,South College NSG 2600 Exam 3 | Adult
Health I (2026) Q&A
1. A nurse is caring for a client post-abdominal surgery. Which assessment
finding requires immediate action?
A) Hypoactive bowel sounds
B) Pain level of 5/10
C) Firm, distended abdomen
D) Serosanguinous drainage on dressing
Correct Answer: Firm, distended abdomen
Rationale: A firm, distended abdomen may indicate internal bleeding or
paralytic ileus, both of which require immediate intervention. Hypoactive
bowel sounds, pain, and serosanguinous drainage are expected post-
operative findings that should be monitored but do not constitute an
immediate emergency.
2. A patient is receiving IV morphine. Which nursing action has the highest
priority?
A) Monitor for nausea
B) Assess for itching
C) Check respiratory rate
D) Evaluate pain relief
Correct Answer: Check respiratory rate
Rationale: Opioids like morphine can cause respiratory depression,
making respiratory assessment the priority. While monitoring for nausea,
itching, and pain relief are important, they are secondary to ensuring
adequate ventilation.
,3. A nurse notes that a patient’s surgical wound has eviscerated. What is
the priority nursing intervention?
A) Call the provider
B) Apply a dry sterile dressing
C) Cover the wound with sterile saline-soaked gauze
D) Reinsert the organs gently
Correct Answer: Cover the wound with sterile saline-soaked gauze
Rationale: Evisceration is a medical emergency; moist gauze helps
prevent tissue drying and infection until surgical repair. The provider
should be notified, but covering the wound is the immediate priority.
Organs should never be reinserted.
4. A client with COPD is on 2L nasal cannula. Which assessment would
prompt immediate action?
A) O2 saturation of 91%
B) Barrel chest
C) Respiratory rate of 8/min
D) Clubbed fingers
Correct Answer: Respiratory rate of 8/min
Rationale: A respiratory rate of 8/min indicates respiratory depression,
which is life-threatening in a COPD patient. An O2 saturation of 91% is
within the acceptable target range for COPD, and barrel chest and clubbed
fingers are chronic findings.
5. A patient with heart failure reports sudden shortness of breath and
crackles are heard bilaterally. What is the FIRST action by the nurse?
A) Administer oral fluids
B) Place the patient in high Fowler's position
, C) Encourage ambulation
D) Document the findings
Correct Answer: Place the patient in high Fowler's position
Rationale: High Fowler's position improves lung expansion and reduces
pulmonary congestion. This is the immediate priority to improve
oxygenation. Oral fluids would worsen fluid overload, and ambulation is
not appropriate in acute respiratory distress.
6. A postoperative patient has a respiratory rate of 8 breaths/min after
opioid administration. What is the priority action?
A) Give the next opioid dose
B) Stimulate the patient and prepare naloxone
C) Encourage deep breathing only
D) Document as expected
Correct Answer: Stimulate the patient and prepare naloxone
Rationale: Opioid-induced respiratory depression requires immediate
intervention. Naloxone is the antidote for opioids and should be prepared
for administration. Encouraging deep breathing alone is insufficient, and
giving more opioids would worsen the situation.
7. A patient with diabetes has a blood glucose of 52 mg/dL and is
conscious. What should the nurse do FIRST?
A) Administer IV insulin
B) Give 15g fast-acting carbohydrates
C) Restrict oral intake
D) Notify provider before action
Correct Answer: Give 15g fast-acting carbohydrates
Health I (2026) Q&A
1. A nurse is caring for a client post-abdominal surgery. Which assessment
finding requires immediate action?
A) Hypoactive bowel sounds
B) Pain level of 5/10
C) Firm, distended abdomen
D) Serosanguinous drainage on dressing
Correct Answer: Firm, distended abdomen
Rationale: A firm, distended abdomen may indicate internal bleeding or
paralytic ileus, both of which require immediate intervention. Hypoactive
bowel sounds, pain, and serosanguinous drainage are expected post-
operative findings that should be monitored but do not constitute an
immediate emergency.
2. A patient is receiving IV morphine. Which nursing action has the highest
priority?
A) Monitor for nausea
B) Assess for itching
C) Check respiratory rate
D) Evaluate pain relief
Correct Answer: Check respiratory rate
Rationale: Opioids like morphine can cause respiratory depression,
making respiratory assessment the priority. While monitoring for nausea,
itching, and pain relief are important, they are secondary to ensuring
adequate ventilation.
,3. A nurse notes that a patient’s surgical wound has eviscerated. What is
the priority nursing intervention?
A) Call the provider
B) Apply a dry sterile dressing
C) Cover the wound with sterile saline-soaked gauze
D) Reinsert the organs gently
Correct Answer: Cover the wound with sterile saline-soaked gauze
Rationale: Evisceration is a medical emergency; moist gauze helps
prevent tissue drying and infection until surgical repair. The provider
should be notified, but covering the wound is the immediate priority.
Organs should never be reinserted.
4. A client with COPD is on 2L nasal cannula. Which assessment would
prompt immediate action?
A) O2 saturation of 91%
B) Barrel chest
C) Respiratory rate of 8/min
D) Clubbed fingers
Correct Answer: Respiratory rate of 8/min
Rationale: A respiratory rate of 8/min indicates respiratory depression,
which is life-threatening in a COPD patient. An O2 saturation of 91% is
within the acceptable target range for COPD, and barrel chest and clubbed
fingers are chronic findings.
5. A patient with heart failure reports sudden shortness of breath and
crackles are heard bilaterally. What is the FIRST action by the nurse?
A) Administer oral fluids
B) Place the patient in high Fowler's position
, C) Encourage ambulation
D) Document the findings
Correct Answer: Place the patient in high Fowler's position
Rationale: High Fowler's position improves lung expansion and reduces
pulmonary congestion. This is the immediate priority to improve
oxygenation. Oral fluids would worsen fluid overload, and ambulation is
not appropriate in acute respiratory distress.
6. A postoperative patient has a respiratory rate of 8 breaths/min after
opioid administration. What is the priority action?
A) Give the next opioid dose
B) Stimulate the patient and prepare naloxone
C) Encourage deep breathing only
D) Document as expected
Correct Answer: Stimulate the patient and prepare naloxone
Rationale: Opioid-induced respiratory depression requires immediate
intervention. Naloxone is the antidote for opioids and should be prepared
for administration. Encouraging deep breathing alone is insufficient, and
giving more opioids would worsen the situation.
7. A patient with diabetes has a blood glucose of 52 mg/dL and is
conscious. What should the nurse do FIRST?
A) Administer IV insulin
B) Give 15g fast-acting carbohydrates
C) Restrict oral intake
D) Notify provider before action
Correct Answer: Give 15g fast-acting carbohydrates
