NSG 4100 -Adult Health III Assessment 5 with
Complete Solutions
Question 1
A patient with chronic obstructive pulmonary disease (COPD) is admitted with
worsening dyspnea. Which nursing intervention is the priority?
A. Encourage increased oral fluid intake
B. Position the patient in high Fowler’s
C. Provide a high-calorie meal
D. Administer a sedative for anxiety
Answer: B. Position the patient in high Fowler’s
Rationale: High Fowler’s maximizes lung expansion and improves oxygenation.
While fluids and nutrition are important, airway and breathing take priority.
Sedatives can depress respiratory drive.
Question 2
A patient with heart failure reports sudden weight gain of 3 pounds in 24 hours.
What is the nurse’s best action?
A. Document the finding and continue monitoring
B. Notify the healthcare provider immediately
C. Restrict oral fluids to 500 mL/day
D. Administer an extra dose of diuretic without an order
Answer: B. Notify the healthcare provider immediately
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
The provider must be notified to adjust treatment. Nurses cannot independently
change medication doses.
Question 3
A patient with type 2 diabetes is scheduled for surgery. The morning blood glucose
is 250 mg/dL. What is the nurse’s priority action?
A. Administer the scheduled insulin dose and proceed
B. Notify the surgeon and anticipate possible delay
C. Give the patient orange juice to lower glucose
,D. Document and continue with pre-op checklist
Answer: B. Notify the surgeon and anticipate possible delay
Rationale: Hyperglycemia increases risk of infection and poor healing. Surgery may
need to be delayed until glucose is controlled. Orange juice would worsen
hyperglycemia.
Question 4
A patient with acute kidney injury (AKI) has serum potassium of 6.2 mEq/L. Which
intervention should the nurse anticipate?
A. Administer oral potassium supplements
B. Encourage potassium-rich foods
C. Prepare to administer IV insulin with glucose
D. Restrict protein intake
Answer: C. Prepare to administer IV insulin with glucose
Rationale: Insulin drives potassium into cells, lowering serum levels quickly. High
potassium is life-threatening due to risk of arrhythmias. Supplements and
potassium-rich foods would worsen the condition.
Question 5
A patient with stroke (CVA) has right-sided weakness and difficulty swallowing.
Which intervention is most appropriate?
A. Place food on the right side of the mouth
B. Position the patient upright during meals
C. Offer thin liquids with a straw
D. Encourage rapid eating to finish meals
Answer: B. Position the patient upright during meals
Rationale: Upright positioning reduces aspiration risk. Thin liquids increase
aspiration risk, and food should be placed on the unaffected side. Eating slowly with
supervision is safer.
Question 6
A patient with pneumonia has an oxygen saturation of 88% on room air. What is
the nurse’s priority?
A. Encourage coughing and deep breathing
,B. Apply supplemental oxygen
C. Increase fluid intake
D. Notify respiratory therapy
Answer: B. Apply supplemental oxygen
Rationale: Oxygenation is the immediate priority. Coughing and fluids help long-
term, but hypoxemia must be corrected first.
Question 7
A patient with myocardial infarction reports chest pain unrelieved by nitroglycerin.
What is the next best action?
A. Encourage ambulation
B. Administer morphine as ordered
C. Provide a high-protein snack
D. Reassure the patient
Answer: B. Administer morphine as ordered
Rationale: Morphine relieves pain, decreases preload, and reduces cardiac
workload. Ambulation and snacks are inappropriate during acute chest pain.
Question 8
A patient with cirrhosis develops confusion and asterixis. Which lab value is most
concerning?
A. Sodium 140 mEq/L
B. Potassium 4.0 mEq/L
C. Ammonia 120 mcg/dL
D. Hemoglobin 13 g/dL
Answer: C. Ammonia 120 mcg/dL
Rationale: Elevated ammonia indicates hepatic encephalopathy, a serious
complication of cirrhosis.
Question 9
A patient with deep vein thrombosis (DVT) is prescribed heparin. Which finding
requires immediate action?
A. Mild bruising at injection site
, B. Hematuria
C. Slight gum bleeding
D. Nosebleed lasting 2 minutes
Answer: B. Hematuria
Rationale: Hematuria indicates internal bleeding, a serious complication of
anticoagulation therapy.
Question 10
A patient with chronic renal failure is prescribed erythropoietin. Which outcome
indicates effectiveness?
A. Decreased potassium
B. Increased hemoglobin
C. Reduced creatinine
D. Lower blood pressure
Answer: B. Increased hemoglobin
Rationale: Erythropoietin stimulates red blood cell production, improving anemia in
renal failure.
Question 11
A patient with Parkinson’s disease is at risk for aspiration. Which intervention is
most appropriate?
A. Provide thin liquids
B. Offer small, frequent meals
C. Encourage rapid eating
D. Position supine after meals
Answer: B. Offer small, frequent meals
Rationale: Smaller meals reduce fatigue and aspiration risk. Thin liquids and supine
positioning increase risk.
Question 12
A patient with hypertension is prescribed a thiazide diuretic. Which lab value should
the nurse monitor?
