NSG3800 Exam 2 –Adult Health II
Questions and Answers
Question 1
A patient with chronic obstructive pulmonary disease (COPD) is admitted with
worsening dyspnea. Which nursing intervention is most appropriate?
A. Encourage the patient to lie flat in bed
B. Administer high-flow oxygen at 10 L/min
C. Position the patient in high Fowler’s and encourage pursed-lip breathing
D. Restrict fluid intake to prevent pulmonary edema
Rationale: High Fowler’s improves lung expansion, and pursed-lip breathing helps
prevent airway collapse. High-flow oxygen can suppress hypoxic drive in COPD
patients, and fluid restriction is not indicated unless there is concurrent heart failure.
Question 2
A patient with heart failure is prescribed furosemide. Which lab value should the nurse
monitor most closely?
A. Hemoglobin
B. Potassium
C. White blood cell count
D. Calcium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia, increasing the risk
of arrhythmias. Monitoring potassium is essential for safe management.
Question 3
A patient with type 2 diabetes presents with a foot ulcer. Which nursing intervention is
most important?
A. Teach the patient to soak feet daily
B. Encourage barefoot walking to promote circulation
C. Assess for signs of infection and impaired healing
D. Apply ice packs to reduce swelling
Rationale: Diabetic foot ulcers are prone to infection and poor healing due to
neuropathy and vascular compromise. Soaking and barefoot walking increase risk of
injury, and ice packs may worsen circulation.
Question 4
A patient with pneumonia is receiving IV antibiotics. Which finding indicates the
treatment is effective?
A. Increased sputum production
B. Decreased breath sounds in affected lung
C. Normalization of temperature and improved oxygen saturation
,D. Elevated white blood cell count
Rationale: Resolution of infection is indicated by improved vital signs and oxygenation.
Elevated WBC and decreased breath sounds suggest ongoing infection or
consolidation.
Question 5
A patient with cirrhosis develops ascites. Which nursing intervention is most appropriate
to evaluate fluid status?
A. Monitor daily weight
B. Measure abdominal girth once a week
C. Assess for pedal edema only
D. Restrict oral fluids to 500 mL/day
Rationale: Daily weights are the most accurate indicator of fluid balance. Abdominal
girth is useful but less precise, and fluid restriction is not always indicated unless
hyponatremia is present.
Question 6
A patient with a history of myocardial infarction reports new chest pain. Which action
should the nurse take first?
A. Administer nitroglycerin sublingually
B. Obtain a 12-lead ECG
C. Notify the healthcare provider
D. Assess pain characteristics
Rationale: A 12-lead ECG provides immediate diagnostic information to determine if the
patient is experiencing another MI. Nitroglycerin may be given after ECG confirmation,
but rapid assessment is critical.
Question 7
A patient with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
intervention is priority?
A. Place the patient on a cardiac monitor
B. Restrict dietary potassium
C. Administer oral sodium polystyrene sulfonate
D. Prepare the patient for dialysis
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Continuous cardiac
monitoring is the immediate priority, followed by interventions to lower potassium.
Question 8
A patient with a tracheostomy suddenly develops respiratory distress. The nurse finds
the tracheostomy tube dislodged. What is the best initial action?
A. Call the rapid response team
B. Attempt to reinsert the tracheostomy tube immediately
, C. Use a bag-valve mask to ventilate the patient over the stoma
D. Cover the stoma and provide oxygen via nasal cannula
Rationale: Ventilating over the stoma with a bag-valve mask ensures oxygenation until
the airway can be re-established. Reinsertion may be attempted if trained, but
oxygenation is the priority.
Question 9
A patient with hypothyroidism is prescribed levothyroxine. Which teaching is most
important?
A. Take the medication with food for best absorption
B. Take the medication at bedtime with milk
C. Take the medication in the morning on an empty stomach
D. Skip doses if feeling well
Rationale: Levothyroxine should be taken in the morning on an empty stomach to
maximize absorption. Food and calcium interfere with absorption.
Question 10
A patient with a history of stroke has right-sided weakness. Which intervention is priority
for preventing complications?
A. Encourage ambulation without assistance
B. Place objects on the patient’s left side
C. Implement fall precautions and assist with mobility
D. Restrict fluid intake
Rationale: Safety and fall prevention are critical in stroke patients with weakness.
Ambulation should be assisted.
Question 11
A patient with deep vein thrombosis (DVT) is prescribed heparin. Which lab value
should be monitored?
A. INR
B. aPTT
C. Platelets
D. Hematocrit
Rationale: Heparin therapy is monitored using aPTT. Platelets are also monitored for
heparin-induced thrombocytopenia, but aPTT is the primary test.
Question 12
A patient with chronic heart failure reports sudden weight gain of 5 pounds in 2 days.
What does this indicate?
