NSG 320 Final Exam V1 | NSG 320 Adult
Health Nursing I | Actual Q&A with
Rationale (NSG320 Final Exam) | Grand
Canyon University
1. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which of the following
cardiac changes should the nurse immediately monitor for on the EKG?
A. Tall, peaked T-waves
B. ST-segment depression
C. Presence of a U-wave
D. Shortened PR interval
Correct Answer: A
Explanation: Hyperkalemia is characterized by a serum potassium level greater than 5.0
mEq/L and can cause life-threatening cardiac dysrhythmias. Tall, peaked T-waves are one
of the earliest signs of hyperkalemia on an EKG, followed by a widened QRS complex and
loss of P-waves. The nurse must prioritize monitoring the EKG to identify these changes
early and prevent cardiac arrest.
2. The nurse is preparing to administer levothyroxine to a patient with hypothyroidism.
Which assessment finding would require the nurse to hold the medication and notify the
healthcare provider?
A. Blood pressure of 110/70 mmHg
,B. Heart rate of 112 beats per minute
C. Respiratory rate of 14 breaths per minute
D. Temperature of 98.2 F
Correct Answer: B
Explanation: Levothyroxine is a synthetic thyroid hormone that increases the metabolic
rate and can cause tachycardia as a side effect. A heart rate greater than 100 beats per
minute suggests that the dose may be too high or the patient is experiencing adverse
cardiac effects. The nurse should hold the dose to prevent further cardiovascular stress and
consult the provider for further orders.
3. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which
of the following instructions should the nurse include? (Select All That Apply)
A. Do not cross your legs at the knees or ankles.
B. Use a raised toilet seat when using the bathroom.
C. Clean the incision with hydrogen peroxide daily.
D. Avoid flexing the hip more than 90 degrees.
E. Keep an abduction pillow between your legs while sleeping.
F. You may lean forward to pull up your socks.
Correct Answer: A, B, D, E
,Explanation: Postoperative care for hip arthroplasty focuses on preventing dislocation of
the new prosthesis. Patients must avoid adduction and excessive flexion, which is why
crossing legs and leaning forward are prohibited. Using raised toilet seats and abduction
pillows helps maintain the joint in a safe alignment during the healing process.
4. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. The
fingerstick glucose reads 42 mg/dL. What is the priority nursing action?
A. Administer 15g of oral glucose gel
B. Administer 1 mg of Glucagon intramuscularly
C. Start an intravenous infusion of Normal Saline
D. Recheck the blood glucose in 15 minutes
Correct Answer: B
Explanation: In an unconscious patient with severe hypoglycemia, the oral route is
contraindicated due to the risk of aspiration. Intramuscular glucagon is the standard
emergency intervention when IV access is not immediately available to rapidly increase
blood glucose levels. Once the patient regains consciousness and can swallow safely, the
nurse should provide a complex carbohydrate and protein snack.
5. A client is diagnosed with Left-sided Heart Failure. Which of the following clinical
manifestations should the nurse expect to assess?
A. Jugular venous distention
B. Crackles in the lungs
, C. Peripheral edema in the lower extremities
D. Hepatomegaly
Correct Answer: B
Explanation: Left-sided heart failure leads to pulmonary congestion because the left
ventricle cannot effectively pump blood into the systemic circulation. This results in fluid
backing up into the pulmonary veins and capillaries, causing crackles, dyspnea, and
orthopnea. In contrast, peripheral edema and jugular venous distention are classic signs of
right-sided heart failure.
6. Which of the following laboratory values should a nurse monitor for a patient receiving
heparin therapy for a deep vein thrombosis?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Platelet count only
D. Activated partial thromboplastin time (aPTT)
Correct Answer: D
Explanation: The aPTT is the standard laboratory test used to monitor the effectiveness
and safety of unfractionated heparin therapy. The therapeutic range is typically 1.5 to 2.5
times the normal control value. While platelet counts are monitored to detect heparin-
induced thrombocytopenia, the aPTT is the primary indicator for titration of the dose.
