,South College NSG 2600 Exam 2 | Adult
Health I (2026) Q&A
1. A nurse is caring for a patient with heart failure who reports sudden
shortness of breath. The nurse auscultates bilateral crackles. What is the
priority nursing action?
A) Encourage the patient to cough and deep breathe
B) Place the patient in high-Fowler's position
C) Restrict oral fluids to 500 mL per day
D) Administer a PRN dose of morphine sulfate
Correct Answer: Place the patient in high-Fowler's position
Rationale: High-Fowler's position improves lung expansion and reduces
venous return, which decreases pulmonary congestion. This is the
immediate priority to improve oxygenation in a patient with pulmonary
edema. While administering morphine and restricting fluids are
appropriate interventions, positioning is the first and fastest action to
alleviate respiratory distress.
2. A patient on an IV morphine infusion has a respiratory rate of 8
breaths/min and is difficult to arouse. What is the nurse's priority action?
A) Administer naloxone and stimulate the patient
B) Increase the morphine infusion rate
C) Place the patient in a supine position
D) Administer a dose of flumazenil
Correct Answer: Administer naloxone and stimulate the patient
Rationale: A respiratory rate of 8 breaths/min indicates severe opioid-
induced respiratory depression. Naloxone is the specific antagonist for
opioids and should be administered immediately to reverse respiratory
,depression. Stimulating the patient helps maintain airway patency while
the medication takes effect.
3. A patient with diabetes has a blood glucose of 52 mg/dL and is
conscious. Which action should the nurse take first?
A) Administer 15 g of fast-acting carbohydrates
B) Administer 1 mg of glucagon intramuscularly
C) Notify the healthcare provider immediately
D) Recheck the blood glucose in 30 minutes
Correct Answer: Administer 15 g of fast-acting carbohydrates
Rationale: For a conscious patient with hypoglycemia, the priority is to
administer 15 g of fast-acting carbohydrates (such as glucose tablets,
juice, or regular soda). The blood glucose should be rechecked in 15
minutes. Glucagon is used for unconscious patients or when IV access is
unavailable.
4. A patient is receiving a continuous IV heparin infusion for a pulmonary
embolism. The most recent aPTT is 85 seconds. What is the most
appropriate action by the nurse?
A) Increase the heparin infusion rate
B) Decrease the heparin infusion rate
C) Continue the infusion at the current rate
D) Discontinue the heparin infusion
Correct Answer: Decrease the heparin infusion rate
Rationale: The therapeutic aPTT for heparin is typically 46-70 seconds
(1.5-2.5 times the control value). An aPTT of 85 seconds is above the
therapeutic range and indicates an increased risk of bleeding. The infusion
rate should be decreased and the provider notified.
, 5. A patient on warfarin therapy has an INR of 1.5. What should the nurse
anticipate?
A) Continuing the current warfarin dose
B) Increasing the warfarin dose
C) Decreasing the warfarin dose
D) Discontinuing the warfarin
Correct Answer: Increasing the warfarin dose
Rationale: An INR of 1.5 is below the therapeutic range of 2.0-3.0 for
most indications. The provider will likely increase the warfarin dose to
achieve therapeutic anticoagulation. The nurse should also assess for
factors that may interfere with warfarin metabolism, such as dietary
vitamin K intake.
6. A patient with a pulmonary embolism is being transitioned from heparin
to warfarin. Which statement reflects correct understanding of this
transition?
A) Heparin should be discontinued immediately when warfarin is started
B) Heparin and warfarin should be overlapped until the INR is therapeutic
C) Warfarin alone is sufficient for acute treatment of pulmonary embolism
D) Heparin is not effective for pulmonary embolism
Correct Answer: Heparin and warfarin should be overlapped until the
INR is therapeutic
Rationale: When transitioning from heparin to warfarin, the medications
must be overlapped for several days until the INR reaches the therapeutic
range. Heparin provides immediate anticoagulation while warfarin takes 3-
5 days to achieve full effect.
7. A patient with a history of heparin-induced thrombocytopenia (HIT)
requires anticoagulation. Which agent is most appropriate?
