NURS 620 ADULT 1 EXAM 3 Q&A | COMPLETE STUDYGUIDE
WITH PRACTICE QUESTIONS AND ANSWERS| ALL QUESTIONS
AND ANSWERS PLUS DETAILED RATIONALES | GUARANTEED
PASS | DOWNLOAD INSTANT PDF 2026/2027
1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2
L/min by nasal cannula. Which assessment finding requires the nurse's immediate
attention?
A. Oxygen saturation of 91%
B. Respiratory rate of 22/min
C. New onset of confusion and increasing drowsiness
D. Productive cough with clear sputum
Answer: C
New confusion and increasing drowsiness may indicate worsening hypoxemia or carbon
dioxide retention. This change requires immediate assessment and intervention.
2. A client with heart failure reports increasing shortness of breath when lying flat. Which
additional finding most strongly supports worsening fluid overload?
A. Weight gain of 2.5 kg over 3 days
B. Heart rate of 72/min
C. Dry oral mucosa
D. Decreased ankle circumference
Answer: A
Rapid weight gain is a sensitive indicator of fluid retention in heart failure and may precede
more severe manifestations.
3. A client with pneumonia has a temperature of 39.1°C (102.4°F), respiratory rate of
30/min, and oxygen saturation of 88% on room air. Which intervention should the nurse
prioritize?
A. Encourage oral fluids
B. Apply oxygen as prescribed and reassess respiratory status
C. Obtain a dietary history
D. Provide a warm blanket
Answer: B
The client's low oxygen saturation and tachypnea indicate impaired oxygenation. Supporting
oxygenation takes priority over less urgent interventions.
,4. A client with asthma develops wheezing and chest tightness after exposure to a known
trigger. Which medication should the nurse expect to administer for rapid relief?
A. Montelukast
B. Fluticasone
C. Salmeterol
D. Albuterol
Answer: D
Albuterol is a short-acting beta2-adrenergic agonist used for rapid bronchodilation during
acute asthma symptoms.
5. A client with emphysema asks why pursed-lip breathing is recommended. Which
explanation is most accurate?
A. It increases respiratory rate.
B. It promotes prolonged exhalation and helps prevent airway collapse.
C. It eliminates the need for supplemental oxygen.
D. It increases mucus production.
Answer: B
Pursed-lip breathing slows exhalation, increases airway pressure, and can reduce air trapping
by helping keep smaller airways open.
6. A client with suspected pulmonary embolism suddenly develops dyspnea, pleuritic chest
pain, and tachycardia. What should the nurse do first?
A. Encourage ambulation.
B. Place the client flat.
C. Administer oxygen and rapidly assess respiratory status.
D. Offer oral fluids.
Answer: C
Pulmonary embolism can cause life-threatening impairment of oxygenation. Immediate
support of airway and breathing is a priority.
7. Which assessment finding is most characteristic of left-sided heart failure?
A. Pulmonary crackles
B. Ascites only
C. Dependent edema without respiratory symptoms
D. Enlarged liver
Answer: A
Left-sided heart failure causes pulmonary congestion, which commonly produces crackles,
dyspnea, and orthopnea.
,8. A client taking furosemide for heart failure has a potassium level of 2.9 mEq/L. Which
action is most appropriate?
A. Administer the medication and document the result.
B. Encourage a low-potassium diet.
C. Notify the healthcare provider and anticipate potassium replacement.
D. Restrict all fluids.
Answer: C
Furosemide can cause potassium loss. A potassium level of 2.9 mEq/L represents significant
hypokalemia and increases the risk of dysrhythmias.
9. Which assessment finding in a client with heart failure most strongly indicates decreased
cardiac output?
A. Warm, flushed skin
B. Bounding peripheral pulses
C. Increased urine output
D. Cool extremities and decreased urine output
Answer: D
Poor cardiac output reduces tissue perfusion, commonly producing cool extremities and
decreased renal perfusion with reduced urine output.
10. A client taking digoxin reports nausea, poor appetite, and seeing yellow halos around
lights. What should the nurse suspect?
