelets as ordered
• Place the patient in contact and droplet isolation
• Assessing for signs of bleeding and checking the patient’s medication list

Question 24

A client with a history of chronic obstructive pulmonary disease (COPD) and leukemia is admitted to the hospital with respiratory failure. In evaluating the management of this patient, which action should the nurse prioritize to reduce the risk of a hospital acquired infection (HAI)?

• administering prophylactic antibiotics to treat the HAI.
• implementing strict hand hygiene practices among the healthcare team
• ensuring proper nutritional support for the patient’s overall health
• increasing the frequency of the respiratory treatments for the underlying COPD

Question 25

A client is admitted for repair of an abdominal aortic aneurysm and begins to report severe “ripping” abdominal pain and a sense of impending doom. What assessment is a priority?

• Bilateral blood pressures
• Respiratory rate
• Auscultation of bowel sounds
• Pain scale

Question 26

A nurse is caring for a client in the emergency department with an acute asthma exacerbation. The client has received continuous albuterol treatments and IV methylprednisolone (Solu-Medrol) but still shows moderate respiratory distress. Which medication should the nurse anticipate giving next?

• Intravenous lorazepam (Ativan)
• Inhaled montelukast (Singulair)
• Intravenous magnesium sulfate
• Intravenous diphenhydramine (Benadryl)

Question 27

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

• Assist the client in placing their home nicotine patch on their right upper arm.
• Transport the client to the intensive care unit via a stretcher.
• Provide the client with discharge-teaching instructions before going home.
• Help position the client who is having a portable x-ray done.

Question 28

A 165-pound patient is started on a nitroglycerin IV drip. The order is to administer the nitroglycerin at 25 mcg/min. The pharmacy sends nitroglycerin 25 mg in 250mL. Calculate the rate in mL/hr.

• 2 mL/hr
• 15 mL/hr (Calculation: 25mg = 25,000mcg. 25,000mcg/250mL = 100mcg/mL. 25mcg/min = 0.25mL/min. 0.25mL/min * 60min = 15mL/hr)
• 1.5 mL/hr
• 4.25 mL/hr

Question 29

A nurse is assessing a client with right-sided heart failure. Which of the following findings would the nurse expect to observe?

• Crackles in the lungs and persistent cough
• Orthopnea and decreased oxygen saturation
• Peripheral edema and jugular vein distension
• Bradycardia and hypotension

Question 30

The nurse is caring for a client who is orally intubated and on a mechanical ventilator. Which behavior is the best indicator that the client is experiencing pain and discomfort?

• Restlessness and increased respiratory rate
• Consistent eye contact with the nurse
• Decreased respiratory rate
• Glasgow Coma Scale (GCS) of 3 Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm

Question 31

A patient is receiving oxygen via a low-flow device. Which nursing interventions are appropriate? Select all that apply.

• 1) Assess the patient’s skin and nasal passages for signs of breakdown
• 2) Ensure the oxygen device fits properly to deliver the correct FiO₂
• 3) Monitor the patient’s oxygen saturation and overall respiratory status
• 4) Use humidification for oxygen flow rates of 4 L/min or higher
  5. Increase the FiO₂ to the highest level possible to prevent hypoxia
• 6) Monitor for signs of oxygen toxicity, such as coughing or chest discomfort

Question 32

The nurse is assessing a client 45 minutes into a packed red blood cell (PRBC) transfusion. A patient reports chills and back pain. The patient’s temperature is 39°C (102.2°F) and blood pressure is 70/42 mmHg. Which type of transfusion reaction is the nurse most likely suspecting?

• 1) Hemolytic transfusion reaction
• Allergic reaction
• Transfusion related acute lung injury (TRALI)
• Transfusion associated circulatory overload (TACO)

Question 33

A nurse is providing education to a patient recently diagnosed with asthma. Which of the following statements made by the patient indicates a correct understanding of asthma management?

