NSG 4100 Adult Health III – Assessment 7 with
Complete Solutions
1. Cardiac Perfusion
A patient with acute coronary syndrome is prescribed nitroglycerin. Which finding
requires immediate intervention?
• a. Headache after administration
• b. Blood pressure 88/56 mmHg
• c. Flushing of the face
• d. Mild dizziness
Rationale: Nitroglycerin causes vasodilation and can lead to hypotension. A BP of
88/56 indicates dangerously low perfusion requiring urgent action.
2. Neurological Emergencies
A patient with a traumatic brain injury develops unequal pupils. What is the nurse’s
priority?
• a. Document findings
• b. Notify provider immediately
• c. Reassess in 30 minutes
• d. Elevate head of bed
Rationale: Unequal pupils suggest increased intracranial pressure or herniation.
Immediate provider notification is critical.
3. Endocrine Disorders
A patient with diabetic ketoacidosis (DKA) is receiving IV insulin. Which lab value
requires immediate action?
• a. Potassium 3.0 mEq/L
• b. Glucose 250 mg/dL
• c. Bicarbonate 18 mEq/L
• d. pH 7.30
Rationale: Insulin drives potassium into cells, worsening hypokalemia. Potassium of 3.0
is dangerously low and must be corrected before continuing insulin.
4. Respiratory Failure
,A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. Which finding
indicates oxygen toxicity risk?
• a. SpO₂ 92%
• b. SpO₂ 99%
• c. Respiratory rate 22/min
• d. Productive cough
Rationale: COPD patients rely on hypoxic drive. SpO₂ of 99% suggests excessive
oxygen, which can suppress respiratory drive.
5. Renal Function
A patient with chronic kidney disease reports muscle weakness. Which lab result
explains this symptom?
• a. Elevated creatinine
• b. Hyperkalemia
• c. Low hemoglobin
• d. Elevated BUN
Rationale: Hyperkalemia affects neuromuscular function, causing weakness and
arrhythmias. This is a priority finding.
6. Shock Management
A patient in septic shock is receiving norepinephrine. Which assessment finding shows
the drug is effective?
• a. Urine output 35 mL/hr
• b. Heart rate 120 bpm
• c. MAP 55 mmHg
• d. Skin cool and clammy
Rationale: Adequate urine output indicates improved perfusion. MAP should be ≥65
mmHg, and urine output ≥30 mL/hr is a positive response.
7. Hematology
A patient receiving chemotherapy develops a WBC count of 2,000/mm³. Which
intervention is most appropriate?
• a. Encourage fresh fruit intake
• b. Place patient in protective isolation
• c. Administer iron supplements
• d. Increase fluid intake
, Rationale: WBC count <4,000 indicates neutropenia. Protective isolation reduces
infection risk, which is life-threatening in immunocompromised patients.
8. Heart Failure
Which finding indicates worsening left-sided heart failure?
• a. Jugular vein distention
• b. Crackles in lungs
• c. Peripheral edema
• d. Weight gain
Rationale: Left-sided HF causes pulmonary congestion. Crackles are a direct sign of
fluid accumulation in alveoli.
9. Stroke
A patient with acute ischemic stroke is scheduled for tPA. Which is a contraindication?
• a. BP 160/90 mmHg
• b. Recent GI bleed
• c. Age 72 years
• d. Onset 2 hours ago
Rationale: Active or recent bleeding is a contraindication for thrombolytic therapy due
to risk of hemorrhage.
10. GI Bleeding
Which assessment finding suggests upper GI bleeding?
• a. Bright red blood in stool
• b. Coffee-ground emesis
• c. Occult blood in stool
• d. Melena
Rationale: Coffee-ground emesis indicates partially digested blood from the stomach or
duodenum.
11. Pneumonia
Which nursing intervention is most effective in preventing hospital-acquired pneumonia?
