NSG 300/NSG300 Exam 4 V3 | Foundations
of Nursing Q&A with Rationale | Grand
Canyon University
1. Which assessment finding is an early sign of hypoxia in a client with a respiratory disorder?
A. Cyanosis of the mucous membranes
B. Bradypnea and hypotension
C. Restlessness and anxiety
D. Clubbing of the fingers
Correct Answer: C
Expert Explanation: Restlessness and anxiety are often the first behavioral signs of
hypoxia as the brain responds to decreased oxygen levels. Cyanosis is considered a late
sign of hypoxia indicating severe oxygen deprivation. Nursing assessments should
prioritize cognitive and behavioral changes to detect early respiratory distress.
2. When instructing a client on the use of an incentive spirometer, which action should the
nurse emphasize?
A. Exhale forcefully into the mouthpiece
B. Inhale slowly and deeply through the mouthpiece
C. Perform the exercise once every 4 hours
D. Hold your breath for at least 30 seconds
,Correct Answer: B
Expert Explanation: The incentive spirometer is designed to promote lung expansion by
encouraging slow, deep inhalations. Clients should be taught to reach a target volume and
hold the breath for 3 to 5 seconds to keep alveoli open. This intervention is critical for
preventing postoperative atelectasis and pneumonia.
3. A nurse is caring for a client with a prescription for oxygen via nasal cannula at 4 L/min.
What is the priority nursing intervention?
A. Apply petroleum jelly to the nares to prevent drying
B. Ensure the client is in a prone position
C. Monitor the skin behind the ears for breakdown
D. Adjust the flow rate to 8 L/min during sleep
Correct Answer: C
Expert Explanation: The pressure from the tubing of a nasal cannula can cause skin
breakdown, particularly over the ears and in the nares. Nurses must regularly inspect these
areas and can use padding if necessary to protect the skin. Maintaining skin integrity is a
standard component of oxygen therapy management in Foundations of Nursing.
4. A client is diagnosed with fluid volume excess. Which clinical manifestation should the
nurse expect to find?
A. Flat neck veins when supine
B. Weight gain of 2 lbs in 24 hours
, C. Increased hematocrit levels
D. Weak, thready pulse
Correct Answer: B
Expert Explanation: Rapid weight gain is a primary indicator of fluid retention, with 1
liter of fluid equaling approximately 2.2 pounds. Other signs include distended neck veins,
edema, and a bounding pulse. Monitoring daily weights at the same time and with the same
clothing is a crucial nursing action for these patients.
5. Which electrolyte imbalance is a client most at risk for when taking a non-potassium-
sparing diuretic?
A. Hyperkalemia
B. Hyponatremia
C. Hypokalemia
D. Hypermagnesemia
Correct Answer: C
Expert Explanation: Loop and thiazide diuretics increase the excretion of potassium
through the kidneys, leading to low serum potassium levels. Hypokalemia can cause muscle
weakness and potentially fatal cardiac dysrhythmias. Patients on these medications often
require potassium supplements or increased dietary intake of potassium-rich foods.
of Nursing Q&A with Rationale | Grand
Canyon University
1. Which assessment finding is an early sign of hypoxia in a client with a respiratory disorder?
A. Cyanosis of the mucous membranes
B. Bradypnea and hypotension
C. Restlessness and anxiety
D. Clubbing of the fingers
Correct Answer: C
Expert Explanation: Restlessness and anxiety are often the first behavioral signs of
hypoxia as the brain responds to decreased oxygen levels. Cyanosis is considered a late
sign of hypoxia indicating severe oxygen deprivation. Nursing assessments should
prioritize cognitive and behavioral changes to detect early respiratory distress.
2. When instructing a client on the use of an incentive spirometer, which action should the
nurse emphasize?
A. Exhale forcefully into the mouthpiece
B. Inhale slowly and deeply through the mouthpiece
C. Perform the exercise once every 4 hours
D. Hold your breath for at least 30 seconds
,Correct Answer: B
Expert Explanation: The incentive spirometer is designed to promote lung expansion by
encouraging slow, deep inhalations. Clients should be taught to reach a target volume and
hold the breath for 3 to 5 seconds to keep alveoli open. This intervention is critical for
preventing postoperative atelectasis and pneumonia.
3. A nurse is caring for a client with a prescription for oxygen via nasal cannula at 4 L/min.
What is the priority nursing intervention?
A. Apply petroleum jelly to the nares to prevent drying
B. Ensure the client is in a prone position
C. Monitor the skin behind the ears for breakdown
D. Adjust the flow rate to 8 L/min during sleep
Correct Answer: C
Expert Explanation: The pressure from the tubing of a nasal cannula can cause skin
breakdown, particularly over the ears and in the nares. Nurses must regularly inspect these
areas and can use padding if necessary to protect the skin. Maintaining skin integrity is a
standard component of oxygen therapy management in Foundations of Nursing.
4. A client is diagnosed with fluid volume excess. Which clinical manifestation should the
nurse expect to find?
A. Flat neck veins when supine
B. Weight gain of 2 lbs in 24 hours
, C. Increased hematocrit levels
D. Weak, thready pulse
Correct Answer: B
Expert Explanation: Rapid weight gain is a primary indicator of fluid retention, with 1
liter of fluid equaling approximately 2.2 pounds. Other signs include distended neck veins,
edema, and a bounding pulse. Monitoring daily weights at the same time and with the same
clothing is a crucial nursing action for these patients.
5. Which electrolyte imbalance is a client most at risk for when taking a non-potassium-
sparing diuretic?
A. Hyperkalemia
B. Hyponatremia
C. Hypokalemia
D. Hypermagnesemia
Correct Answer: C
Expert Explanation: Loop and thiazide diuretics increase the excretion of potassium
through the kidneys, leading to low serum potassium levels. Hypokalemia can cause muscle
weakness and potentially fatal cardiac dysrhythmias. Patients on these medications often
require potassium supplements or increased dietary intake of potassium-rich foods.