• “I will stop taking my medications as soon as I feel better.”
• “I can use my rescue inhaler only when I have a severe asthma attack.”
• “I should avoid my asthma triggers, like smoke and allergens.”
• “It’s fine to exercise outdoors even when the air quality is poor.”

Question 34

A nurse is assessing a client with asthma who is experiencing increased airway resistance. Which assessment finding best indicates this condition?

• Increased oxygen saturation with supplemental oxygen
• 2) Prolonged expiratory phase with audible wheezing
• Use of accessory muscles with a respiratory rate of 12 breaths per minute
• Elevated arterial oxygen and bicarbonate levels on an arterial blood gas (ABG)

Question 35

The nurse has completed an assessment on a client with heart failure. Which findings should receive the highest priority?

• Blood pressure 118/62 mm Hg, atrial fibrillation with heart rate 88, bilateral lung crackles
• 2) Confusion, urine output 15 mL over the last 2 hours, orthopnea
• SpO2 92% on 2L nasal cannula, respirations 20, 1+ edema of lower extremities
• Weight gain of 1 kg in 3 days, temperature 37 degrees celsius (98.6F), mild dyspnea with exercise

Question 36

A client who is 5 days post coronary artery bypass surgery has developed tachycardia, a low-grade fever, and an elevated total white blood cell (WBC) count. What additional sign or symptom would support the nurse’s suspicion of a postoperative infection?

• 1) Purulent drainage from the chest incision
• Chest incision edges are pink and swollen.
• Elevated red blood cells and platelets
• Severe incisional pain with cough

Question 37

You are to give a 600 mL bolus of 0.9% NS over 2 hours. The IV tubing gtt factor is 12 gtt/mL. Calculate the rate in mL/hr.

• 50 mL/hr
• 80 mL/hr
  3. 300 mL/hr
• 4) 150 mL/hr (Calculation: 600mL / 2 hours = 300 mL/hr. Note: The question asks for rate in mL/hr, not gtt/min)

Question 38

A nurse is caring for a client diagnosed with iron deficiency anemia. During the assessment, the nurse notes the client is fatigued, has pale skin, and reports experiencing dizziness upon standing. Which intervention should the nurse prioritize to promote the client’s recovery?

• Educate the client about potassium-rich dietary sources.
• Schedule a follow-up appointment for blood work in one month.
• 3) Administer prescribed iron supplements as ordered.
• Recommend increasing fluid intake to prevent dehydration.

Question 39

A nurse caring for a patient with a hemoglobin of 5.4 g/dL from a lower GI bleed is preparing to hang a unit of blood. Which actions by the nurse demonstrate blood administration safety? Select all that apply.

• 1) Hanging the blood product only with normal saline
• 2) Taking a full set of vitals within 15 minutes prior to beginning blood
• 3) Staying with the patient for the first 15 to 30 minutes
• 4) Using gloves to handle the blood product
  5. Transfusing the blood product within 5 hours
  6. Using previous blood tubing from 8 hours ago

Question 40

A nurse is assessing a client with a pulmonary embolism (PE) who has developed cor pulmonale. What findings should the nurse expect? Select all that apply.

• 1) Jugular vein distention
• 2) Peripheral edema
  3. Barrel-shaped chest
• 4) Shortness of breath
• 5) Hepatomegaly (ascites)
  6. Bradycardia

Question 41

The nurse is caring for a patient with aspiration pneumonia who is receiving oxygen via a 100% non-rebreather mask. Which finding would most indicate the development of acute respiratory distress syndrome (ARDS)?

• 1) Increased respiratory effort and low oxygen levels despite high oxygen therapy
• Fever and productive cough with green sputum
• Clear breath sounds and normal respiratory rate
• Chest pain that worsens with deep breathing

Question 42

The nurse is teaching a client with heart failure how to prevent complications associated with this disease. What statement by the client demonstrates understanding of the teaching?