Health I (2026) Q&A
1. A nurse is caring for a patient with heart failure who reports sudden
shortness of breath. The nurse auscultates bilateral crackles. What is the
priority nursing action?
A) Encourage the patient to cough and deep breathe
B) Place the patient in high-Fowler's position
C) Restrict oral fluids to 500 mL per day
D) Administer a PRN dose of morphine sulfate
Correct Answer: Place the patient in high-Fowler's position
Rationale: High-Fowler's position improves lung expansion and reduces
venous return, which decreases pulmonary congestion. This is the
immediate priority to improve oxygenation in a patient with pulmonary
edema. While administering morphine and restricting fluids are
appropriate interventions, positioning is the first and fastest action to
alleviate respiratory distress.
2. A patient on an IV morphine infusion has a respiratory rate of 8
breaths/min and is difficult to arouse. What is the nurse's priority action?
A) Administer naloxone and stimulate the patient
B) Increase the morphine infusion rate
C) Place the patient in a supine position
D) Administer a dose of flumazenil
Correct Answer: Administer naloxone and stimulate the patient
Rationale: A respiratory rate of 8 breaths/min indicates severe opioid-
induced respiratory depression. Naloxone is the specific antagonist for
opioids and should be administered immediately to reverse respiratory
,depression. Stimulating the patient helps maintain airway patency while
the medication takes effect.
3. A patient with diabetes has a blood glucose of 52 mg/dL and is
conscious. Which action should the nurse take first?
A) Administer 15 g of fast-acting carbohydrates
B) Administer 1 mg of glucagon intramuscularly
C) Notify the healthcare provider immediately
D) Recheck the blood glucose in 30 minutes
Correct Answer: Administer 15 g of fast-acting carbohydrates
Rationale: For a conscious patient with hypoglycemia, the priority is to
administer 15 g of fast-acting carbohydrates (such as glucose tablets,
juice, or regular soda). The blood glucose should be rechecked in 15
minutes. Glucagon is used for unconscious patients or when IV access is
unavailable.
4. A patient is receiving a continuous IV heparin infusion for a pulmonary
embolism. The most recent aPTT is 85 seconds. What is the most
appropriate action by the nurse?
A) Increase the heparin infusion rate
B) Decrease the heparin infusion rate
C) Continue the infusion at the current rate
D) Discontinue the heparin infusion
Correct Answer: Decrease the heparin infusion rate
Rationale: The therapeutic aPTT for heparin is typically 46-70 seconds
(1.5-2.5 times the control value). An aPTT of 85 seconds is above the
therapeutic range and indicates an increased risk of bleeding. The infusion
rate should be decreased and the provider notified.
, 5. A patient on warfarin therapy has an INR of 1.5. What should the nurse
anticipate?
A) Continuing the current warfarin dose
B) Increasing the warfarin dose
C) Decreasing the warfarin dose
D) Discontinuing the warfarin
Correct Answer: Increasing the warfarin dose
Rationale: An INR of 1.5 is below the therapeutic range of 2.0-3.0 for
most indications. The provider will likely increase the warfarin dose to
achieve therapeutic anticoagulation. The nurse should also assess for
factors that may interfere with warfarin metabolism, such as dietary
vitamin K intake.
6. A patient with a pulmonary embolism is being transitioned from heparin
to warfarin. Which statement reflects correct understanding of this
transition?
A) Heparin should be discontinued immediately when warfarin is started
B) Heparin and warfarin should be overlapped until the INR is therapeutic
C) Warfarin alone is sufficient for acute treatment of pulmonary embolism
D) Heparin is not effective for pulmonary embolism
Correct Answer: Heparin and warfarin should be overlapped until the
INR is therapeutic
Rationale: When transitioning from heparin to warfarin, the medications
must be overlapped for several days until the INR reaches the therapeutic
range. Heparin provides immediate anticoagulation while warfarin takes 3-
5 days to achieve full effect.
7. A patient with a history of heparin-induced thrombocytopenia (HIT)
requires anticoagulation. Which agent is most appropriate?
