NSG 4100- Adult Health III Assessment 1- 8 Review
Questions with Complete Solutions
Content
Renal
Endocrine/metabolic
Cardiac perfusion
Neurological emergencies
Q1: A patient with end-stage renal disease has elevated potassium. What is the
priority intervention?
Answer: Administer IV insulin with glucose.
Rationale: Insulin drives potassium into cells, lowering serum levels quickly. Glucose
prevents hypoglycemia. Dialysis is definitive but not immediate.
Q2: Which lab finding indicates worsening renal function?
Answer: Rising serum creatinine.
Rationale: Creatinine is the most reliable indicator of renal function decline compared
to BUN, which can be influenced by hydration.
Q3: A patient with diabetic ketoacidosis (DKA) presents with Kussmaul respirations.
What is the underlying cause?
Answer: Metabolic acidosis.
Rationale: Deep, rapid breathing is the body’s compensatory mechanism to blow off
CO₂ and correct acidosis.
Q4: Which finding requires immediate intervention in a patient with SIADH?
Answer: Serum sodium of 118 mEq/L.
Rationale: Severe hyponatremia can cause seizures and cerebral edema; hypertonic
saline may be indicated.
Q5: A patient with an arterial line develops sudden restlessness and hypotension. What
should the nurse suspect?
,Answer: Air embolism.
Rationale: Restlessness and hypotension are early signs; immediate action is to place
the patient in Trendelenburg and notify provider.
Q6: Which ECG change is most concerning in acute myocardial infarction?
Answer: ST-segment elevation.
Rationale: Indicates ongoing injury to myocardium; requires rapid reperfusion therapy
(PCI or thrombolytics).
Q7: A patient with a traumatic brain injury has unequal pupils. What is the priority
action?
Answer: Notify provider immediately.
Rationale: Unequal pupils suggest increased intracranial pressure or herniation—life-
threatening emergency.
Q8: Which intervention is most appropriate for a patient with spinal cord injury at T4
experiencing autonomic dysreflexia?
Answer: Sit the patient upright and check for bladder distention.
Rationale: Elevating head reduces blood pressure; bladder distention is a common
trigger.
Q9. A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. He becomes
increasingly drowsy. What is the priority action?
Answer: Lower oxygen flow rate.
Rationale: High oxygen can suppress hypoxic drive, leading to CO₂ retention and
narcosis. Oxygen must be titrated carefully.
Q10. Which finding indicates effective teaching for a patient with asthma using a
metered-dose inhaler?
Answer: Patient waits one minute between puffs.
Rationale: This allows proper absorption and improves the effectiveness of the second
dose.
Q11. A patient with sickle cell crisis reports severe pain. What is the most appropriate
nursing intervention?
, Answer: Administer prescribed opioid analgesics.
Rationale: Pain is due to vaso-occlusion; opioids are necessary. Hydration and oxygen
are supportive but not immediate relief.
Q12. Which lab result requires immediate intervention in a patient receiving
chemotherapy?
Answer: Absolute neutrophil count (ANC) of 400.
Rationale: Severe neutropenia places the patient at high infection risk; protective
isolation and infection prevention are critical.
Q13. A patient with Guillain-Barré syndrome develops shallow respirations and weak
cough. What is the priority action?
Answer: Prepare for intubation.
Rationale: Progressive paralysis can impair respiratory muscles; airway protection is
essential.
Q14. Which finding suggests increased intracranial pressure (ICP)?
Answer: Cushing’s triad (bradycardia, hypertension, irregular respirations).
Rationale: This is a classic late sign of ICP requiring urgent intervention.
Q15. A patient with heart failure reports sudden weight gain of 5 pounds in 2 days. What
should the nurse do?
Answer: Notify provider immediately.
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
Q16. A patient with pneumonia suddenly develops pleuritic chest pain and absent
breath sounds on one side. What is the priority action?
Answer: Suspect pneumothorax and notify provider.
Rationale: Sudden unilateral absent breath sounds indicate lung collapse requiring
urgent intervention.
Q17. Which ABG result indicates respiratory acidosis?
Answer: pH 7.30, PaCO₂ 55 mmHg.