• “I should note how many times I eat each day.”
• 2) “I should weigh myself every day at the same time.”
• “I should skip doses of my diuretic if I have plans for that day.”
• “I should lift weights and do 30 minutes of cardio exercise every day.”

Question 43

The nurse is preparing a client with thrombocytopenia for discharge. Which statements by the client about measures to minimize injury indicate that discharge teaching was effective? Select all that apply.

• 1) “I may continue to use an electric shaver.”
• 2) “I will not blow my nose strongly if I get a cold.”
  3. “I should use an enema instead of laxatives for constipation.”
  4. “I will play football with my friends this weekend.”
• 5) “I should use a soft-bristled toothbrush to avoid mouth trauma.”
  6. “If I cut myself, the bleeding will slow on its own.”

Question 44

A client with an artificial airway is unable to speak. Which communication methods should the nurse use to help the client communicate effectively? Select all that apply.

• 1) Provide a communication board with pictures and phrases.
• 2) Teach the patient to use a speaking valve.
• 3) Encourage the client to write messages on a notepad.
  4. Speak loudly and clearly to help the client understand.
• 5) Provide a tablet or device with a text-to-speech function.
• 6) Ask the client to mouth words while reading their lips.

Question 45

The nurse is providing discharge teaching to a client diagnosed with infective endocarditis. Which statement by the client indicates an understanding of how to prevent complications?

• “I should stop taking my antibiotics as soon as I start feeling better.”
• 2) “I need to take antibiotics before my dental appointments.”
• “I can resume lifting heavy weights as long as my energy returns.”
• “It’s not necessary to follow up with my cardiologist unless I have symptoms.”

Question 46

The nurse is caring for a client who underwent a coronary artery bypass graft (CABG), and is providing discharge teaching. What statement by the client indicates a need for further teaching?

• “I will avoid lifting heavy objects greater than 10-15 lbs for the first 3 months.”
• 2) “I will be able to drive home upon discharge from the hospital.”
• “I will report any palpitations or irregular heart beats to my physician immediately.”
• “I will seek care if I have dizziness, increased fatigue, shortness of breath, or chest pain.”

Question 47

A client recovering from cardiopulmonary bypass surgery presents to the intensive care unit (ICU) with shivering. Why should the nurse be concerned about shivering in a postoperative cardiac client?

• Shivering is a sign of cardiogenic shock.
• Shivering can indicate inadequate pain management.
• 3) Shivering increases myocardial workload and oxygen consumption.
• Shivering is a normal response to anesthesia.

Question 48

A client is being treated for hypertrophic cardiomyopathy (HCM). During discharge teaching, what is the most important information to include?

• Engage in strenuous daily exercise to improve cardiac function.
• Only a heart transplant is associated with increased longevity.
• 3) Make an appointment for genetic screening and counseling. Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm
• A high sodium diet is recommended to maintain blood pressure

Question 49

A client with a tracheostomy and pneumonia has hypoxemia and impaired gas exchange due to a mucus plug obstructing the lower trachea. What is the nurse’s priority action?

• Administer supplemental oxygen to the client.
• Suction the tracheostomy to remove the mucus plug. ✓
• Increase the client’s fluid intake to thin secretions.
• Assess the client’s vital signs and respiratory status.

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Question 50

A client in Stage 1 of acute respiratory distress syndrome (ARDS) is being transferred from the medical-surgical unit to the ICU. Which symptoms would the nurse expect to see in this stage of ARDS?

• Dyspnea, restlessness, and normal chest x-ray ✓
• Severe hypoxemia and pulmonary edema on chest x-ray
• Decreased urine output and hypotension
• Severe respiratory acidosis and cyanosis

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Question 51

The nurse is administering an intravenous beta-blocker to a client who presented in a severe hypertensive crisis with a blood pressure of 210/94 mmHg. Which is a nursing priority in this case?

• Administer aspirin to prevent impending myocardial infarction.
• Encourage fluid intake to reduce the risk of kidney failure.
• Reduce the mean arterial pressure by no more than 25% over 1 hour. ✓
• Monitor the patient’s blood glucose for hypoglycemia.

