NSG3800 Exam 3 –Adult Health II Questions and
Answers Rated A+
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 fluids to prevent pulmonary
Rationale: High Fowler’s position maximizes lung expansion, and pursed-lip breathing
helps prevent airway collapse. High-flow oxygen can suppress respiratory 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 finding requires immediate
nursing action?
A. Weight loss of 2 lbs in 24 hours
B. Serum potassium of 2.9 mEq/L
C. Mild dizziness when standing
D. Increased urine output
Rationale: Hypokalemia (K+ < 3.5 mEq/L) is a dangerous side effect of loop diuretics
and can lead to life-threatening arrhythmias. The other findings are expected or
manageable.
Question 3:
A patient with type 2 diabetes is scheduled for surgery. Which preoperative finding is
most concerning?
A. Blood glucose of 180 mg/dL
B. HbA1c of 7.5%
C. Presence of a foot ulcer with drainage
D. Blood pressure of 140/85 mmHg
Rationale: Active infection increases surgical risk and may delay wound healing. Blood
glucose and HbA1c are slightly elevated but not critical, and mild hypertension is
common.
Question 4:
A patient with pneumonia is receiving IV antibiotics. Which assessment indicates the
treatment is effective?
A. WBC count decreases from 15,000 to 8,000
,B. Patient reports increased sputum production
C. Respiratory rate increases from 20 to 28
D. Oxygen saturation decreases from 95% to 90%
Rationale: A decrease in WBC count suggests resolution of infection. Increased
sputum, tachypnea, and decreased oxygen saturation indicate worsening condition.
Question 6
A patient with pneumonia is receiving IV antibiotics. Which finding indicates the
treatment is effective?
A. Decreased white blood cell count
B. Increased respiratory rate
C. Persistent crackles in lungs
D. Elevated temperature
Rationale: A falling WBC count suggests infection is resolving. Persistent crackles and
fever indicate ongoing illness, while increased respiratory rate reflects distress.
Question 7
A patient with a spinal cord injury at T4 develops sudden hypertension, bradycardia,
and severe headache. What is the nurse’s priority action?
A. Administer antihypertensive medication
B. Place patient in supine position
C. Assess for bladder distention
D. Notify the healthcare provider
Rationale: These are signs of autonomic dysreflexia, often triggered by bladder or bowel
irritation. Relieving the cause is the immediate priority before medications or provider
notification.
Question 8
A patient with chronic kidney disease has serum potassium of 6.2 mEq/L. Which
intervention should the nurse anticipate?
A. Administer IV insulin with glucose
B. Restrict sodium intake
,C. Encourage oral fluids
D. Provide potassium-rich foods
Rationale: Hyperkalemia is life-threatening due to risk of arrhythmias. Insulin with
glucose shifts potassium into cells, lowering serum levels quickly. Restricting sodium or
fluids does not address the acute danger.
Question 9
A patient with a new colostomy is anxious about self-care. Which nursing intervention is
most therapeutic?
A. Provide written instructions only
B. Encourage patient to watch a demonstration
C. Allow patient to practice with supervision
D. Refer patient to a support group immediately
Rationale: Hands-on practice builds confidence and skill. Written instructions and
demonstrations are helpful, but supervised practice is most effective for learning.
Question 10
A patient with myocardial infarction reports chest pain unrelieved by nitroglycerin. Which
action should the nurse take first?
A. Administer morphine as prescribed
B. Reassess pain after 30 minutes
C. Encourage deep breathing exercises
D. Document the patient’s report
Rationale: Morphine relieves pain, decreases preload, and reduces anxiety. Prompt
intervention is critical to reduce cardiac workload and prevent complications.
Question 11
A patient with acute pancreatitis reports severe abdominal pain radiating to the back.
Which intervention is most appropriate?
A. Provide a high-fat diet
B. Place patient in supine position
, C. Administer prescribed opioid analgesic
D. Encourage ambulation
Rationale: Pain control is the priority in acute pancreatitis. Supine positioning worsens
pain, and ambulation or high-fat diet are contraindicated.
Question 12
A patient with a tracheostomy suddenly develops respiratory distress. The nurse notes
the tracheostomy tube is dislodged. What is the priority action?
A. Call respiratory therapy
B. Insert a new tracheostomy tube immediately
C. Cover stoma with sterile gauze
D. Ventilate with bag-mask over stoma
Rationale: Airway patency is the priority. Replacing the tube restores ventilation. Other
actions may follow if reinsertion is unsuccessful.
Question 13
A patient with hypothyroidism is prescribed levothyroxine. Which statement indicates
effective teaching?
A. “I will take this medication with food.”
B. “I should expect rapid improvement in symptoms.”
C. “I will take this medication every morning on an empty stomach.”
D. “I can stop taking the medication once I feel better.”
Rationale: Levothyroxine is best absorbed on an empty stomach. It requires lifelong
therapy and gradual improvement.
Question 14
A patient with a history of DVT is prescribed warfarin. Which lab value should the nurse
monitor?
