NSG3800 Exam 4- Adult Health II Questions and
Answers Graded 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 fluid intake to prevent pulmonary edema
Rationale: High Fowler’s position maximizes 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 finding requires immediate
nursing intervention?
A. Serum potassium of 3.0 mEq/L
B. Weight loss of 2 lbs in 24 hours
C. Blood pressure of 110/70 mmHg
D. Urine output of 1,200 mL in 24 hours
Rationale: Hypokalemia (K+ < 3.5 mEq/L) is a dangerous side effect of loop diuretics
and can precipitate life-threatening arrhythmias. The other findings are expected or
within normal limits.
Question 3
A patient with type 2 diabetes is scheduled for surgery. Which preoperative nursing
action is most important?
A. Hold all insulin doses
B. Monitor blood glucose levels closely
C. Encourage the patient to drink juice before surgery
D. Administer oral hypoglycemics with sips of water
Rationale: Blood glucose monitoring is critical to prevent perioperative complications.
Insulin may be adjusted, but not universally withheld. Oral hypoglycemics are usually
held due to NPO status, and juice intake is contraindicated before surgery.
Question 4
A patient with a history of stroke presents with unilateral weakness and slurred speech.
What is the priority nursing action?
A. Perform passive range-of-motion exercises
B. Assess airway and swallowing ability
C. Encourage oral fluids immediately
,D. Place the patient in Trendelenburg position
Rationale: Airway and swallowing assessment is essential to prevent aspiration. ROM
exercises are important later, fluids are unsafe until swallowing is assessed, and
Trendelenburg is contraindicated.
Question 5
A patient with cirrhosis develops ascites. Which nursing intervention is most
appropriate?
A. Encourage high-sodium diet
B. Measure abdominal girth daily
C. Restrict protein intake completely
D. Place the patient in Trendelenburg position
Rationale: Measuring abdominal girth helps monitor fluid accumulation. Sodium
restriction is usually recommended, not high intake. Protein restriction is only
considered in severe encephalopathy, not universally. Trendelenburg worsens
breathing difficulty.
Question 6
A patient with pneumonia is receiving IV antibiotics. Which finding indicates the
treatment is effective?
A. WBC count increases to 15,000/mm³
B. Patient reports pleuritic chest pain
C. Oxygen saturation improves from 88% to 95%
D. Temperature rises to 101°F
Rationale: Improved oxygenation shows resolution of infection and better lung function.
Elevated WBC and fever indicate ongoing infection. Pain is a symptom, not a sign of
improvement.
Question 7
A patient with acute pancreatitis reports severe abdominal pain. Which nursing action is
most appropriate?
A. Provide a high-fat diet to reduce pain
B. Place the patient in supine position
C. Administer prescribed opioid analgesics
D. Encourage ambulation immediately
Rationale: Pain management is the priority in acute pancreatitis. High-fat diet worsens
symptoms, supine position increases discomfort, and ambulation is not the immediate
intervention.
Question 8
A patient with chronic kidney disease is scheduled for dialysis. Which lab value requires
immediate attention before treatment?
, A. Hemoglobin 11 g/dL
B. Potassium 6.2 mEq/L
C. Calcium 8.8 mg/dL
D. BUN 45 mg/dL
Rationale: Hyperkalemia (>5.0 mEq/L) is life-threatening and must be addressed
urgently. The other values are abnormal but not immediately dangerous.
Question 9
A patient with multiple sclerosis is experiencing muscle spasticity. Which intervention is
most appropriate?
A. Encourage hot baths daily
B. Provide passive stretching exercises
C. Restrict fluid intake
D. Place the patient on strict bed rest
Rationale: Stretching helps reduce spasticity and maintain mobility. Hot baths may
worsen fatigue, fluid restriction is not indicated, and bed rest increases complications.
Question 10
A patient with myocardial infarction is receiving thrombolytic therapy. Which finding
indicates the therapy is effective?
A. ST segment returns to baseline
B. Patient reports chest pain
C. Troponin levels increase
D. Blood pressure decreases
Rationale: Resolution of ST elevation shows reperfusion. Chest pain and elevated
troponin are expected initially. Blood pressure changes are nonspecific.
Question 11
A patient with chronic heart failure reports sudden weight gain of 5 lbs in 2 days. What
is the priority nursing action?
A. Reassure the patient this is normal
B. Notify the healthcare provider immediately
C. Encourage increased fluid intake
D. Schedule daily exercise
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
Immediate provider notification is necessary.
Question 12
A patient with COPD is prescribed albuterol. Which side effect should the nurse monitor
for?