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Question 52

A nurse is caring for a client scheduled for a cardiac catheterization to assess coronary artery function. Which of the following is the highest priority nursing intervention before the procedure?

• Instruct the client to avoid eating or drinking for at least 2 hours before the procedure
• Assess for allergies to iodine or shellfish ✓
• Provide reassurance about minimal discomfort during the procedure
• Teach the client to expect mild discomfort at the IV insertion site

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Question 53

The client is receiving metoprolol for hypertension. What is the most significant effect on cardiac function that the nurse will monitor?

• Decreased cardiac output ✓
• Supraventricular tachycardia
• Increased stroke volume
• Increased blood pressure

Question 54

A client in the CCU has an abdominal aortic aneurysm that is 7 cm in diameter. The nurse recognizes the most appropriate treatment for this client.

• Anticoagulant therapy
• Heart transplant
• Genetic screening and counseling
• Surgical repair

Question 55

A young college athlete is admitted to the intensive care unit (ICU) following an echocardiogram due to recurrent complaints of dyspnea on exertion, particularly after team workouts. The nurse identifies a risk of sudden death in this client due to which condition?

• Pulmonary embolism
• Hypertrophic cardiomyopathy
• Chronic obstructive pulmonary disease
• Coronary artery disease

Question 56

A nurse is caring for a patient diagnosed with acute respiratory failure. The patient exhibits signs of hypoxemia, including confusion, restlessness, and a pulse oximetry of 85% on room air. Which of the following interventions should the nurse prioritize to improve the patient’s respiratory status?

• Administer oral antibiotics as prescribed
• Encourage the patient to cough and deep breathe
• Place the patient in a high-Fowler’s position
• Initiate a continuous nebulizer treatment with saline

Question 57

A nurse is caring for a client who has developed cardiac tamponade following cardiac surgery. The client presents with hypotension, muffled heart sounds, and distended neck veins. Which priority intervention should the nurse implement to manage this condition?

• Administer intravenous fluids to increase blood volume.
• Monitor the client’s vital signs every 15 minutes.
• Position the client in a supine position for comfort.
• Prepare the client for immediate pericardiocentesis.

Question 58

A sedated client in the intensive care unit (ICU) on a mechanical ventilator is being turned every 2 hours. The family asks why frequent turning is needed. What is the nurse’s best response?

• “Turning prevents the client from waking up too early.”
• “Turning the client helps prevent lung infections and makes it easier for the ventilator to work.”
• “Turning reduces the risk of pressure ulcers and improves oxygenation.”
• “Turning improves comfort for the client and allows them to sleep more deeply.”

Question 59

The nurse is caring for an unconscious client with a Glasgow Coma Scale (GCS) score of 5 and no gag reflex. Before using a bag valve mask to assist with breathing, the nurse prepares to insert an oropharyngeal airway (OPA). What is the main reason for using this device?

• To prevent the client from biting down on a nasogastric tube
• To assist with suctioning secretions from the client’s airway
• To deliver a higher concentration of oxygen directly into the lungs
• To keep the airway open by preventing the tongue from obstructing the throat

Question 60

A client with pneumonia is admitted to the medical-surgical unit. The unlicensed assistive personnel (UAP) reports the client’s vital signs as: temperature of 38.6 degrees celsius (101.5F), respiratory rate of 22, oxygen saturation of 94% on room air, and heart rate of 98 beats per minute. Morning laboratory results show the client’s white blood cell count is 16,500/mm3. Based on this clinical data, which nursing action should the nurse prioritize?

• Administer prescribed antipyretics to reduce fever and heart rate.
• Notify the healthcare provider about the client meeting systemic inflammatory response syndrome (SIRS) criteria.
• Place the client on continuous cardiac and oxygen saturation monitoring.
• Encourage the client to increase fluid intake to prevent dehydration.

