NSG 320 Exam 2 V2 | NSG 320 Adult
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 2) | Grand
Canyon University
1. A nurse is assessing a client who is 24 hours postoperative following abdominal surgery.
Which of the following findings should the nurse identify as an early manifestation of
respiratory distress? (Select all that apply)
A. Tachypnea
B. Tachycardia
C. Restlessness
D. Cyanosis
E. Stridor
F. Use of accessory muscles
Correct Answer: ABC
Explanation: Early manifestations of respiratory distress or hypoxia include restlessness,
tachycardia, and tachypnea as the body attempts to compensate for decreased oxygen
levels. Cyanosis is considered a late sign of hypoxia and indicates severe desaturation. The
nurse must prioritize monitoring the patient’s mental status and vital signs to detect early
deterioration before physical signs like accessory muscle use become prominent.
,2. A nurse is caring for a client with a potassium level of 6.2 mEq/L. Which of the following
medications should the nurse expect to administer to stabilize the cardiac membrane?
A. Furosemide
B. Sodium polystyrene sulfonate
C. Calcium gluconate
D. Insulin with dextrose
Correct Answer: C
Explanation: Calcium gluconate is administered in severe hyperkalemia to antagonize the
effect of potassium on the heart and stabilize the myocardial cell membrane. While insulin
with dextrose and sodium polystyrene sulfonate help lower the actual potassium level, they
do not provide immediate protection to the heart. The nurse should monitor the ECG for
changes such as peaked T waves or widened QRS complexes during administration.
3. A client is admitted with metabolic acidosis. Which of the following arterial blood gas
(ABG) results should the nurse expect?
A. pH 7.32, PaCO2 50, HCO3 28
B. pH 7.50, PaCO2 30, HCO3 24
C. pH 7.30, PaCO2 40, HCO3 18
D. pH 7.48, PaCO2 45, HCO3 30
Correct Answer: C
,Explanation: Metabolic acidosis is characterized by a low pH (less than 7.35) and a low
bicarbonate level (less than 22 mEq/L). In this scenario, the pH of 7.30 and HCO3 of 18
reflect a primary metabolic problem. The PaCO2 remains within the normal range,
indicating that respiratory compensation has not yet occurred or is insufficient.
4. A nurse is teaching a client about pursed-lip breathing. Which of the following statements
by the nurse explains the purpose of this technique?
A. It increases the rate of breathing to expel CO2.
B. It increases the strength of the diaphragm.
C. It prevents airway collapse during expiration.
D. It allows for deeper inhalation of oxygen.
Correct Answer: C
Explanation: Pursed-lip breathing helps to maintain positive pressure in the airways,
which prevents them from collapsing during exhalation. This technique is particularly
beneficial for clients with COPD who experience air trapping in the alveoli. By prolonging
exhalation, the client can more effectively clear carbon dioxide from the lungs.
5. Which of the following actions should the nurse take when obtaining informed consent
from a client scheduled for surgery?
A. Explain the risks and benefits of the procedure.
B. Describe the alternative treatments available.
C. Verify that the client understands the information provided.
, D. Provide the client with a detailed description of the surgical steps.
Correct Answer: C
Explanation: The nurse’s primary responsibility in the informed consent process is to
witness the signature and verify that the client is competent and understands the
information. It is the surgeon’s responsibility to explain the procedure, risks, benefits, and
alternatives to the client. If the nurse identifies that the client has further questions, the
surgeon must be called back to provide clarification.
6. A client has a serum sodium level of 128 mEq/L. Which of the following nursing
interventions is a priority?
A. Implement seizure precautions.
B. Administer a 0.45% sodium chloride IV infusion.
C. Encourage increased oral fluid intake.
D. Initiate a low-sodium diet.
Correct Answer: A
Explanation: Hyponatremia (sodium level less than 135 mEq/L) puts the client at high risk
for cerebral edema and neurological complications, including seizures. Implementing
seizure precautions is a critical safety measure for clients with significantly low sodium
levels. The nurse should also anticipate fluid restrictions or hypertonic saline depending on
the severity and cause of the imbalance.
