NSG 320 Exam 2 V3 | NSG 320 Adult
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 2) | Grand
Canyon University
1. A patient with a history of heart failure is admitted with reports of shortness of breath and
a 5-lb weight gain over the last 48 hours. Which assessment finding is most indicative of fluid
volume excess?
A. Flat neck veins when the patient is supine
B. Tenting of the skin on the forehead
C. Decrease in central venous pressure (CVP)
D. Presence of S3 gallop and crackles in lungs
Correct Answer: D
Explanation: The presence of an S3 gallop and crackles in the lungs are hallmark signs of
fluid overload affecting the cardiovascular and respiratory systems. These findings indicate
that the heart is struggling to pump the excess volume and fluid is backing up into the
pulmonary circulation. The nurse should prioritize respiratory assessment and notify the
provider for potential diuretic administration.
2. A nurse is reviewing the lab results for a patient with prolonged nasogastric suctioning.
Which findings would suggest the patient is experiencing hypokalemia? (Select all that apply)
A. Serum potassium 3.2 mEq/L
,B. Prominent U waves on ECG
C. Muscle weakness and leg cramps
D. Hyperactive bowel sounds
E. Peaked T waves on ECG
F. Weak, irregular pulse
Correct Answer: A, B, C, F
Explanation: Hypokalemia is characterized by a serum potassium level below 3.5 mEq/L
and specific cardiac changes like prominent U waves. Clinical symptoms often include
muscle weakness and cardiac dysrhythmias such as a weak or irregular pulse due to the
role of potassium in muscle contraction and electrical conduction. Peaked T waves and
hyperactive bowel sounds are more commonly associated with hyperkalemia, not
hypokalemia.
3. The nurse is caring for a patient whose arterial blood gas (ABG) results are as follows: pH
7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the nurse interpret these results?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Correct Answer: A
,Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate level (HCO3) is within the normal range of 22-26
mEq/L, the condition is respiratory acidosis without compensation. This state is frequently
seen in patients with hypoventilation or obstructive lung diseases.
4. A patient is scheduled for an elective cholecystectomy. During the preoperative
assessment, the patient states, ‘I am not really sure why they are taking out my gallbladder.’
Which action by the nurse is most appropriate?
A. Explain the risks and benefits of the surgery to the patient.
B. Ask the patient’s spouse to sign the consent form instead.
C. Notify the surgeon that the patient does not understand the procedure.
D. Document that the patient is anxious but proceed with preoperative meds.
Correct Answer: C
Explanation: The surgeon is legally responsible for obtaining informed consent and
explaining the procedure’s risks, benefits, and alternatives. If the patient expresses a lack of
understanding, the nurse’s role is to act as an advocate and notify the surgeon to provide
further clarification. The nurse should not explain the procedure themselves, as this falls
outside their scope of practice regarding informed consent.
5. Which nursing intervention is a priority for a patient in the immediate postoperative period
to prevent atelectasis?
A. Administering prophylactic antibiotics
, B. Maintaining the patient in a supine position
C. Encouraging frequent use of the incentive spirometer
D. Limiting fluid intake to prevent pulmonary edema
Correct Answer: C
Explanation: Incentive spirometry encourages deep breathing and lung expansion, which
helps prevent the collapse of alveoli known as atelectasis. This is a critical intervention
during the postoperative phase when patients are at risk due to anesthesia and pain-
related shallow breathing. The nurse should also encourage early ambulation and
repositioning to further promote respiratory function.
6. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula at 2 L/min. Which finding would be most concerning to the nurse?
A. Oxygen saturation (SpO2) of 90%
B. Patient reporting mild dyspnea on exertion
C. Bicarbonate (HCO3) level of 28 mEq/L
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Explanation: In some patients with chronic hypercapnia (COPD), high levels of oxygen can
potentially suppress the hypoxic drive, leading to significant hypoventilation. A respiratory
rate of 10 is low and may indicate that the patient’s drive to breathe is diminishing,
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 2) | Grand
Canyon University
1. A patient with a history of heart failure is admitted with reports of shortness of breath and
a 5-lb weight gain over the last 48 hours. Which assessment finding is most indicative of fluid
volume excess?