A. Hemoglobin
Complete Solutions
Question 1
A patient with chronic obstructive pulmonary disease (COPD) is admitted with
worsening dyspnea. Which nursing intervention is the priority?
A. Encourage increased oral fluid intake
B. Position the patient in high Fowler’s
C. Provide a high-calorie meal
D. Administer a sedative for anxiety
Answer: B. Position the patient in high Fowler’s
Rationale: High Fowler’s maximizes lung expansion and improves oxygenation.
While fluids and nutrition are important, airway and breathing take priority.
Sedatives can depress respiratory drive.
Question 2
A patient with heart failure reports sudden weight gain of 3 pounds in 24 hours.
What is the nurse’s best action?
A. Document the finding and continue monitoring
B. Notify the healthcare provider immediately
C. Restrict oral fluids to 500 mL/day
D. Administer an extra dose of diuretic without an order
Answer: B. Notify the healthcare provider immediately
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
The provider must be notified to adjust treatment. Nurses cannot independently
change medication doses.
Question 3
A patient with type 2 diabetes is scheduled for surgery. The morning blood glucose
is 250 mg/dL. What is the nurse’s priority action?
A. Administer the scheduled insulin dose and proceed
B. Notify the surgeon and anticipate possible delay
C. Give the patient orange juice to lower glucose
,D. Document and continue with pre-op checklist
Answer: B. Notify the surgeon and anticipate possible delay
Rationale: Hyperglycemia increases risk of infection and poor healing. Surgery may
need to be delayed until glucose is controlled. Orange juice would worsen
hyperglycemia.
Question 4
A patient with acute kidney injury (AKI) has serum potassium of 6.2 mEq/L. Which
intervention should the nurse anticipate?
A. Administer oral potassium supplements
B. Encourage potassium-rich foods
C. Prepare to administer IV insulin with glucose
D. Restrict protein intake
Answer: C. Prepare to administer IV insulin with glucose
Rationale: Insulin drives potassium into cells, lowering serum levels quickly. High
potassium is life-threatening due to risk of arrhythmias. Supplements and
potassium-rich foods would worsen the condition.
Question 5
A patient with stroke (CVA) has right-sided weakness and difficulty swallowing.
Which intervention is most appropriate?
A. Place food on the right side of the mouth
B. Position the patient upright during meals
C. Offer thin liquids with a straw
D. Encourage rapid eating to finish meals
Answer: B. Position the patient upright during meals
Rationale: Upright positioning reduces aspiration risk. Thin liquids increase
aspiration risk, and food should be placed on the unaffected side. Eating slowly with
supervision is safer.
Question 6
A patient with pneumonia has an oxygen saturation of 88% on room air. What is
the nurse’s priority?
A. Encourage coughing and deep breathing
,B. Apply supplemental oxygen
C. Increase fluid intake
D. Notify respiratory therapy
Answer: B. Apply supplemental oxygen
Rationale: Oxygenation is the immediate priority. Coughing and fluids help long-
term, but hypoxemia must be corrected first.
Question 7
A patient with myocardial infarction reports chest pain unrelieved by nitroglycerin.
What is the next best action?
A. Encourage ambulation
B. Administer morphine as ordered
C. Provide a high-protein snack
D. Reassure the patient
Answer: B. Administer morphine as ordered
Rationale: Morphine relieves pain, decreases preload, and reduces cardiac
workload. Ambulation and snacks are inappropriate during acute chest pain.
Question 8
A patient with cirrhosis develops confusion and asterixis. Which lab value is most
concerning?
A. Sodium 140 mEq/L
B. Potassium 4.0 mEq/L
C. Ammonia 120 mcg/dL
D. Hemoglobin 13 g/dL
Answer: C. Ammonia 120 mcg/dL
Rationale: Elevated ammonia indicates hepatic encephalopathy, a serious
complication of cirrhosis.
Question 9
A patient with deep vein thrombosis (DVT) is prescribed heparin. Which finding
requires immediate action?
A. Mild bruising at injection site
, B. Hematuria
C. Slight gum bleeding
D. Nosebleed lasting 2 minutes
Answer: B. Hematuria
Rationale: Hematuria indicates internal bleeding, a serious complication of
anticoagulation therapy.
Question 10
A patient with chronic renal failure is prescribed erythropoietin. Which outcome
indicates effectiveness?
A. Decreased potassium
B. Increased hemoglobin
C. Reduced creatinine
D. Lower blood pressure
Answer: B. Increased hemoglobin
Rationale: Erythropoietin stimulates red blood cell production, improving anemia in
renal failure.
Question 11
A patient with Parkinson’s disease is at risk for aspiration. Which intervention is
most appropriate?
A. Provide thin liquids
B. Offer small, frequent meals
C. Encourage rapid eating
D. Position supine after meals
Answer: B. Offer small, frequent meals
Rationale: Smaller meals reduce fatigue and aspiration risk. Thin liquids and supine
positioning increase risk.
Question 12
A patient with hypertension is prescribed a thiazide diuretic. Which lab value should
the nurse monitor?
A. Hemoglobin
