NSG430 Exam 1 V2 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L/min via nasal cannula. The patient’s oxygen saturation is 89%. What is
the most appropriate nursing action?
A. Continue to monitor the patient as this is an expected finding for COPD.
B. Increase the oxygen flow rate to 10 L/min immediately.
C. Switch the patient to a non-rebreather mask at 15 L/min.
D. Notify the rapid response team for impending respiratory failure.
Answer: A
Rationale: Patients with COPD often have a lower baseline oxygen saturation, typically
ranging from 88% to 92%. Providing too much oxygen can suppress their hypoxic drive to
breathe, leading to carbon dioxide retention. The nurse should maintain the current
therapy and continue assessing for signs of respiratory distress.
2. Which assessment finding is most indicative of right-sided heart failure?
A. Crackles in the lower lung bases.
B. Jugular venous distention (JVD).
C. Pink, frothy sputum production.
,D. Orthopnea and paroxysmal nocturnal dyspnea.
Answer: B
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle cannot effectively pump blood into the lungs. This congestion manifests as
jugular venous distention, peripheral edema, and hepatomegaly. Left-sided heart failure
symptoms, such as crackles and frothy sputum, relate to pulmonary congestion.
3. A nurse is assigned to four patients. Which patient should the nurse assess first?
A. A patient with a history of heart failure reporting a 2-pound weight gain in a week.
B. A patient with chronic pain requesting their scheduled PRN analgesic.
C. A patient with hypertension who needs their morning dose of Lisinopril.
D. A patient who had a thoracentesis 2 hours ago and is now reporting shortness of breath.
Answer: D
Rationale: Shortness of breath after a thoracentesis is a critical finding that may indicate a
pneumothorax, which is a medical emergency. The nurse must prioritize the airway and
breathing of this patient over the routine assessments or medications of others. Timely
intervention can prevent further respiratory compromise and improve patient outcomes.
4. The nurse is educating a patient about a new prescription for Lisinopril. Which side effect
should the nurse instruct the patient to report immediately?
A. Swelling of the lips or tongue.
, B. Increased appetite.
C. Occasional mild headache.
D. A slight increase in urine output.
Answer: A
Rationale: Swelling of the lips or tongue indicates angioedema, a potentially life-
threatening adverse effect of ACE inhibitors like Lisinopril. This condition can lead to
airway obstruction and requires immediate medical intervention. Other common side
effects like a dry cough should be noted, but angioedema is the highest priority.
5. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Assisting a stable patient with a bed bath and oral hygiene.
B. Evaluating the effectiveness of a patient’s pain medication.
C. Teaching a patient how to use an incentive spirometer.
D. Assessing the lung sounds of a patient with pneumonia.
Answer: A
Rationale: The UAP’s scope of practice includes routine tasks such as hygiene, nutrition,
and ambulation for stable patients. Evaluation, assessment, and teaching are professional
nursing responsibilities that cannot be delegated. Ensuring tasks are delegated
appropriately maintains patient safety and adheres to legal nursing standards.
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen at 2 L/min via nasal cannula. The patient’s oxygen saturation is 89%. What is
the most appropriate nursing action?
A. Continue to monitor the patient as this is an expected finding for COPD.
B. Increase the oxygen flow rate to 10 L/min immediately.
C. Switch the patient to a non-rebreather mask at 15 L/min.
D. Notify the rapid response team for impending respiratory failure.
Answer: A
Rationale: Patients with COPD often have a lower baseline oxygen saturation, typically
ranging from 88% to 92%. Providing too much oxygen can suppress their hypoxic drive to
breathe, leading to carbon dioxide retention. The nurse should maintain the current
therapy and continue assessing for signs of respiratory distress.
2. Which assessment finding is most indicative of right-sided heart failure?
A. Crackles in the lower lung bases.
B. Jugular venous distention (JVD).
C. Pink, frothy sputum production.
,D. Orthopnea and paroxysmal nocturnal dyspnea.
Answer: B
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle cannot effectively pump blood into the lungs. This congestion manifests as
jugular venous distention, peripheral edema, and hepatomegaly. Left-sided heart failure
symptoms, such as crackles and frothy sputum, relate to pulmonary congestion.
3. A nurse is assigned to four patients. Which patient should the nurse assess first?
A. A patient with a history of heart failure reporting a 2-pound weight gain in a week.
B. A patient with chronic pain requesting their scheduled PRN analgesic.
C. A patient with hypertension who needs their morning dose of Lisinopril.
D. A patient who had a thoracentesis 2 hours ago and is now reporting shortness of breath.
Answer: D
Rationale: Shortness of breath after a thoracentesis is a critical finding that may indicate a
pneumothorax, which is a medical emergency. The nurse must prioritize the airway and
breathing of this patient over the routine assessments or medications of others. Timely
intervention can prevent further respiratory compromise and improve patient outcomes.
4. The nurse is educating a patient about a new prescription for Lisinopril. Which side effect
should the nurse instruct the patient to report immediately?
A. Swelling of the lips or tongue.
, B. Increased appetite.
C. Occasional mild headache.
D. A slight increase in urine output.
Answer: A
Rationale: Swelling of the lips or tongue indicates angioedema, a potentially life-
threatening adverse effect of ACE inhibitors like Lisinopril. This condition can lead to
airway obstruction and requires immediate medical intervention. Other common side
effects like a dry cough should be noted, but angioedema is the highest priority.
5. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Assisting a stable patient with a bed bath and oral hygiene.
B. Evaluating the effectiveness of a patient’s pain medication.
C. Teaching a patient how to use an incentive spirometer.
D. Assessing the lung sounds of a patient with pneumonia.
Answer: A
Rationale: The UAP’s scope of practice includes routine tasks such as hygiene, nutrition,
and ambulation for stable patients. Evaluation, assessment, and teaching are professional
nursing responsibilities that cannot be delegated. Ensuring tasks are delegated
appropriately maintains patient safety and adheres to legal nursing standards.