Question 61

A nurse is caring for a client with hypoxemia and suspects a ventilation/perfusion (V/Q) mismatch. Which conditions could cause a V/Q mismatch in this client? Select all that apply.

• Pulmonary embolism
• Chronic obstructive pulmonary disease (COPD)
• Atelectasis
• Severe anemia
• Pulmonary edema
• Pneumonia

(Note: Severe anemia reduces oxygen-carrying capacity, resulting in hemic hypoxia or low mixed venous oxygen saturation rather than a true pulmonary V/Q mismatch.)

Question 62

The nurse is assessing an 80-year-old patient with congestive heart failure with a reduced ejection fraction (HFrEF) of 25% and auscultates an S3 heart sound. What would this heart sound suggest?

• Renal artery stenosis
• A faulty stethoscope
• Hypotension
• Fluid overload

Question 63 (2 points)

A client has been admitted to the intensive care unit (ICU) in severe distress with acute respiratory failure. Initial arterial blood gasses are pH 7.28; {PaCO}_2, 68; {HCO}_3$, 30; PaO}_2$, 42. Vital signs are: respiratory rate of 28 breaths/min, heart rate of 111 beats/min, and SpO2 of 83% on 100% non-rebreather mask. What is the priority nursing action?

• Administer oxygen via simple face mask
• Prepare for intubation.
• Obtain arterial blood gases.
• Measure functional expiratory volume.

Question 64 (2 points)

A client has been prescribed tenecteplase (TNKase) thrombolytic therapy for the treatment of a large burden of bilateral pulmonary embolism (PE). Which of the following nursing interventions is most important to ensure the safety and effectiveness of this therapy?

• Assess the patient for signs of bleeding and neurological changes.
• Monitor the patient’s blood pressure and heart rate every hour.
• Educate the patient about the benefits of thrombolytic therapy.
• Administer prescribed anticoagulants immediately after thrombolytic therapy.

Question 65 (2 points)

The nurse receives an order to infuse dobutamine at 15 mL/hr. Pharmacy sends a bag of 500 mL of D5W with 500 mg of dobutamine mixed in. Calculate the mg/hr.

• 15 mg/hr.
• 30 mg/hr.
• 7.5 mg/hr.
• 3 mg/hr.

Question 66 (2 points)

The nurse is assessing a client admitted with acute decompensated heart failure (ADHF). What clinical finding should the nurse prioritize and report immediately to the healthcare provider?

• Jugular vein distention and dependent edema
• Productive cough with frothy, pink-tinged sputum
• Weight gain of 2 pounds in the past week
• Shortness of breath when climbing stairs

Question 67 (2 points)

A client who has undergone coronary artery bypass graft (CABG) surgery is at risk for significant fluid volume shifts and losses. Which nursing assessment finding would be most indicative of fluid volume deficit?

• Increased central venous pressure (CVP)
• Jugular vein distention (JVD)
• Decreased urine output
• Diminished core body temperature

Question 68 (2 points)

A patient weighing 120 pounds has an order to receive 6 mcg/kg/minute of Nipride. The solution available is 50 mg Nipride in 250 mL of D5W. Calculate the mL/minute. Round to the nearest tenth.

• 1.6 mL/minute
• 27 mL/minute
• 16 mL/minute
• 160 mL/minute

Question 69 (2 points)

A nurse is performing an admission assessment on a patient with a history of hypertension. The client’s blood pressure is 192/110 mm Hg, complains of blurred vision and a headache of 10/10. The nurse notifies the provider. Which of the following findings should the nurse include when notifying the provider? Select all that apply.

• Severe headache rated a 10/10 Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm
• Recent urine culture results
• Blood pressure 192/110 mm Hg
• Blurred vision
• Activities of daily living
• Percentage of meals eaten

Question 70 (2 points)

A nurse is caring for a patient who is ordered to have dobutamine 5 mcg/kg/min. The patient weighs 220 lbs. The solution available is 1 gm dobutamine in 250 mL of D5W. Calculate the rate in mL/hr.