A. Flat neck veins when the patient is supine
B. Tenting of the skin on the forehead
C. Decrease in central venous pressure (CVP)
D. Presence of S3 gallop and crackles in lungs
Correct Answer: D
Explanation: The presence of an S3 gallop and crackles in the lungs are hallmark signs of
fluid overload affecting the cardiovascular and respiratory systems. These findings indicate
that the heart is struggling to pump the excess volume and fluid is backing up into the
pulmonary circulation. The nurse should prioritize respiratory assessment and notify the
provider for potential diuretic administration.
2. A nurse is reviewing the lab results for a patient with prolonged nasogastric suctioning.
Which findings would suggest the patient is experiencing hypokalemia? (Select all that apply)
A. Serum potassium 3.2 mEq/L
,B. Prominent U waves on ECG
C. Muscle weakness and leg cramps
D. Hyperactive bowel sounds
E. Peaked T waves on ECG
F. Weak, irregular pulse
Correct Answer: A, B, C, F
Explanation: Hypokalemia is characterized by a serum potassium level below 3.5 mEq/L
and specific cardiac changes like prominent U waves. Clinical symptoms often include
muscle weakness and cardiac dysrhythmias such as a weak or irregular pulse due to the
role of potassium in muscle contraction and electrical conduction. Peaked T waves and
hyperactive bowel sounds are more commonly associated with hyperkalemia, not
hypokalemia.
3. The nurse is caring for a patient whose arterial blood gas (ABG) results are as follows: pH
7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the nurse interpret these results?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Correct Answer: A
,Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate level (HCO3) is within the normal range of 22-26
mEq/L, the condition is respiratory acidosis without compensation. This state is frequently
seen in patients with hypoventilation or obstructive lung diseases.
4. A patient is scheduled for an elective cholecystectomy. During the preoperative
assessment, the patient states, ‘I am not really sure why they are taking out my gallbladder.’
Which action by the nurse is most appropriate?
A. Explain the risks and benefits of the surgery to the patient.
B. Ask the patient’s spouse to sign the consent form instead.
C. Notify the surgeon that the patient does not understand the procedure.
D. Document that the patient is anxious but proceed with preoperative meds.
Correct Answer: C
Explanation: The surgeon is legally responsible for obtaining informed consent and
explaining the procedure’s risks, benefits, and alternatives. If the patient expresses a lack of
understanding, the nurse’s role is to act as an advocate and notify the surgeon to provide
further clarification. The nurse should not explain the procedure themselves, as this falls
outside their scope of practice regarding informed consent.
5. Which nursing intervention is a priority for a patient in the immediate postoperative period
to prevent atelectasis?
A. Administering prophylactic antibiotics
, B. Maintaining the patient in a supine position
C. Encouraging frequent use of the incentive spirometer
D. Limiting fluid intake to prevent pulmonary edema
Correct Answer: C
Explanation: Incentive spirometry encourages deep breathing and lung expansion, which
helps prevent the collapse of alveoli known as atelectasis. This is a critical intervention
during the postoperative phase when patients are at risk due to anesthesia and pain-
related shallow breathing. The nurse should also encourage early ambulation and
repositioning to further promote respiratory function.
6. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula at 2 L/min. Which finding would be most concerning to the nurse?
A. Oxygen saturation (SpO2) of 90%
B. Patient reporting mild dyspnea on exertion
C. Bicarbonate (HCO3) level of 28 mEq/L
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Explanation: In some patients with chronic hypercapnia (COPD), high levels of oxygen can
potentially suppress the hypoxic drive, leading to significant hypoventilation. A respiratory
rate of 10 is low and may indicate that the patient’s drive to breathe is diminishing,
