NSG 3800 ALL EXAMS BINDER – GALEN COLLEGE OF NURSING (U.S.) | QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% VERIFIED SOLUTIONS | UPDATED PER LATEST GUIDELINES | GRADED A+...
Question 1
A nurse is assessing a client who has fluid volume deficit. Which finding should the nurse expect?
A. Jugular venous distention
B. Orthostatic hypotension
C. Crackles on lung auscultation
D. Bounding peripheral pulses
🟢 Correct Answer:
B. Orthostatic hypotension
🔴 RATIONALE:
Fluid volume deficit leads to decreased circulating volume, causing orthostatic hypotension, weak pulses, and
flat neck veins. Jugular venous distention, crackles, and bounding pulses are associated with fluid volume
excess.
Question 2
A client is receiving furosemide for heart failure. Which laboratory value is most important for the nurse to
monitor?
A. Serum calcium
B. Serum potassium
C. Serum bilirubin
D. Serum amylase
,🟢 Correct Answer:
B. Serum potassium
🔴 RATIONALE:
Furosemide is a loop diuretic that promotes potassium excretion, placing the client at risk for hypokalemia and
cardiac dysrhythmias. Serum potassium must be monitored closely. Calcium, bilirubin, and amylase are less
directly affected by furosemide.
Question 3
A nurse is preparing to administer an intramuscular injection to an adult client using the ventrogluteal site.
Which needle size and angle are most appropriate?
A. 25-gauge, 1-inch needle at a 15-degree angle
B. 21-gauge, 1.5-inch needle at a 90-degree angle
C. 27-gauge, 0.5-inch needle at a 45-degree angle
D. 18-gauge, 2-inch needle at a 90-degree angle
🟢 Correct Answer:
B. 21-gauge, 1.5-inch needle at a 90-degree angle
🔴 RATIONALE:
Intramuscular injections in adults require a 1.5-inch needle at a 90-degree angle. A 21-gauge needle is
appropriate for most medications. A 15-degree angle is for intradermal injections; a 45-degree angle is for
subcutaneous injections; an 18-gauge, 2-inch needle is unnecessarily large.
Question 4
A client with a nasogastric tube connected to low intermittent suction is at risk for which acid-base imbalance?
A. Metabolic acidosis
,B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
🟢 Correct Answer:
B. Metabolic alkalosis
🔴 RATIONALE:
Nasogastric suction removes hydrochloric acid from the stomach, leading to metabolic alkalosis. Metabolic
acidosis results from base loss or acid gain; respiratory imbalances are not directly caused by gastric suctioning.
Question 5
A nurse is caring for a client who has Clostridium difficile infection. Which type of precautions should the nurse
implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
🟢 Correct Answer:
C. Contact precautions
🔴 RATIONALE:
Clostridium difficile is transmitted via spores that persist on surfaces. Contact precautions, including gloves and
gown, and hand hygiene with soap and water are required. Airborne and droplet precautions are not indicated;
standard precautions alone are insufficient.
, Question 6
A client receiving oxygen via nasal cannula at 4 L/min has dry nasal mucous membranes. Which nursing action
is best?
A. Apply petroleum jelly to the nares
B. Increase the oxygen flow rate
C. Use a water-based lubricant or humidification as prescribed
D. Discontinue oxygen until the nares are moisturized
🟢 Correct Answer:
C. Use a water-based lubricant or humidification as prescribed
🔴 RATIONALE:
Oxygen therapy dries mucous membranes; humidification and water-based lubricants are safe interventions.
Petroleum jelly is flammable and should not be used near oxygen. Increasing the flow rate worsens dryness;
discontinuing oxygen without a prescription could compromise oxygenation.
Question 7
A client is receiving continuous enteral tube feeding. Which action by the nurse is most important to prevent
aspiration?
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding
B. Check gastric residual volume every 24 hours
C. Add blue food coloring to the formula
D. Keep the client supine during feeding
🟢 Correct Answer:
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding
GRADED A+. 100% VERIFIED SOLUTIONS | UPDATED PER LATEST GUIDELINES | GRADED A+...