• 7.5 mL/hour
• 5 mL/hour
• 75 mL/hour
• 5.5 mL/hr

Question 71 (2 points)

A nurse is reviewing the electrocardiogram (EKG) of a patient with hypocalcemia. Which EKG change is most commonly associated with hypocalcemia?

• Peaked T waves
• Prolonged QT interval
• Shortened QT interval
• Wide QRS complex

Question 72 (2 points)

A nurse in the coronary care unit (CCU) is creating a teaching plan for clients with heart failure. What key points should be included in the teaching plan? Select all that apply.

• Weigh yourself every day and report a weight gain of more than 2-3 pounds in 24 hours to your healthcare provider.
• Limit fluid intake to help reduce the workload on your heart, following your healthcare provider’s recommendations.
• Follow a diet high in sodium to maintain proper blood pressure levels.
• Exercise vigorously for at least 60 minutes every day to strengthen the heart muscle.
• Take medications as prescribed and understand the purpose of each medication.
• Monitor for symptoms like increased shortness of breath, swelling in the feet or legs, and fatigue, and report them promptly.

Question 73 (2 points)

A client reports that the coughing and deep breathing the nurse is insisting the client perform is extremely painful. What intervention should the nurse perform?

• Offer a back massage after the client does the coughing and deep breathing.
• Provide pain medication before the procedure and allow time for the medication to take effect.
• Document the client’s refusal and notify the health care provider.
• Explain that coughing and deep breathing are necessary to prevent pneumonia.

Question 74 (2 points)

A nurse is caring for a patient with a pneumothorax who has a chest tube in place. To assess for subcutaneous emphysema, which technique should the nurse use?

• Percuss over the chest tube insertion site
• Inspect for visible air bubbles around the chest tube
• Palpate the skin around the chest tube for a crackling sensation
• Use a stethoscope to listen for air movement near the tube insertion site

Question 75 (2 points)

A client has been diagnosed with peripheral arterial disease (PAD). Which symptoms should the nurse expect to assess in this client? Select all that apply.

• Cool, shiny, hairless skin in the affected extremities
• Leg pain that worsens with activity and improves with rest
• Presence of varicose veins
• Weak or absent pulses in the lower extremities
• Warm, flushed skin in the affected extremities
• Edema in the lower extremities

Question 76 (2 points)

A nurse is caring for a patient with lung cancer who suddenly shows signs of distress. The assessment reveals hypotension, jugular vein distention, and muffled heart sounds. What intervention should the nurse prepare for this patient?

• Administering intravenous fluids to increase blood pressure
• Preparing for a pericardiocentesis to remove fluid from around the heart
• Giving medications to manage pain and anxiety
• Monitoring vital signs every 15 minutes

Question 77 (2 points)

A client on the medical-surgical unit has arterial blood gases (ABGs) drawn with the following results: pH 7.2, {PaCO}_265, t{HCO}_3 30, and{PaO}_2 82. How does the nurse interpret these results?

• metabolic alkalosis, uncompensated
• metabolic acidosis, fully compensated
• respiratory alkalosis, fully compensated
• respiratory acidosis, partially compensated

Question 78 (2 points)

A nurse is caring for a patient who has undergone an allogeneic hematopoietic stem cell transplant (HSCT) two months ago. The patient reports new-onset diarrhea, a large red rash on the trunk and extremities, and jaundice. What complication of HSCT is the nurse most concerned about?

• Acute liver failure
• Infection
• Acute graft versus host disease (aGVHD)
• Transplant rejection

Question 80 (2 points)

A client in the ICU is receiving arterial pressure monitoring. The ICU nurse understands the arterial catheter:

• Must be flushed every 15 minutes
• Should be clamped once per shift
• Must never be used for medication administration
• Should be saline locked when not in use

Question 81 (2 points)

An emergency department nurse is assessing a client with labored breathing who reports having numbness, tingling, and cramps in their hands and feet. The nurse observes the patient is anxious and is hyperventilating. Which of the following arterial blood gas results would indicate respiratory alkalosis fully compensated?

