Nclex questions 4100 exam 2 Verified Questions With Complete Solutions.
Course
NSG 4100
Question 1
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
oxygen delivery method is most appropriate for this patient to avoid oxygen-induced
hypoventilation?
A. Non-rebreather mask
B. Nasal cannula at 2 L/min
C. Venturi mask at 50% FiO2
D. Simple face mask at 10 L/min
Answer: B
Rationale: For COPD patients, low-flow oxygen via a nasal cannula at 2 L/min is typically used
to prevent oxygen-induced hypoventilation. High concentrations of oxygen (e.g., 50% or more)
can reduce the patient's hypoxic drive and lead to respiratory depression.
Question 2
A nurse is assessing a patient who had abdominal surgery 2 days ago. The patient reports pain in
the calf, and the nurse notes redness and swelling in the area. What should the nurse do first?
A. Apply a warm compress to the area
B. Elevate the affected leg
C. Notify the healthcare provider immediately
D. Encourage the patient to ambulate
Answer: C
Rationale: The patient's symptoms are consistent with deep vein thrombosis (DVT). Immediate
notification of the healthcare provider is essential to prevent complications such as a pulmonary
embolism. Applying heat or encouraging ambulation could worsen the condition.
Question 3
A client with diabetes mellitus is admitted with hyperglycemia. Which of the following clinical
manifestations should the nurse expect?
,A. Cool, clammy skin; tachycardia
B. Polydipsia, polyuria, and polyphagia
C. Decreased urinary output; hypotension
D. Weight gain and bradycardia
Answer: B
Rationale: Hyperglycemia is characterized by the classic signs of polydipsia (excessive thirst),
polyuria (excessive urination), and polyphagia (excessive hunger). These symptoms occur due to
the osmotic effects of high glucose levels in the blood.
Question 4
A nurse administers a medication that causes a severe allergic reaction. What is the nurse’s
priority intervention?
A. Notify the healthcare provider
B. Administer oxygen and elevate the patient’s legs
C. Stop the medication and maintain the airway
D. Document the reaction in the patient’s medical record
Answer: C
Rationale: The priority is to stop the medication and maintain the airway to prevent further
exposure and ensure the patient can breathe. Other actions, such as notifying the provider, are
important but secondary.
Question 5
A nurse is caring for a patient receiving a potassium-sparing diuretic. Which food should the
nurse advise the patient to avoid?
A. Bananas
B. Rice
C. Apples
D. Bread
Answer: A
Rationale: Potassium-sparing diuretics, such as spironolactone, can cause hyperkalemia. High-
potassium foods, like bananas, should be avoided to prevent further increases in serum potassium
levels.
, Question 6
The nurse is teaching a patient about wound care for a stage 3 pressure ulcer. Which statement
by the patient indicates a need for further teaching?
A. “I will clean the wound with normal saline.”
B. “I will use a heat lamp to dry the wound faster.”
C. “I will eat foods high in protein to promote healing.”
D. “I will change the dressing as instructed by my healthcare provider.”
Answer: B
Rationale: Using a heat lamp can dry the wound and delay healing by damaging tissue. Normal
saline, proper nutrition, and following dressing change protocols are essential for wound care.
Question 7
A patient with heart failure is prescribed furosemide. What is the most important electrolyte
imbalance for the nurse to monitor?
A. Hypocalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypermagnesemia
Answer: B
Rationale: Furosemide, a loop diuretic, can cause significant potassium loss, leading to
hypokalemia. This electrolyte imbalance can result in arrhythmias and other complications.
Question 8
A nurse is providing discharge instructions to a patient prescribed warfarin. Which statement by
the patient indicates understanding of the teaching?
A. “I will take aspirin if I have a headache.”
B. “I need to avoid foods high in vitamin K, such as spinach.”
C. “I can drink alcohol as long as it is in moderation.”
D. “I will stop taking the medication if I notice bruising.”
Answer: B
Rationale: Vitamin K can interfere with warfarin’s anticoagulant effects. Patients should limit
foods high in vitamin K and maintain consistent dietary intake. Aspirin and alcohol should be
avoided, and bruising should be reported rather than discontinuing the medication abruptly.
