NSG 320 exam 4 Questions With Complete
Solutions
Course
NSG 320
1. A nurse is caring for a patient who is 3 days post-operative from a hip
replacement. The patient has a Foley catheter in place. The nurse notes a
decrease in urine output over the past 8 hours. What is the most appropriate first
action for the nurse to take?
A. Notify the healthcare provider immediately.
B. Check the patient's bladder for distention.
C. Irrigate the Foley catheter.
D. Increase the IV fluids.
Correct Answer: B. Check the patient's bladder for distention.
Explanation: Before notifying the healthcare provider, the nurse should first assess for bladder
distention, which could indicate a blockage or kink in the catheter. Checking the bladder allows
for a non-invasive evaluation of the situation.
2. A nurse is caring for a patient who has just been diagnosed with diabetes
mellitus. The patient asks how insulin works. How should the nurse respond?
A. "Insulin helps your body break down carbohydrates."
B. "Insulin helps your body use glucose for energy."
C. "Insulin prevents your body from making glucose."
D. "Insulin helps your body store glucose in the liver."
Correct Answer: B. "Insulin helps your body use glucose for energy."
Explanation: Insulin allows glucose to enter cells, where it can be used for energy. In people
with diabetes, insulin is either insufficient or ineffective, preventing glucose from entering cells.
3. A nurse is assessing a postoperative patient who had abdominal surgery. The
nurse notices absent bowel sounds and the patient reports nausea and vomiting.
What is the most likely cause?
A. Paralytic ileus
B. Gastrointestinal hemorrhage
C. Appendicitis
D. Bowel perforation
,Correct Answer: A. Paralytic ileus
Explanation: Paralytic ileus is a common postoperative complication, characterized by absent
bowel sounds and nausea/vomiting. It is caused by a temporary cessation of bowel motility
following surgery.
4. A nurse is caring for a patient who has been receiving morphine for pain
management. The nurse notes the patient is drowsy but arousable, has a
respiratory rate of 8 breaths per minute, and is difficult to rouse. What is the
priority intervention?
A. Administer naloxone (Narcan).
B. Decrease the dose of morphine.
C. Increase the oxygen supply.
D. Reassure the patient that these symptoms are normal.
Correct Answer: A. Administer naloxone (Narcan).
Explanation: The patient is exhibiting signs of opioid overdose (respiratory depression and
decreased arousal). Naloxone is an opioid antagonist and should be administered to reverse the
effects of morphine and prevent respiratory arrest.
5. A patient is receiving warfarin therapy. The nurse notes that the patient's
International Normalized Ratio (INR) is 4.5. What action should the nurse take?
A. Administer vitamin K.
B. Continue with the current dose of warfarin.
C. Increase the dose of warfarin.
D. Hold the next dose of warfarin.
Correct Answer: A. Administer vitamin K.
Explanation: An INR of 4.5 is above the therapeutic range for warfarin, indicating that the
blood is too thin, and there is a risk for bleeding. Vitamin K is the antidote to reverse the effects
of warfarin.
6. A nurse is teaching a patient with hypertension about lifestyle modifications.
Which of the following should the nurse include in the teaching?
A. Increase intake of foods high in sodium.
B. Engage in regular aerobic exercise.
,C. Limit alcohol intake to more than three drinks per day.
D. Use relaxation techniques only when blood pressure is elevated.
Correct Answer: B. Engage in regular aerobic exercise.
Explanation: Regular aerobic exercise can help lower blood pressure and improve overall
cardiovascular health. Patients with hypertension should also reduce sodium intake, limit alcohol
consumption, and use relaxation techniques regularly.
7. A nurse is caring for a patient with chronic obstructive pulmonary disease
(COPD). The patient is on oxygen therapy and has an oxygen saturation level of
92%. The nurse should assess the patient for which of the following?
A. Hypercapnia
B. Hypokalemia
C. Hypoglycemia
D. Dehydration
Correct Answer: A. Hypercapnia
Explanation: Patients with COPD are at risk for hypercapnia (increased carbon dioxide levels)
due to their compromised ability to expel CO2. An oxygen saturation level of 92% is acceptable
for COPD patients, but further assessment for CO2 retention is necessary.
8. A nurse is caring for a patient with a new diagnosis of heart failure. The
patient reports shortness of breath, increased fatigue, and swelling in the legs.
What is the most appropriate nursing intervention?