• a. Encourage fluid intake
• b. Perform oral care regularly
• c. Administer antibiotics prophylactically
Complete Solutions
1. Cardiac Perfusion
A patient with acute coronary syndrome is prescribed nitroglycerin. Which finding
requires immediate intervention?
• a. Headache after administration
• b. Blood pressure 88/56 mmHg
• c. Flushing of the face
• d. Mild dizziness
Rationale: Nitroglycerin causes vasodilation and can lead to hypotension. A BP of
88/56 indicates dangerously low perfusion requiring urgent action.
2. Neurological Emergencies
A patient with a traumatic brain injury develops unequal pupils. What is the nurse’s
priority?
• a. Document findings
• b. Notify provider immediately
• c. Reassess in 30 minutes
• d. Elevate head of bed
Rationale: Unequal pupils suggest increased intracranial pressure or herniation.
Immediate provider notification is critical.
3. Endocrine Disorders
A patient with diabetic ketoacidosis (DKA) is receiving IV insulin. Which lab value
requires immediate action?
• a. Potassium 3.0 mEq/L
• b. Glucose 250 mg/dL
• c. Bicarbonate 18 mEq/L
• d. pH 7.30
Rationale: Insulin drives potassium into cells, worsening hypokalemia. Potassium of 3.0
is dangerously low and must be corrected before continuing insulin.
4. Respiratory Failure
,A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. Which finding
indicates oxygen toxicity risk?
• a. SpO₂ 92%
• b. SpO₂ 99%
• c. Respiratory rate 22/min
• d. Productive cough
Rationale: COPD patients rely on hypoxic drive. SpO₂ of 99% suggests excessive
oxygen, which can suppress respiratory drive.
5. Renal Function
A patient with chronic kidney disease reports muscle weakness. Which lab result
explains this symptom?
• a. Elevated creatinine
• b. Hyperkalemia
• c. Low hemoglobin
• d. Elevated BUN
Rationale: Hyperkalemia affects neuromuscular function, causing weakness and
arrhythmias. This is a priority finding.
6. Shock Management
A patient in septic shock is receiving norepinephrine. Which assessment finding shows
the drug is effective?
• a. Urine output 35 mL/hr
• b. Heart rate 120 bpm
• c. MAP 55 mmHg
• d. Skin cool and clammy
Rationale: Adequate urine output indicates improved perfusion. MAP should be ≥65
mmHg, and urine output ≥30 mL/hr is a positive response.
7. Hematology
A patient receiving chemotherapy develops a WBC count of 2,000/mm³. Which
intervention is most appropriate?
• a. Encourage fresh fruit intake
• b. Place patient in protective isolation
• c. Administer iron supplements
• d. Increase fluid intake
, Rationale: WBC count <4,000 indicates neutropenia. Protective isolation reduces
infection risk, which is life-threatening in immunocompromised patients.
8. Heart Failure
Which finding indicates worsening left-sided heart failure?
• a. Jugular vein distention
• b. Crackles in lungs
• c. Peripheral edema
• d. Weight gain
Rationale: Left-sided HF causes pulmonary congestion. Crackles are a direct sign of
fluid accumulation in alveoli.
9. Stroke
A patient with acute ischemic stroke is scheduled for tPA. Which is a contraindication?
• a. BP 160/90 mmHg
• b. Recent GI bleed
• c. Age 72 years
• d. Onset 2 hours ago
Rationale: Active or recent bleeding is a contraindication for thrombolytic therapy due
to risk of hemorrhage.
10. GI Bleeding
Which assessment finding suggests upper GI bleeding?
• a. Bright red blood in stool
• b. Coffee-ground emesis
• c. Occult blood in stool
• d. Melena
Rationale: Coffee-ground emesis indicates partially digested blood from the stomach or
duodenum.
11. Pneumonia
Which nursing intervention is most effective in preventing hospital-acquired pneumonia?
• a. Encourage fluid intake
• b. Perform oral care regularly
• c. Administer antibiotics prophylactically