• pH 7.38, pCO₂ 60, HCO₃ 24
• pH 7.43, pCO₂ 28, HCO₃ 16 (Note: Full compensation brings pH back into the normal range of 7.35–7.45. Since the primary problem is respiratory alkalosis—low pCO₂—the kidney compensates by excreting HCO₃, which is decreased to 16.)
• pH 7.2, pCO₂ 45, HCO₃ 23
• pH 7.6, pCO₂ 55, HCO₃ 18

Question 82 (2 points)

A patient is to receive 500 mg of PO amoxicillin. The pharmacy sends a bottle of amoxicillin labeled 100 mg / 3 mL. Calculate mL the nurse should administer per dose.

• 15 mL

Question 83 (2 points)

The client shows the following rhythm on the telemetry monitor at the nurse’s station.

(Image shows Asystole with two occasional, extremely sparse QRS complexes / agonal beats)

The assessment reveals the client is unconscious and does not have a pulse. After calling for help, what should the nurse do next?

• Administer epinephrine IV
• Prepare to defibrillate the client.
• Administer magnesium sulfate IV
• Start cardiopulmonary resuscitation

Question 84 (2 points)

Which of the following blood tests is most indicative of cardiac muscle damage?

• Lactate dehydrogenase
• Brain-Type Natriuretic Peptide (BNP)
• Creatine kinase-MB (CK-MB)
• Troponin I

Question 85 (2 points)

During a follow-up visit, a client who had a kidney transplant two months ago shows 3+ swelling in his feet and ankles, and his blood pressure is 154/92. He reports feeling short of breath with activity and is very fatigued. Suspecting acute kidney rejection, what is the most important question for the nurse to ask the client?

• “Have you been taking your immunosuppressive medications as prescribed?”
• “Have you been following a low salt diet?”
• “Have you had an increase in urine output?” (Note: While medication adherence is important, checking for a decrease/change in urine output directly assesses active graft function and is a classic hallmark sign of acute rejection.)
• “Does anyone in your family have a history of heart failure?” Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm

Question 86 (2 points)

The nurse is caring for a client with acute decompensated heart failure (ADHF) who presents with severe dyspnea, crackles in the lungs, an SpO₂ of 88% on low flow O₂, and a blood pressure of 90/60 mm Hg. What intervention should the nurse prioritize to address the client’s immediate needs?

• Administer a prescribed vasopressor to improve blood pressure
• Place the client in a supine position to maximize cardiac output
• Prepare for a possible insertion of a pulmonary artery catheter
• Increase the oxygen flow rate to improve oxygen saturation

Question 87 (2 points)

The Registered Nurse (RN) and Licensed Practical Nurse (LPN) are working together to provide care for a client experiencing tachypnea and shortness of breath. The following nursing interventions can all be delegated to the LPN except:

• Administering prescribed metered-dose inhaler (MDI) bronchodilator
• Monitoring vital signs and reporting changes
• Performing a comprehensive respiratory assessment and patient teaching
• Assisting with oxygen therapy setup

Question 88 (2 points)

A patient is to start on PO levofloxacin 300 mg every 24 hours. The pharmacy sends levofloxacin 500 mg / 25 mL. Calculate the mL the nurse should administer for each dose.

• 2 mL
• 15 mL
• 12 mL
• 1.5 mL

Question 89 (2 points)

The nurse is caring for a client with a history of heart failure. The client has a prescription for enalapril. Which of the following is a potential adverse effect of this medication that the nurse should monitor for?

• Hyperkalemia
• Hypokalemia
• Dry cough
• Bradycardia

Question 90 (2 points)

A client is to receive heparin at 1,500 units/hour. The solution available is 25,000 units of heparin in 250 mL of D5W. Calculate the infusion rate in mL/hour.