A. Increase the patient's fluid intake.
B. Encourage the patient to rest in a supine position.
C. Administer a diuretic as prescribed.
D. Monitor blood pressure every 4 hours.
Correct Answer: C. Administer a diuretic as prescribed.
Explanation: Diuretics are commonly used to treat heart failure by reducing fluid retention,
which helps relieve symptoms like shortness of breath and leg swelling. Ensuring fluid balance is
crucial in heart failure management.
9. A nurse is assessing a patient who is 24 hours post-abdominal surgery. The
nurse notes that the patient is experiencing sharp abdominal pain, distension,
and has not passed flatus. What is the most likely cause of these symptoms?
, A. Bowel obstruction
B. Postoperative ileus
C. Pancreatitis
D. Gastrointestinal bleeding
Correct Answer: B. Postoperative ileus
Explanation: A postoperative ileus is common after abdominal surgery and is characterized by
abdominal pain, distension, and an inability to pass flatus or stool. This condition results from
temporary cessation of bowel motility.
10. A patient with diabetes mellitus is admitted with diabetic ketoacidosis (DKA).
The nurse should prioritize which of the following interventions?
A. Administer insulin infusion.
B. Administer a diuretic.
C. Increase fluid intake.
D. Monitor the blood glucose every 2 hours.
Correct Answer: A. Administer insulin infusion.
Explanation: The primary treatment for DKA is insulin administration to lower blood glucose
levels and resolve ketosis. Fluid replacement is also essential, but the immediate priority is to
correct the hyperglycemia.
11. A nurse is caring for a patient with pneumonia. The patient’s oxygen saturation is 88%,
and the respiratory rate is 28 breaths per minute. What is the most appropriate
intervention?
A. Administer a bronchodilator as ordered.
B. Increase the oxygen flow rate.
C. Encourage the patient to deep breathe and cough.
D. Notify the healthcare provider immediately.
Correct Answer: B. Increase the oxygen flow rate.
Explanation: The patient's oxygen saturation of 88% is below the normal range, indicating
hypoxia. Increasing the oxygen flow rate is necessary to improve oxygenation and ensure
adequate tissue perfusion.
12. A nurse is caring for a patient with a newly inserted nasogastric (NG) tube. What is the
most important action to confirm proper placement of the NG tube?
A. Attach the NG tube to suction.
B. Check the pH of aspirate from the tube.
Solutions
Course
NSG 320
1. A nurse is caring for a patient who is 3 days post-operative from a hip
replacement. The patient has a Foley catheter in place. The nurse notes a
decrease in urine output over the past 8 hours. What is the most appropriate first
action for the nurse to take?
A. Notify the healthcare provider immediately.
B. Check the patient's bladder for distention.
C. Irrigate the Foley catheter.
D. Increase the IV fluids.
Correct Answer: B. Check the patient's bladder for distention.
Explanation: Before notifying the healthcare provider, the nurse should first assess for bladder
distention, which could indicate a blockage or kink in the catheter. Checking the bladder allows
for a non-invasive evaluation of the situation.
2. A nurse is caring for a patient who has just been diagnosed with diabetes
mellitus. The patient asks how insulin works. How should the nurse respond?
A. "Insulin helps your body break down carbohydrates."
B. "Insulin helps your body use glucose for energy."
C. "Insulin prevents your body from making glucose."
D. "Insulin helps your body store glucose in the liver."
Correct Answer: B. "Insulin helps your body use glucose for energy."
Explanation: Insulin allows glucose to enter cells, where it can be used for energy. In people
with diabetes, insulin is either insufficient or ineffective, preventing glucose from entering cells.
3. A nurse is assessing a postoperative patient who had abdominal surgery. The
nurse notices absent bowel sounds and the patient reports nausea and vomiting.
What is the most likely cause?
A. Paralytic ileus
B. Gastrointestinal hemorrhage
C. Appendicitis
D. Bowel perforation
,Correct Answer: A. Paralytic ileus
Explanation: Paralytic ileus is a common postoperative complication, characterized by absent
bowel sounds and nausea/vomiting. It is caused by a temporary cessation of bowel motility
following surgery.
4. A nurse is caring for a patient who has been receiving morphine for pain
management. The nurse notes the patient is drowsy but arousable, has a
respiratory rate of 8 breaths per minute, and is difficult to rouse. What is the
priority intervention?
A. Administer naloxone (Narcan).
B. Decrease the dose of morphine.
C. Increase the oxygen supply.
D. Reassure the patient that these symptoms are normal.
Correct Answer: A. Administer naloxone (Narcan).
