NSG430 Exam 1 V1 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A nurse is assessing a patient with a history of heart failure who presents with dyspnea and
orthopnea. Which physical assessment finding most specifically indicates left-sided heart
failure?
A. Jugular venous distention (JVD)
B. Peripheral edema in the lower extremities
C. Hepatosplenomegaly
D. Crackles heard upon lung auscultation
Answer: D
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
leading to pulmonary congestion and crackles. JVD and peripheral edema are primary
indicators of right-sided heart failure, as blood backs up into the systemic circulation. This
distinction is critical for identifying the specific pathophysiology and guiding appropriate
nursing interventions for the adult patient.
2. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The pH is below the normal range of 7.35-7.45, indicating acidosis. The PaCO2
is elevated above 45 mmHg, which points toward a respiratory cause for the low pH.
Because the bicarbonate level is within the normal range, this represents uncompensated
respiratory acidosis, often seen in conditions like COPD or respiratory depression.
3. A nurse is caring for a patient with a serum potassium level of 6.2 mEq/L. Which cardiac
monitor change should the nurse prioritize for reporting?
A. ST-segment depression
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged PR interval
Answer: C
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, directly affects
cardiac conduction and can lead to lethal dysrhythmias. Tall, peaked T waves are one of the
earliest signs of hyperkalemia on an EKG. Prompt recognition is essential for initiating life-
saving treatments like calcium gluconate or insulin/dextrose to shift potassium back into
cells.
, 4. Which assessment finding should the nurse prioritize in a patient receiving a new
prescription for an ACE inhibitor?
A. A dry, nonproductive cough
B. A slight decrease in blood pressure
C. Increased urinary output
D. Swelling of the lips and tongue
Answer: D
Rationale: Angioedema is a rare but life-threatening adverse effect of ACE inhibitors that
causes rapid swelling of the airway. While a dry cough is a common side effect, it is not an
emergency like airway compromise. The nurse must prioritize airway safety and advocate
for immediate discontinuation of the medication if angioedema is suspected.
5. A patient is diagnosed with Chronic Obstructive Pulmonary Disease (COPD). Which
instruction is most important for the nurse to include in the discharge teaching regarding
oxygen therapy?
A. Maintain oxygen flow at high rates (6-10 L/min) to prevent hypoxia.
B. Only use oxygen when feeling severely short of breath.
C. Ensure the oxygen tubing is at least 50 feet long for mobility.
D. Do not change the flow rate of the oxygen without a physician’s order.
Answer: D
Nursing II | Grand Canyon University
1. A nurse is assessing a patient with a history of heart failure who presents with dyspnea and
orthopnea. Which physical assessment finding most specifically indicates left-sided heart
failure?
A. Jugular venous distention (JVD)
B. Peripheral edema in the lower extremities
C. Hepatosplenomegaly
D. Crackles heard upon lung auscultation
Answer: D
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
leading to pulmonary congestion and crackles. JVD and peripheral edema are primary
indicators of right-sided heart failure, as blood backs up into the systemic circulation. This
distinction is critical for identifying the specific pathophysiology and guiding appropriate
nursing interventions for the adult patient.
2. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The pH is below the normal range of 7.35-7.45, indicating acidosis. The PaCO2
is elevated above 45 mmHg, which points toward a respiratory cause for the low pH.
Because the bicarbonate level is within the normal range, this represents uncompensated
respiratory acidosis, often seen in conditions like COPD or respiratory depression.
3. A nurse is caring for a patient with a serum potassium level of 6.2 mEq/L. Which cardiac
monitor change should the nurse prioritize for reporting?
A. ST-segment depression
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged PR interval
Answer: C
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, directly affects
cardiac conduction and can lead to lethal dysrhythmias. Tall, peaked T waves are one of the
earliest signs of hyperkalemia on an EKG. Prompt recognition is essential for initiating life-
saving treatments like calcium gluconate or insulin/dextrose to shift potassium back into
cells.
, 4. Which assessment finding should the nurse prioritize in a patient receiving a new
prescription for an ACE inhibitor?
A. A dry, nonproductive cough
B. A slight decrease in blood pressure
C. Increased urinary output
D. Swelling of the lips and tongue
Answer: D
Rationale: Angioedema is a rare but life-threatening adverse effect of ACE inhibitors that
causes rapid swelling of the airway. While a dry cough is a common side effect, it is not an
emergency like airway compromise. The nurse must prioritize airway safety and advocate
for immediate discontinuation of the medication if angioedema is suspected.
5. A patient is diagnosed with Chronic Obstructive Pulmonary Disease (COPD). Which
instruction is most important for the nurse to include in the discharge teaching regarding
oxygen therapy?
A. Maintain oxygen flow at high rates (6-10 L/min) to prevent hypoxia.
B. Only use oxygen when feeling severely short of breath.
C. Ensure the oxygen tubing is at least 50 feet long for mobility.
D. Do not change the flow rate of the oxygen without a physician’s order.
Answer: D