• 15 mL/hour
• 150 mL/hour
• 10 mL/hour
• 25 mL/hour

Question 91 (2 points)

A patient with a history of COPD is admitted to the hospital with a respiratory infection. The arterial blood gas (ABG) results are pH 7.33, pCO₂ 55 mm Hg, HCO₃ 28 mEq/L, and pO₂ 62 mm Hg. How does the nurse interpret these results?

• Respiratory acidosis, partially compensated
• Metabolic acidosis, uncompensated
• Respiratory alkalosis, fully compensated
• Respiratory acidosis, fully compensated

Question 92 (2 points)

A nurse is reviewing the laboratory results of a patient diagnosed with small-cell lung cancer. Which laboratory finding would be most indicative of Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?

• Serum sodium level of 145 mEq/L
• Serum sodium level of 122 mEq/L
• Serum potassium level of 5.2 mEq/L
• Serum potassium level of 3.1 mEq/L

Question 93 (2 points)

A nurse is caring for a client who is being treated with a nitroprusside (Nipride) infusion for hypertensive crisis. Which of the following is a clinical manifestation of cyanide toxicity, a potential complication of nitroprusside therapy?

• Increased urine output
• Altered mental status
• Severe hypertension
• Hyperthermia

Question 94 (2 points)

A nurse is evaluating a patient with heart failure. Which of the following clinical findings indicates the patient is experiencing a therapeutic response to diuretic therapy?

• Increased heart rate
• Increased body weight
• Decreased edema
• Decreased urine output

Question 95 (2 points)

A nurse is assessing a patient with a history of heart failure who is receiving digoxin. The patient reports anorexia, nausea, and vomiting. What is the nurse’s priority action?

• Check the patient’s blood pressure
• Assess the patient’s digoxin level and electrolytes
• Administer the next dose of digoxin as scheduled
• Encourage the patient to eat small, frequent meals

Question 96 (2 points)

The nurse is reviewing a telemetry strip for a patient. The strip shows a regular rhythm, a heart rate of 70 beats/minute, a normal P wave preceding every QRS complex, a PR interval of 0.16 seconds, and a QRS duration of 0.08 seconds. How should the nurse interpret this EKG rhythm?

• Sinus bradycardia
• Atrial fibrillation
• Normal sinus rhythm
• First-degree atrioventricular (AV) block

Question 97 (2 points)

The nurse is reviewing the lab results of a patient admitted with acute decompensated heart failure (ADHF). Which lab result is most specific in confirming the diagnosis of heart failure?

• Serum potassium 3.2 mEq/L
• B-type natriuretic peptide (BNP) 900 pg/mL
• Troponin I 0.02 ng/mL
• Blood urea nitrogen (BUN) 25 mg/dL

Question 98 (2 points)

A patient is to receive amoxicillin 250 mg PO. The pharmacy sends amoxicillin suspension labeled 125 mg / 5 mL. Calculate the mL the nurse should administer per dose.

• 10 mL

Question 99 (2 points)

A client is admitted to the emergency department with a history of heart failure. The nurse’s assessment reveals crackles in the lungs, a productive cough with pink frothy sputum, and a respiratory rate of 32 breaths/minute. Which of the following is the priority nursing diagnosis?

• Decreased cardiac output
• Impaired gas exchange
• Excess fluid volume
• Activity intolerance

Question 100 (2 points)

A nurse is reviewing the electrocardiogram (EKG) strip of a patient and notes a regular rhythm with a rate of 110 beats/minute. Every P wave is followed by a QRS complex, and the PR interval is 0.16 seconds. How should the nurse interpret this EKG rhythm?

• Normal sinus rhythm Purdue Global NU263 Medical Surgical Nursing III Unit 5Midterm
• Atrial fibrillation
• First-degree atrioventricular (AV) block
• Sinus tachycardia