A. Platelet count
B. INR
C. aPTT
Answers Rated A+
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 fluids to prevent pulmonary
Rationale: High Fowler’s position maximizes lung expansion, and pursed-lip breathing
helps prevent airway collapse. High-flow oxygen can suppress respiratory 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 finding requires immediate
nursing action?
A. Weight loss of 2 lbs in 24 hours
B. Serum potassium of 2.9 mEq/L
C. Mild dizziness when standing
D. Increased urine output
Rationale: Hypokalemia (K+ < 3.5 mEq/L) is a dangerous side effect of loop diuretics
and can lead to life-threatening arrhythmias. The other findings are expected or
manageable.
Question 3:
A patient with type 2 diabetes is scheduled for surgery. Which preoperative finding is
most concerning?
A. Blood glucose of 180 mg/dL
B. HbA1c of 7.5%
C. Presence of a foot ulcer with drainage
D. Blood pressure of 140/85 mmHg
Rationale: Active infection increases surgical risk and may delay wound healing. Blood
glucose and HbA1c are slightly elevated but not critical, and mild hypertension is
common.
Question 4:
A patient with pneumonia is receiving IV antibiotics. Which assessment indicates the
treatment is effective?
A. WBC count decreases from 15,000 to 8,000
,B. Patient reports increased sputum production
C. Respiratory rate increases from 20 to 28
D. Oxygen saturation decreases from 95% to 90%
Rationale: A decrease in WBC count suggests resolution of infection. Increased
sputum, tachypnea, and decreased oxygen saturation indicate worsening condition.
Question 6
A patient with pneumonia is receiving IV antibiotics. Which finding indicates the
treatment is effective?
A. Decreased white blood cell count
B. Increased respiratory rate
C. Persistent crackles in lungs
D. Elevated temperature
Rationale: A falling WBC count suggests infection is resolving. Persistent crackles and
fever indicate ongoing illness, while increased respiratory rate reflects distress.
Question 7
A patient with a spinal cord injury at T4 develops sudden hypertension, bradycardia,
and severe headache. What is the nurse’s priority action?
A. Administer antihypertensive medication
B. Place patient in supine position
C. Assess for bladder distention
D. Notify the healthcare provider
Rationale: These are signs of autonomic dysreflexia, often triggered by bladder or bowel
irritation. Relieving the cause is the immediate priority before medications or provider
notification.
Question 8
A patient with chronic kidney disease has serum potassium of 6.2 mEq/L. Which
intervention should the nurse anticipate?
A. Administer IV insulin with glucose
B. Restrict sodium intake
,C. Encourage oral fluids
D. Provide potassium-rich foods
Rationale: Hyperkalemia is life-threatening due to risk of arrhythmias. Insulin with
glucose shifts potassium into cells, lowering serum levels quickly. Restricting sodium or
fluids does not address the acute danger.
Question 9
A patient with a new colostomy is anxious about self-care. Which nursing intervention is
most therapeutic?
A. Provide written instructions only
B. Encourage patient to watch a demonstration
C. Allow patient to practice with supervision
D. Refer patient to a support group immediately
Rationale: Hands-on practice builds confidence and skill. Written instructions and
demonstrations are helpful, but supervised practice is most effective for learning.
Question 10
A patient with myocardial infarction reports chest pain unrelieved by nitroglycerin. Which
action should the nurse take first?
A. Administer morphine as prescribed
B. Reassess pain after 30 minutes
C. Encourage deep breathing exercises
D. Document the patient’s report
Rationale: Morphine relieves pain, decreases preload, and reduces anxiety. Prompt
intervention is critical to reduce cardiac workload and prevent complications.
Question 11
A patient with acute pancreatitis reports severe abdominal pain radiating to the back.
Which intervention is most appropriate?
A. Provide a high-fat diet
B. Place patient in supine position
, C. Administer prescribed opioid analgesic
D. Encourage ambulation
Rationale: Pain control is the priority in acute pancreatitis. Supine positioning worsens
pain, and ambulation or high-fat diet are contraindicated.
Question 12
A patient with a tracheostomy suddenly develops respiratory distress. The nurse notes
the tracheostomy tube is dislodged. What is the priority action?
A. Call respiratory therapy
B. Insert a new tracheostomy tube immediately
C. Cover stoma with sterile gauze
D. Ventilate with bag-mask over stoma
Rationale: Airway patency is the priority. Replacing the tube restores ventilation. Other
actions may follow if reinsertion is unsuccessful.
Question 13
A patient with hypothyroidism is prescribed levothyroxine. Which statement indicates
effective teaching?
A. “I will take this medication with food.”
B. “I should expect rapid improvement in symptoms.”
C. “I will take this medication every morning on an empty stomach.”
D. “I can stop taking the medication once I feel better.”
Rationale: Levothyroxine is best absorbed on an empty stomach. It requires lifelong
therapy and gradual improvement.
Question 14
A patient with a history of DVT is prescribed warfarin. Which lab value should the nurse
monitor?
A. Platelet count
B. INR
C. aPTT