Explanation: The patient is exhibiting signs of opioid overdose (respiratory depression and
decreased arousal). Naloxone is an opioid antagonist and should be administered to reverse the
effects of morphine and prevent respiratory arrest.
5. A patient is receiving warfarin therapy. The nurse notes that the patient's
International Normalized Ratio (INR) is 4.5. What action should the nurse take?
A. Administer vitamin K.
B. Continue with the current dose of warfarin.
C. Increase the dose of warfarin.
D. Hold the next dose of warfarin.
Correct Answer: A. Administer vitamin K.
Explanation: An INR of 4.5 is above the therapeutic range for warfarin, indicating that the
blood is too thin, and there is a risk for bleeding. Vitamin K is the antidote to reverse the effects
of warfarin.
6. A nurse is teaching a patient with hypertension about lifestyle modifications.
Which of the following should the nurse include in the teaching?
A. Increase intake of foods high in sodium.
B. Engage in regular aerobic exercise.
,C. Limit alcohol intake to more than three drinks per day.
D. Use relaxation techniques only when blood pressure is elevated.
Correct Answer: B. Engage in regular aerobic exercise.
Explanation: Regular aerobic exercise can help lower blood pressure and improve overall
cardiovascular health. Patients with hypertension should also reduce sodium intake, limit alcohol
consumption, and use relaxation techniques regularly.
7. A nurse is caring for a patient with chronic obstructive pulmonary disease
(COPD). The patient is on oxygen therapy and has an oxygen saturation level of
92%. The nurse should assess the patient for which of the following?
A. Hypercapnia
B. Hypokalemia
C. Hypoglycemia
D. Dehydration
Correct Answer: A. Hypercapnia
Explanation: Patients with COPD are at risk for hypercapnia (increased carbon dioxide levels)
due to their compromised ability to expel CO2. An oxygen saturation level of 92% is acceptable
for COPD patients, but further assessment for CO2 retention is necessary.
8. A nurse is caring for a patient with a new diagnosis of heart failure. The
patient reports shortness of breath, increased fatigue, and swelling in the legs.
What is the most appropriate nursing intervention?
A. Increase the patient's fluid intake.
B. Encourage the patient to rest in a supine position.
C. Administer a diuretic as prescribed.
D. Monitor blood pressure every 4 hours.
Correct Answer: C. Administer a diuretic as prescribed.
Explanation: Diuretics are commonly used to treat heart failure by reducing fluid retention,
which helps relieve symptoms like shortness of breath and leg swelling. Ensuring fluid balance is
crucial in heart failure management.
9. A nurse is assessing a patient who is 24 hours post-abdominal surgery. The
nurse notes that the patient is experiencing sharp abdominal pain, distension,
and has not passed flatus. What is the most likely cause of these symptoms?
, A. Bowel obstruction
B. Postoperative ileus
C. Pancreatitis
D. Gastrointestinal bleeding
Correct Answer: B. Postoperative ileus
Explanation: A postoperative ileus is common after abdominal surgery and is characterized by
abdominal pain, distension, and an inability to pass flatus or stool. This condition results from
temporary cessation of bowel motility.
10. A patient with diabetes mellitus is admitted with diabetic ketoacidosis (DKA).
The nurse should prioritize which of the following interventions?
A. Administer insulin infusion.
B. Administer a diuretic.
C. Increase fluid intake.
D. Monitor the blood glucose every 2 hours.
Correct Answer: A. Administer insulin infusion.
Explanation: The primary treatment for DKA is insulin administration to lower blood glucose
levels and resolve ketosis. Fluid replacement is also essential, but the immediate priority is to
correct the hyperglycemia.
11. A nurse is caring for a patient with pneumonia. The patient’s oxygen saturation is 88%,
and the respiratory rate is 28 breaths per minute. What is the most appropriate
intervention?
A. Administer a bronchodilator as ordered.
B. Increase the oxygen flow rate.
C. Encourage the patient to deep breathe and cough.
D. Notify the healthcare provider immediately.
Correct Answer: B. Increase the oxygen flow rate.
Explanation: The patient's oxygen saturation of 88% is below the normal range, indicating
hypoxia. Increasing the oxygen flow rate is necessary to improve oxygenation and ensure
adequate tissue perfusion.
12. A nurse is caring for a patient with a newly inserted nasogastric (NG) tube. What is the
most important action to confirm proper placement of the NG tube?
A. Attach the NG tube to suction.
B. Check the pH of aspirate from the tube.