Health Nursing I | Actual Q&A with
Rationale (NSG320 Final Exam) | Grand
Canyon University
1. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which of the following
cardiac changes should the nurse immediately monitor for on the EKG?
A. Tall, peaked T-waves
B. ST-segment depression
C. Presence of a U-wave
D. Shortened PR interval
Correct Answer: A
Explanation: Hyperkalemia is characterized by a serum potassium level greater than 5.0
mEq/L and can cause life-threatening cardiac dysrhythmias. Tall, peaked T-waves are one
of the earliest signs of hyperkalemia on an EKG, followed by a widened QRS complex and
loss of P-waves. The nurse must prioritize monitoring the EKG to identify these changes
early and prevent cardiac arrest.
2. The nurse is preparing to administer levothyroxine to a patient with hypothyroidism.
Which assessment finding would require the nurse to hold the medication and notify the
healthcare provider?
A. Blood pressure of 110/70 mmHg
,B. Heart rate of 112 beats per minute
C. Respiratory rate of 14 breaths per minute
D. Temperature of 98.2 F
Correct Answer: B
Explanation: Levothyroxine is a synthetic thyroid hormone that increases the metabolic
rate and can cause tachycardia as a side effect. A heart rate greater than 100 beats per
minute suggests that the dose may be too high or the patient is experiencing adverse
cardiac effects. The nurse should hold the dose to prevent further cardiovascular stress and
consult the provider for further orders.
3. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which
of the following instructions should the nurse include? (Select All That Apply)
A. Do not cross your legs at the knees or ankles.
B. Use a raised toilet seat when using the bathroom.
C. Clean the incision with hydrogen peroxide daily.
D. Avoid flexing the hip more than 90 degrees.
E. Keep an abduction pillow between your legs while sleeping.
F. You may lean forward to pull up your socks.
Correct Answer: A, B, D, E
,Explanation: Postoperative care for hip arthroplasty focuses on preventing dislocation of
the new prosthesis. Patients must avoid adduction and excessive flexion, which is why
crossing legs and leaning forward are prohibited. Using raised toilet seats and abduction
pillows helps maintain the joint in a safe alignment during the healing process.
4. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. The
fingerstick glucose reads 42 mg/dL. What is the priority nursing action?
A. Administer 15g of oral glucose gel
B. Administer 1 mg of Glucagon intramuscularly
C. Start an intravenous infusion of Normal Saline
D. Recheck the blood glucose in 15 minutes
Correct Answer: B
Explanation: In an unconscious patient with severe hypoglycemia, the oral route is
contraindicated due to the risk of aspiration. Intramuscular glucagon is the standard
emergency intervention when IV access is not immediately available to rapidly increase
blood glucose levels. Once the patient regains consciousness and can swallow safely, the
nurse should provide a complex carbohydrate and protein snack.
5. A client is diagnosed with Left-sided Heart Failure. Which of the following clinical
manifestations should the nurse expect to assess?
A. Jugular venous distention
B. Crackles in the lungs
, C. Peripheral edema in the lower extremities
D. Hepatomegaly
Correct Answer: B
Explanation: Left-sided heart failure leads to pulmonary congestion because the left
ventricle cannot effectively pump blood into the systemic circulation. This results in fluid
backing up into the pulmonary veins and capillaries, causing crackles, dyspnea, and
orthopnea. In contrast, peripheral edema and jugular venous distention are classic signs of
right-sided heart failure.
6. Which of the following laboratory values should a nurse monitor for a patient receiving
heparin therapy for a deep vein thrombosis?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Platelet count only
D. Activated partial thromboplastin time (aPTT)
Correct Answer: D
Explanation: The aPTT is the standard laboratory test used to monitor the effectiveness
and safety of unfractionated heparin therapy. The therapeutic range is typically 1.5 to 2.5
times the normal control value. While platelet counts are monitored to detect heparin-
induced thrombocytopenia, the aPTT is the primary indicator for titration of the dose.