A. Bradycardia
B. Tremors and tachycardia
Answers Graded 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 fluid intake to prevent pulmonary edema
Rationale: High Fowler’s position maximizes 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 finding requires immediate
nursing intervention?
A. Serum potassium of 3.0 mEq/L
B. Weight loss of 2 lbs in 24 hours
C. Blood pressure of 110/70 mmHg
D. Urine output of 1,200 mL in 24 hours
Rationale: Hypokalemia (K+ < 3.5 mEq/L) is a dangerous side effect of loop diuretics
and can precipitate life-threatening arrhythmias. The other findings are expected or
within normal limits.
Question 3
A patient with type 2 diabetes is scheduled for surgery. Which preoperative nursing
action is most important?
A. Hold all insulin doses
B. Monitor blood glucose levels closely
C. Encourage the patient to drink juice before surgery
D. Administer oral hypoglycemics with sips of water
Rationale: Blood glucose monitoring is critical to prevent perioperative complications.
Insulin may be adjusted, but not universally withheld. Oral hypoglycemics are usually
held due to NPO status, and juice intake is contraindicated before surgery.
Question 4
A patient with a history of stroke presents with unilateral weakness and slurred speech.
What is the priority nursing action?
A. Perform passive range-of-motion exercises
B. Assess airway and swallowing ability
C. Encourage oral fluids immediately
,D. Place the patient in Trendelenburg position
Rationale: Airway and swallowing assessment is essential to prevent aspiration. ROM
exercises are important later, fluids are unsafe until swallowing is assessed, and
Trendelenburg is contraindicated.
Question 5
A patient with cirrhosis develops ascites. Which nursing intervention is most
appropriate?
A. Encourage high-sodium diet
B. Measure abdominal girth daily
C. Restrict protein intake completely
D. Place the patient in Trendelenburg position
Rationale: Measuring abdominal girth helps monitor fluid accumulation. Sodium
restriction is usually recommended, not high intake. Protein restriction is only
considered in severe encephalopathy, not universally. Trendelenburg worsens
breathing difficulty.
Question 6
A patient with pneumonia is receiving IV antibiotics. Which finding indicates the
treatment is effective?
A. WBC count increases to 15,000/mm³
B. Patient reports pleuritic chest pain
C. Oxygen saturation improves from 88% to 95%
D. Temperature rises to 101°F
Rationale: Improved oxygenation shows resolution of infection and better lung function.
Elevated WBC and fever indicate ongoing infection. Pain is a symptom, not a sign of
improvement.
Question 7
A patient with acute pancreatitis reports severe abdominal pain. Which nursing action is
most appropriate?
A. Provide a high-fat diet to reduce pain
B. Place the patient in supine position
C. Administer prescribed opioid analgesics
D. Encourage ambulation immediately
Rationale: Pain management is the priority in acute pancreatitis. High-fat diet worsens
symptoms, supine position increases discomfort, and ambulation is not the immediate
intervention.
Question 8
A patient with chronic kidney disease is scheduled for dialysis. Which lab value requires
immediate attention before treatment?
, A. Hemoglobin 11 g/dL
B. Potassium 6.2 mEq/L
C. Calcium 8.8 mg/dL
D. BUN 45 mg/dL
Rationale: Hyperkalemia (>5.0 mEq/L) is life-threatening and must be addressed
urgently. The other values are abnormal but not immediately dangerous.
Question 9
A patient with multiple sclerosis is experiencing muscle spasticity. Which intervention is
most appropriate?
A. Encourage hot baths daily
B. Provide passive stretching exercises
C. Restrict fluid intake
D. Place the patient on strict bed rest
Rationale: Stretching helps reduce spasticity and maintain mobility. Hot baths may
worsen fatigue, fluid restriction is not indicated, and bed rest increases complications.
Question 10
A patient with myocardial infarction is receiving thrombolytic therapy. Which finding
indicates the therapy is effective?
A. ST segment returns to baseline
B. Patient reports chest pain
C. Troponin levels increase
D. Blood pressure decreases
Rationale: Resolution of ST elevation shows reperfusion. Chest pain and elevated
troponin are expected initially. Blood pressure changes are nonspecific.
Question 11
A patient with chronic heart failure reports sudden weight gain of 5 lbs in 2 days. What
is the priority nursing action?
A. Reassure the patient this is normal
B. Notify the healthcare provider immediately
C. Encourage increased fluid intake
D. Schedule daily exercise
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
Immediate provider notification is necessary.
Question 12
A patient with COPD is prescribed albuterol. Which side effect should the nurse monitor
for?
A. Bradycardia
B. Tremors and tachycardia