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 2) | Grand
Canyon University
1. A nurse is assessing a client who is 24 hours postoperative following abdominal surgery.
Which of the following findings should the nurse identify as an early manifestation of
respiratory distress? (Select all that apply)
A. Tachypnea
B. Tachycardia
C. Restlessness
D. Cyanosis
E. Stridor
F. Use of accessory muscles
Correct Answer: ABC
Explanation: Early manifestations of respiratory distress or hypoxia include restlessness,
tachycardia, and tachypnea as the body attempts to compensate for decreased oxygen
levels. Cyanosis is considered a late sign of hypoxia and indicates severe desaturation. The
nurse must prioritize monitoring the patient’s mental status and vital signs to detect early
deterioration before physical signs like accessory muscle use become prominent.
,2. A nurse is caring for a client with a potassium level of 6.2 mEq/L. Which of the following
medications should the nurse expect to administer to stabilize the cardiac membrane?
A. Furosemide
B. Sodium polystyrene sulfonate
C. Calcium gluconate
D. Insulin with dextrose
Correct Answer: C
Explanation: Calcium gluconate is administered in severe hyperkalemia to antagonize the
effect of potassium on the heart and stabilize the myocardial cell membrane. While insulin
with dextrose and sodium polystyrene sulfonate help lower the actual potassium level, they
do not provide immediate protection to the heart. The nurse should monitor the ECG for
changes such as peaked T waves or widened QRS complexes during administration.
3. A client is admitted with metabolic acidosis. Which of the following arterial blood gas
(ABG) results should the nurse expect?
A. pH 7.32, PaCO2 50, HCO3 28
B. pH 7.50, PaCO2 30, HCO3 24
C. pH 7.30, PaCO2 40, HCO3 18
D. pH 7.48, PaCO2 45, HCO3 30
Correct Answer: C
,Explanation: Metabolic acidosis is characterized by a low pH (less than 7.35) and a low
bicarbonate level (less than 22 mEq/L). In this scenario, the pH of 7.30 and HCO3 of 18
reflect a primary metabolic problem. The PaCO2 remains within the normal range,
indicating that respiratory compensation has not yet occurred or is insufficient.
4. A nurse is teaching a client about pursed-lip breathing. Which of the following statements
by the nurse explains the purpose of this technique?
A. It increases the rate of breathing to expel CO2.
B. It increases the strength of the diaphragm.
C. It prevents airway collapse during expiration.
D. It allows for deeper inhalation of oxygen.
Correct Answer: C
Explanation: Pursed-lip breathing helps to maintain positive pressure in the airways,
which prevents them from collapsing during exhalation. This technique is particularly
beneficial for clients with COPD who experience air trapping in the alveoli. By prolonging
exhalation, the client can more effectively clear carbon dioxide from the lungs.
5. Which of the following actions should the nurse take when obtaining informed consent
from a client scheduled for surgery?
A. Explain the risks and benefits of the procedure.
B. Describe the alternative treatments available.
C. Verify that the client understands the information provided.
, D. Provide the client with a detailed description of the surgical steps.
Correct Answer: C
Explanation: The nurse’s primary responsibility in the informed consent process is to
witness the signature and verify that the client is competent and understands the
information. It is the surgeon’s responsibility to explain the procedure, risks, benefits, and
alternatives to the client. If the nurse identifies that the client has further questions, the
surgeon must be called back to provide clarification.
6. A client has a serum sodium level of 128 mEq/L. Which of the following nursing
interventions is a priority?
A. Implement seizure precautions.
B. Administer a 0.45% sodium chloride IV infusion.
C. Encourage increased oral fluid intake.
D. Initiate a low-sodium diet.
Correct Answer: A
Explanation: Hyponatremia (sodium level less than 135 mEq/L) puts the client at high risk
for cerebral edema and neurological complications, including seizures. Implementing
seizure precautions is a critical safety measure for clients with significantly low sodium
levels. The nurse should also anticipate fluid restrictions or hypertonic saline depending on
the severity and cause of the imbalance.
