NSG 320 Exam 1 V2 | NSG 320 Adult
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 1) | Grand
Canyon University
1. A nurse is completing the preoperative checklist for a client scheduled for a
cholecystectomy. Which of the following actions are the responsibility of the nurse in the
preoperative phase? (Select all that apply)
A. Verifying that the informed consent form is signed and witnessed.
B. Ensuring the client has been NPO for the prescribed timeframe.
C. Performing the surgical site marking with the client.
D. Administering the prescribed preoperative antibiotics.
E. Explaining the risks and benefits of the surgical procedure.
F. Confirming the client’s identity using two identifiers.
Correct Answer: ABDF
Explanation: The preoperative nurse is responsible for verifying that the surgeon has
obtained consent and ensuring the client is physically prepared, such as being NPO. While
the nurse may witness the site marking, the surgeon is primarily responsible for marking
the site. The nurse never explains risks and benefits as this is the legal responsibility of the
provider performing the surgery.
,2. A client is admitted with a serum potassium level of 2.8 mEq/L. Which of the following
assessment findings should the nurse prioritize?
A. Hyperactive bowel sounds and diarrhea.
B. Increased muscle tone and tetany.
C. Irregular heart rate and flattened T-waves.
D. Tall, peaked T-waves on the ECG.
Correct Answer: C
Explanation: Hypokalemia significantly affects cardiac conduction and can lead to life-
threatening dysrhythmias. Flattened T-waves and U-waves are classic electrocardiogram
changes associated with low potassium. The nurse must prioritize cardiac monitoring to
ensure client safety during replacement therapy.
3. A client returns to the surgical unit from the PACU. Which assessment finding is most
indicative of a potential postoperative complication?
A. Sanguineous drainage on the dressing the size of a quarter.
B. Absent bowel sounds 2 hours after abdominal surgery.
C. A pulse oximetry reading of 89% on room air.
D. Pain rated as 7 on a scale of 0 to 10.
Correct Answer: C
, Explanation: A pulse oximetry reading below 90% indicates hypoxia and is the most
urgent finding among the choices. Postoperative clients are at high risk for atelectasis or
respiratory depression from anesthesia. While absent bowel sounds and pain are expected,
respiratory compromise requires immediate intervention.
4. A nurse is caring for a client with a pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 24 mEq/L.
The nurse interprets these results as:
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is above 45 mmHg,
indicating a respiratory cause. The bicarbonate level is within the normal range, suggesting
no compensation has occurred. This state is often seen in clients with hypoventilation or
COPD exacerbations.
5. Which of the following clients is at the highest risk for developing fluid volume deficit?
A. An elderly client with a persistent fever and diaphoresis.
B. A client with congestive heart failure receiving diuretics.
C. A client with end-stage renal disease on hemodialysis.
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 1) | Grand
Canyon University
1. A nurse is completing the preoperative checklist for a client scheduled for a
cholecystectomy. Which of the following actions are the responsibility of the nurse in the
preoperative phase? (Select all that apply)
A. Verifying that the informed consent form is signed and witnessed.
B. Ensuring the client has been NPO for the prescribed timeframe.
C. Performing the surgical site marking with the client.
D. Administering the prescribed preoperative antibiotics.
E. Explaining the risks and benefits of the surgical procedure.
F. Confirming the client’s identity using two identifiers.
Correct Answer: ABDF
Explanation: The preoperative nurse is responsible for verifying that the surgeon has
obtained consent and ensuring the client is physically prepared, such as being NPO. While
the nurse may witness the site marking, the surgeon is primarily responsible for marking
the site. The nurse never explains risks and benefits as this is the legal responsibility of the
provider performing the surgery.
,2. A client is admitted with a serum potassium level of 2.8 mEq/L. Which of the following
assessment findings should the nurse prioritize?
A. Hyperactive bowel sounds and diarrhea.
B. Increased muscle tone and tetany.
C. Irregular heart rate and flattened T-waves.
D. Tall, peaked T-waves on the ECG.
Correct Answer: C
Explanation: Hypokalemia significantly affects cardiac conduction and can lead to life-
threatening dysrhythmias. Flattened T-waves and U-waves are classic electrocardiogram
changes associated with low potassium. The nurse must prioritize cardiac monitoring to
ensure client safety during replacement therapy.
3. A client returns to the surgical unit from the PACU. Which assessment finding is most
indicative of a potential postoperative complication?
A. Sanguineous drainage on the dressing the size of a quarter.
B. Absent bowel sounds 2 hours after abdominal surgery.
C. A pulse oximetry reading of 89% on room air.
D. Pain rated as 7 on a scale of 0 to 10.
Correct Answer: C
, Explanation: A pulse oximetry reading below 90% indicates hypoxia and is the most
urgent finding among the choices. Postoperative clients are at high risk for atelectasis or
respiratory depression from anesthesia. While absent bowel sounds and pain are expected,
respiratory compromise requires immediate intervention.
4. A nurse is caring for a client with a pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 24 mEq/L.
The nurse interprets these results as:
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is above 45 mmHg,
indicating a respiratory cause. The bicarbonate level is within the normal range, suggesting
no compensation has occurred. This state is often seen in clients with hypoventilation or
COPD exacerbations.
5. Which of the following clients is at the highest risk for developing fluid volume deficit?
A. An elderly client with a persistent fever and diaphoresis.
B. A client with congestive heart failure receiving diuretics.
C. A client with end-stage renal disease on hemodialysis.