Question 1
A nurse is assessing a client who has fluid volume deficit. Which finding should the nurse expect?
A. Jugular venous distention
B. Orthostatic hypotension
C. Crackles on lung auscultation
D. Bounding peripheral pulses
🟢 Correct Answer:
B. Orthostatic hypotension
🔴 RATIONALE:
Fluid volume deficit leads to decreased circulating volume, causing orthostatic hypotension, weak pulses, and
flat neck veins. Jugular venous distention, crackles, and bounding pulses are associated with fluid volume
excess.
Question 2
A client is receiving furosemide for heart failure. Which laboratory value is most important for the nurse to
monitor?
A. Serum calcium
B. Serum potassium
C. Serum bilirubin
D. Serum amylase
,🟢 Correct Answer:
B. Serum potassium
🔴 RATIONALE:
Furosemide is a loop diuretic that promotes potassium excretion, placing the client at risk for hypokalemia and
cardiac dysrhythmias. Serum potassium must be monitored closely. Calcium, bilirubin, and amylase are less
directly affected by furosemide.
Question 3
A nurse is preparing to administer an intramuscular injection to an adult client using the ventrogluteal site.
Which needle size and angle are most appropriate?
A. 25-gauge, 1-inch needle at a 15-degree angle
B. 21-gauge, 1.5-inch needle at a 90-degree angle
C. 27-gauge, 0.5-inch needle at a 45-degree angle
D. 18-gauge, 2-inch needle at a 90-degree angle
🟢 Correct Answer:
B. 21-gauge, 1.5-inch needle at a 90-degree angle
🔴 RATIONALE:
Intramuscular injections in adults require a 1.5-inch needle at a 90-degree angle. A 21-gauge needle is
appropriate for most medications. A 15-degree angle is for intradermal injections; a 45-degree angle is for
subcutaneous injections; an 18-gauge, 2-inch needle is unnecessarily large.
Question 4
A client with a nasogastric tube connected to low intermittent suction is at risk for which acid-base imbalance?
A. Metabolic acidosis
,B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
🟢 Correct Answer:
B. Metabolic alkalosis
🔴 RATIONALE:
Nasogastric suction removes hydrochloric acid from the stomach, leading to metabolic alkalosis. Metabolic
acidosis results from base loss or acid gain; respiratory imbalances are not directly caused by gastric suctioning.
Question 5
A nurse is caring for a client who has Clostridium difficile infection. Which type of precautions should the nurse
implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
🟢 Correct Answer:
C. Contact precautions
🔴 RATIONALE:
Clostridium difficile is transmitted via spores that persist on surfaces. Contact precautions, including gloves and
gown, and hand hygiene with soap and water are required. Airborne and droplet precautions are not indicated;
standard precautions alone are insufficient.
, Question 6
A client receiving oxygen via nasal cannula at 4 L/min has dry nasal mucous membranes. Which nursing action
is best?
A. Apply petroleum jelly to the nares
B. Increase the oxygen flow rate
C. Use a water-based lubricant or humidification as prescribed
D. Discontinue oxygen until the nares are moisturized
🟢 Correct Answer:
C. Use a water-based lubricant or humidification as prescribed
🔴 RATIONALE:
Oxygen therapy dries mucous membranes; humidification and water-based lubricants are safe interventions.
Petroleum jelly is flammable and should not be used near oxygen. Increasing the flow rate worsens dryness;
discontinuing oxygen without a prescription could compromise oxygenation.
Question 7
A client is receiving continuous enteral tube feeding. Which action by the nurse is most important to prevent
aspiration?
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding
B. Check gastric residual volume every 24 hours
C. Add blue food coloring to the formula
D. Keep the client supine during feeding
🟢 Correct Answer:
A. Keep the head of the bed elevated 30 to 45 degrees during and after feeding