A. Normal fluctuation
B. Fluid retention and worsening heart failure
C. Improved nutritional status
Questions and Answers
Question 1
A patient with chronic obstructive pulmonary disease (COPD) is admitted with
worsening dyspnea. Which nursing intervention is most appropriate?
A. Encourage the patient to lie flat in bed
B. Administer high-flow oxygen at 10 L/min
C. Position the patient in high Fowler’s and encourage pursed-lip breathing
D. Restrict fluid intake to prevent pulmonary edema
Rationale: High Fowler’s improves lung expansion, and pursed-lip breathing helps
prevent airway collapse. High-flow oxygen can suppress hypoxic drive in COPD
patients, and fluid restriction is not indicated unless there is concurrent heart failure.
Question 2
A patient with heart failure is prescribed furosemide. Which lab value should the nurse
monitor most closely?
A. Hemoglobin
B. Potassium
C. White blood cell count
D. Calcium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia, increasing the risk
of arrhythmias. Monitoring potassium is essential for safe management.
Question 3
A patient with type 2 diabetes presents with a foot ulcer. Which nursing intervention is
most important?
A. Teach the patient to soak feet daily
B. Encourage barefoot walking to promote circulation
C. Assess for signs of infection and impaired healing
D. Apply ice packs to reduce swelling
Rationale: Diabetic foot ulcers are prone to infection and poor healing due to
neuropathy and vascular compromise. Soaking and barefoot walking increase risk of
injury, and ice packs may worsen circulation.
Question 4
A patient with pneumonia is receiving IV antibiotics. Which finding indicates the
treatment is effective?
A. Increased sputum production
B. Decreased breath sounds in affected lung
C. Normalization of temperature and improved oxygen saturation
,D. Elevated white blood cell count
Rationale: Resolution of infection is indicated by improved vital signs and oxygenation.
Elevated WBC and decreased breath sounds suggest ongoing infection or
consolidation.
Question 5
A patient with cirrhosis develops ascites. Which nursing intervention is most appropriate
to evaluate fluid status?
A. Monitor daily weight
B. Measure abdominal girth once a week
C. Assess for pedal edema only
D. Restrict oral fluids to 500 mL/day
Rationale: Daily weights are the most accurate indicator of fluid balance. Abdominal
girth is useful but less precise, and fluid restriction is not always indicated unless
hyponatremia is present.
Question 6
A patient with a history of myocardial infarction reports new chest pain. Which action
should the nurse take first?
A. Administer nitroglycerin sublingually
B. Obtain a 12-lead ECG
C. Notify the healthcare provider
D. Assess pain characteristics
Rationale: A 12-lead ECG provides immediate diagnostic information to determine if the
patient is experiencing another MI. Nitroglycerin may be given after ECG confirmation,
but rapid assessment is critical.
Question 7
A patient with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
intervention is priority?
A. Place the patient on a cardiac monitor
B. Restrict dietary potassium
C. Administer oral sodium polystyrene sulfonate
D. Prepare the patient for dialysis
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Continuous cardiac
monitoring is the immediate priority, followed by interventions to lower potassium.
Question 8
A patient with a tracheostomy suddenly develops respiratory distress. The nurse finds
the tracheostomy tube dislodged. What is the best initial action?
A. Call the rapid response team
B. Attempt to reinsert the tracheostomy tube immediately
, C. Use a bag-valve mask to ventilate the patient over the stoma
D. Cover the stoma and provide oxygen via nasal cannula
Rationale: Ventilating over the stoma with a bag-valve mask ensures oxygenation until
the airway can be re-established. Reinsertion may be attempted if trained, but
oxygenation is the priority.
Question 9
A patient with hypothyroidism is prescribed levothyroxine. Which teaching is most
important?
A. Take the medication with food for best absorption
B. Take the medication at bedtime with milk
C. Take the medication in the morning on an empty stomach
D. Skip doses if feeling well
Rationale: Levothyroxine should be taken in the morning on an empty stomach to
maximize absorption. Food and calcium interfere with absorption.
Question 10
A patient with a history of stroke has right-sided weakness. Which intervention is priority
for preventing complications?
A. Encourage ambulation without assistance
B. Place objects on the patient’s left side
C. Implement fall precautions and assist with mobility
D. Restrict fluid intake
Rationale: Safety and fall prevention are critical in stroke patients with weakness.
Ambulation should be assisted.
Question 11
A patient with deep vein thrombosis (DVT) is prescribed heparin. Which lab value
should be monitored?
A. INR
B. aPTT
C. Platelets
D. Hematocrit
Rationale: Heparin therapy is monitored using aPTT. Platelets are also monitored for
heparin-induced thrombocytopenia, but aPTT is the primary test.
Question 12
A patient with chronic heart failure reports sudden weight gain of 5 pounds in 2 days.
What does this indicate?
A. Normal fluctuation
B. Fluid retention and worsening heart failure
C. Improved nutritional status