Questions with Complete Solutions
Content
Renal
Endocrine/metabolic
Cardiac perfusion
Neurological emergencies
Q1: A patient with end-stage renal disease has elevated potassium. What is the
priority intervention?
Answer: Administer IV insulin with glucose.
Rationale: Insulin drives potassium into cells, lowering serum levels quickly. Glucose
prevents hypoglycemia. Dialysis is definitive but not immediate.
Q2: Which lab finding indicates worsening renal function?
Answer: Rising serum creatinine.
Rationale: Creatinine is the most reliable indicator of renal function decline compared
to BUN, which can be influenced by hydration.
Q3: A patient with diabetic ketoacidosis (DKA) presents with Kussmaul respirations.
What is the underlying cause?
Answer: Metabolic acidosis.
Rationale: Deep, rapid breathing is the body’s compensatory mechanism to blow off
CO₂ and correct acidosis.
Q4: Which finding requires immediate intervention in a patient with SIADH?
Answer: Serum sodium of 118 mEq/L.
Rationale: Severe hyponatremia can cause seizures and cerebral edema; hypertonic
saline may be indicated.
Q5: A patient with an arterial line develops sudden restlessness and hypotension. What
should the nurse suspect?
,Answer: Air embolism.
Rationale: Restlessness and hypotension are early signs; immediate action is to place
the patient in Trendelenburg and notify provider.
Q6: Which ECG change is most concerning in acute myocardial infarction?
Answer: ST-segment elevation.
Rationale: Indicates ongoing injury to myocardium; requires rapid reperfusion therapy
(PCI or thrombolytics).
Q7: A patient with a traumatic brain injury has unequal pupils. What is the priority
action?
Answer: Notify provider immediately.
Rationale: Unequal pupils suggest increased intracranial pressure or herniation—life-
threatening emergency.
Q8: Which intervention is most appropriate for a patient with spinal cord injury at T4
experiencing autonomic dysreflexia?
Answer: Sit the patient upright and check for bladder distention.
Rationale: Elevating head reduces blood pressure; bladder distention is a common
trigger.
Q9. A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. He becomes
increasingly drowsy. What is the priority action?
Answer: Lower oxygen flow rate.
Rationale: High oxygen can suppress hypoxic drive, leading to CO₂ retention and
narcosis. Oxygen must be titrated carefully.
Q10. Which finding indicates effective teaching for a patient with asthma using a
metered-dose inhaler?
Answer: Patient waits one minute between puffs.
Rationale: This allows proper absorption and improves the effectiveness of the second
dose.
Q11. A patient with sickle cell crisis reports severe pain. What is the most appropriate
nursing intervention?
, Answer: Administer prescribed opioid analgesics.
Rationale: Pain is due to vaso-occlusion; opioids are necessary. Hydration and oxygen
are supportive but not immediate relief.
Q12. Which lab result requires immediate intervention in a patient receiving
chemotherapy?
Answer: Absolute neutrophil count (ANC) of 400.
Rationale: Severe neutropenia places the patient at high infection risk; protective
isolation and infection prevention are critical.
Q13. A patient with Guillain-Barré syndrome develops shallow respirations and weak
cough. What is the priority action?
Answer: Prepare for intubation.
Rationale: Progressive paralysis can impair respiratory muscles; airway protection is
essential.
Q14. Which finding suggests increased intracranial pressure (ICP)?
Answer: Cushing’s triad (bradycardia, hypertension, irregular respirations).
Rationale: This is a classic late sign of ICP requiring urgent intervention.
Q15. A patient with heart failure reports sudden weight gain of 5 pounds in 2 days. What
should the nurse do?
Answer: Notify provider immediately.
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
Q16. A patient with pneumonia suddenly develops pleuritic chest pain and absent
breath sounds on one side. What is the priority action?
Answer: Suspect pneumothorax and notify provider.
Rationale: Sudden unilateral absent breath sounds indicate lung collapse requiring
urgent intervention.
Q17. Which ABG result indicates respiratory acidosis?
Answer: pH 7.30, PaCO₂ 55 mmHg.
