NSG 320 Exam 2 V1 | NSG 320 Adult
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 2) | Grand
Canyon University
1. A nurse is assessing a client admitted with community-acquired pneumonia. Which clinical
manifestations should the nurse expect to find? (Select all that apply.)
A. Fever and chills
B. Productive cough with rust-colored sputum
C. Pleuritic chest pain
D. Bradycardia
E. Tachypnea
F. Dullness on percussion
Correct Answer: A, B, C, E, F
Explanation: Pneumonia is an inflammatory process that results in the accumulation of
exudate in the alveolar spaces, leading to impaired gas exchange. Common findings include
systemic signs of infection such as fever, and localized respiratory signs like a productive
cough and tachypnea. Physical examination often reveals dullness over consolidated lung
tissue and pleuritic pain during deep inspiration.
,2. A client is admitted with a suspected exacerbation of chronic obstructive pulmonary
disease (COPD). The nurse reviews the arterial blood gas (ABG) results: pH 7.31, PaCO2 58
mm Hg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Explanation: A pH of 7.31 is below the normal range of 7.35 to 7.45, indicating acidosis.
The PaCO2 is elevated at 58 mm Hg (normal 35-45), which suggests that the respiratory
system is the primary cause of the imbalance. Because the bicarbonate level is near normal,
this represents an uncompensated respiratory acidosis typical of COPD gas trapping.
3. The nurse is caring for a client with a potassium level of 6.2 mEq/L. Which of the following
interventions should the nurse anticipate? (Select all that apply.)
A. Administration of sodium polystyrene sulfonate
B. Continuous cardiac monitoring
C. Intravenous administration of regular insulin and dextrose
D. Encouraging the intake of bananas and orange juice
E. Administration of calcium gluconate
,Correct Answer: A, B, C, E
Explanation: A potassium level of 6.2 mEq/L indicates hyperkalemia, which poses a
significant risk for life-threatening cardiac dysrhythmias. Cardiac monitoring is essential to
detect changes such as peaked T waves or widened QRS complexes. Interventions like
insulin/dextrose and sodium polystyrene sulfonate help shift or remove potassium, while
calcium gluconate stabilizes the myocardial cell membrane.
4. A client with left-sided heart failure is being assessed by the nurse. Which findings are
consistent with this diagnosis? (Select all that apply.)
A. Dyspnea on exertion
B. Orthopnea
C. Crackles in the lung bases
D. Peripheral edema
E. Jugular venous distention
F. S3 heart sound
Correct Answer: A, B, C, F
Explanation: Left-sided heart failure primarily involves the backup of blood into the
pulmonary circulation, leading to pulmonary congestion. Manifestations include
respiratory distress such as dyspnea, orthopnea, and the presence of crackles upon
auscultation. An S3 gallop is also a common sign of ventricular volume overload, whereas
peripheral edema and JVD are more indicative of right-sided failure.
, 5. The nurse is preparing to administer insulin lispro to a client with type 1 diabetes mellitus.
At what time should the nurse ensure the client consumes their meal?
A. 30 to 60 minutes before administration
B. Within 15 minutes of administration
C. Exactly 1 hour after administration
D. Only if the blood glucose is above 200 mg/dL
Correct Answer: B
Explanation: Insulin lispro is a rapid-acting insulin with an onset of action between 10 to
30 minutes. To prevent hypoglycemia, the nurse must ensure that the meal tray is present
and the client eats within 15 minutes of receiving the injection. Administering this insulin
without immediate food intake can lead to a dangerous drop in blood glucose levels.
6. A nurse is reviewing the preoperative checklist for a client scheduled for an elective
cholecystectomy. Which action is the priority for the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure to the client
B. Informing the client about the recovery time and post-operative pain management
C. Witnessing the surgeon explain the alternative treatments to the client
D. Ensuring the surgeon has provided the necessary information and the client has signed
the form
Correct Answer: D
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 2) | Grand
Canyon University
1. A nurse is assessing a client admitted with community-acquired pneumonia. Which clinical
manifestations should the nurse expect to find? (Select all that apply.)
A. Fever and chills
B. Productive cough with rust-colored sputum
C. Pleuritic chest pain
D. Bradycardia
E. Tachypnea
F. Dullness on percussion
Correct Answer: A, B, C, E, F
Explanation: Pneumonia is an inflammatory process that results in the accumulation of
exudate in the alveolar spaces, leading to impaired gas exchange. Common findings include
systemic signs of infection such as fever, and localized respiratory signs like a productive
cough and tachypnea. Physical examination often reveals dullness over consolidated lung
tissue and pleuritic pain during deep inspiration.
,2. A client is admitted with a suspected exacerbation of chronic obstructive pulmonary
disease (COPD). The nurse reviews the arterial blood gas (ABG) results: pH 7.31, PaCO2 58
mm Hg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Explanation: A pH of 7.31 is below the normal range of 7.35 to 7.45, indicating acidosis.
The PaCO2 is elevated at 58 mm Hg (normal 35-45), which suggests that the respiratory
system is the primary cause of the imbalance. Because the bicarbonate level is near normal,
this represents an uncompensated respiratory acidosis typical of COPD gas trapping.
3. The nurse is caring for a client with a potassium level of 6.2 mEq/L. Which of the following
interventions should the nurse anticipate? (Select all that apply.)
A. Administration of sodium polystyrene sulfonate
B. Continuous cardiac monitoring
C. Intravenous administration of regular insulin and dextrose
D. Encouraging the intake of bananas and orange juice
E. Administration of calcium gluconate
,Correct Answer: A, B, C, E
Explanation: A potassium level of 6.2 mEq/L indicates hyperkalemia, which poses a
significant risk for life-threatening cardiac dysrhythmias. Cardiac monitoring is essential to
detect changes such as peaked T waves or widened QRS complexes. Interventions like
insulin/dextrose and sodium polystyrene sulfonate help shift or remove potassium, while
calcium gluconate stabilizes the myocardial cell membrane.
4. A client with left-sided heart failure is being assessed by the nurse. Which findings are
consistent with this diagnosis? (Select all that apply.)
A. Dyspnea on exertion
B. Orthopnea
C. Crackles in the lung bases
D. Peripheral edema
E. Jugular venous distention
F. S3 heart sound
Correct Answer: A, B, C, F
Explanation: Left-sided heart failure primarily involves the backup of blood into the
pulmonary circulation, leading to pulmonary congestion. Manifestations include
respiratory distress such as dyspnea, orthopnea, and the presence of crackles upon
auscultation. An S3 gallop is also a common sign of ventricular volume overload, whereas
peripheral edema and JVD are more indicative of right-sided failure.
, 5. The nurse is preparing to administer insulin lispro to a client with type 1 diabetes mellitus.
At what time should the nurse ensure the client consumes their meal?
A. 30 to 60 minutes before administration
B. Within 15 minutes of administration
C. Exactly 1 hour after administration
D. Only if the blood glucose is above 200 mg/dL
Correct Answer: B
Explanation: Insulin lispro is a rapid-acting insulin with an onset of action between 10 to
30 minutes. To prevent hypoglycemia, the nurse must ensure that the meal tray is present
and the client eats within 15 minutes of receiving the injection. Administering this insulin
without immediate food intake can lead to a dangerous drop in blood glucose levels.
6. A nurse is reviewing the preoperative checklist for a client scheduled for an elective
cholecystectomy. Which action is the priority for the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure to the client
B. Informing the client about the recovery time and post-operative pain management
C. Witnessing the surgeon explain the alternative treatments to the client
D. Ensuring the surgeon has provided the necessary information and the client has signed
the form
Correct Answer: D