Course
NSG 4100
Question 1
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
oxygen delivery method is most appropriate for this patient to avoid oxygen-induced
hypoventilation?
A. Non-rebreather mask
B. Nasal cannula at 2 L/min
C. Venturi mask at 50% FiO2
D. Simple face mask at 10 L/min
Answer: B
Rationale: For COPD patients, low-flow oxygen via a nasal cannula at 2 L/min is typically used
to prevent oxygen-induced hypoventilation. High concentrations of oxygen (e.g., 50% or more)
can reduce the patient's hypoxic drive and lead to respiratory depression.
Question 2
A nurse is assessing a patient who had abdominal surgery 2 days ago. The patient reports pain in
the calf, and the nurse notes redness and swelling in the area. What should the nurse do first?
A. Apply a warm compress to the area
B. Elevate the affected leg
C. Notify the healthcare provider immediately
D. Encourage the patient to ambulate
Answer: C
Rationale: The patient's symptoms are consistent with deep vein thrombosis (DVT). Immediate
notification of the healthcare provider is essential to prevent complications such as a pulmonary
embolism. Applying heat or encouraging ambulation could worsen the condition.
Question 3
A client with diabetes mellitus is admitted with hyperglycemia. Which of the following clinical
manifestations should the nurse expect?
,A. Cool, clammy skin; tachycardia
B. Polydipsia, polyuria, and polyphagia
C. Decreased urinary output; hypotension
D. Weight gain and bradycardia
Answer: B
Rationale: Hyperglycemia is characterized by the classic signs of polydipsia (excessive thirst),
polyuria (excessive urination), and polyphagia (excessive hunger). These symptoms occur due to
the osmotic effects of high glucose levels in the blood.
Question 4
A nurse administers a medication that causes a severe allergic reaction. What is the nurse’s
priority intervention?
A. Notify the healthcare provider
B. Administer oxygen and elevate the patient’s legs
C. Stop the medication and maintain the airway
D. Document the reaction in the patient’s medical record
Answer: C
Rationale: The priority is to stop the medication and maintain the airway to prevent further
exposure and ensure the patient can breathe. Other actions, such as notifying the provider, are
important but secondary.
Question 5
A nurse is caring for a patient receiving a potassium-sparing diuretic. Which food should the
nurse advise the patient to avoid?
A. Bananas
B. Rice
C. Apples
D. Bread
Answer: A
Rationale: Potassium-sparing diuretics, such as spironolactone, can cause hyperkalemia. High-
potassium foods, like bananas, should be avoided to prevent further increases in serum potassium
levels.
, Question 6
The nurse is teaching a patient about wound care for a stage 3 pressure ulcer. Which statement
by the patient indicates a need for further teaching?
A. “I will clean the wound with normal saline.”
B. “I will use a heat lamp to dry the wound faster.”
C. “I will eat foods high in protein to promote healing.”
D. “I will change the dressing as instructed by my healthcare provider.”
Answer: B
Rationale: Using a heat lamp can dry the wound and delay healing by damaging tissue. Normal
saline, proper nutrition, and following dressing change protocols are essential for wound care.
Question 7
A patient with heart failure is prescribed furosemide. What is the most important electrolyte
imbalance for the nurse to monitor?
A. Hypocalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypermagnesemia
Answer: B
Rationale: Furosemide, a loop diuretic, can cause significant potassium loss, leading to
hypokalemia. This electrolyte imbalance can result in arrhythmias and other complications.
Question 8
A nurse is providing discharge instructions to a patient prescribed warfarin. Which statement by
the patient indicates understanding of the teaching?
A. “I will take aspirin if I have a headache.”
B. “I need to avoid foods high in vitamin K, such as spinach.”
C. “I can drink alcohol as long as it is in moderation.”
D. “I will stop taking the medication if I notice bruising.”
Answer: B
Rationale: Vitamin K can interfere with warfarin’s anticoagulant effects. Patients should limit
foods high in vitamin K and maintain consistent dietary intake. Aspirin and alcohol should be
avoided, and bruising should be reported rather than discontinuing the medication abruptly.