A. Digoxin toxicity
B. Hypercalcemia
C. Acute dehydration
D. Iron deficiency
Answer: A
Nausea, anorexia, visual disturbances, and dysrhythmias are classic manifestations
associated with digoxin toxicity.
11. Before administering digoxin, which assessment is most important?
A. Bowel sounds
B. Apical pulse
C. Temperature
D. Pedal pulse only
Answer: B
Digoxin can slow the heart rate. The apical pulse should be assessed before administration
according to prescribed parameters.
, 12. A client with hypertension has been prescribed lisinopril. Which adverse effect requires
immediate medical attention?
A. Mild fatigue
B. Dry cough
C. Angioedema of the lips and tongue
D. Increased appetite
Answer: C
Angioedema can rapidly compromise the airway and is a potentially life-threatening adverse
effect of ACE inhibitors.
13. A client taking hydrochlorothiazide asks why the medication is prescribed. Which
response is best?
A. “It increases sodium and water retention.”
B. “It helps your kidneys excrete sodium and water, reducing fluid volume.”
C. “It directly increases heart contractility.”
D. “It prevents all electrolyte abnormalities.”
Answer: B
Hydrochlorothiazide is a thiazide diuretic that promotes renal sodium and water excretion,
helping reduce blood pressure and fluid volume.
14. A client with peripheral arterial disease reports severe calf pain while walking that
resolves with rest. How should the nurse interpret this finding?
A. Intermittent claudication
B. Venous stasis
C. Neuropathic pain
D. Acute compartment syndrome
Answer: A
Intermittent claudication is ischemic muscle pain caused by inadequate arterial blood flow
during activity and relieved by rest.
15. Which finding is more consistent with chronic venous insufficiency than peripheral
arterial disease?
A. Cool, pale extremity
B. Diminished pedal pulses
C. Brown pigmentation around the ankles
D. Pain worsened by leg elevation
Answer: C
WITH PRACTICE QUESTIONS AND ANSWERS| ALL QUESTIONS
AND ANSWERS PLUS DETAILED RATIONALES | GUARANTEED
PASS | DOWNLOAD INSTANT PDF 2026/2027
1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2
L/min by nasal cannula. Which assessment finding requires the nurse's immediate
attention?
A. Oxygen saturation of 91%
B. Respiratory rate of 22/min
C. New onset of confusion and increasing drowsiness
D. Productive cough with clear sputum
Answer: C
New confusion and increasing drowsiness may indicate worsening hypoxemia or carbon
dioxide retention. This change requires immediate assessment and intervention.
2. A client with heart failure reports increasing shortness of breath when lying flat. Which
additional finding most strongly supports worsening fluid overload?
A. Weight gain of 2.5 kg over 3 days
B. Heart rate of 72/min
C. Dry oral mucosa
D. Decreased ankle circumference
Answer: A
Rapid weight gain is a sensitive indicator of fluid retention in heart failure and may precede
more severe manifestations.
3. A client with pneumonia has a temperature of 39.1°C (102.4°F), respiratory rate of
30/min, and oxygen saturation of 88% on room air. Which intervention should the nurse
prioritize?
A. Encourage oral fluids
B. Apply oxygen as prescribed and reassess respiratory status
C. Obtain a dietary history
D. Provide a warm blanket
Answer: B
The client's low oxygen saturation and tachypnea indicate impaired oxygenation. Supporting
oxygenation takes priority over less urgent interventions.
,4. A client with asthma develops wheezing and chest tightness after exposure to a known
trigger. Which medication should the nurse expect to administer for rapid relief?
A. Montelukast
B. Fluticasone
C. Salmeterol
D. Albuterol
Answer: D
Albuterol is a short-acting beta2-adrenergic agonist used for rapid bronchodilation during
acute asthma symptoms.
5. A client with emphysema asks why pursed-lip breathing is recommended. Which
explanation is most accurate?
A. It increases respiratory rate.
B. It promotes prolonged exhalation and helps prevent airway collapse.
C. It eliminates the need for supplemental oxygen.
D. It increases mucus production.
Answer: B
Pursed-lip breathing slows exhalation, increases airway pressure, and can reduce air trapping
by helping keep smaller airways open.
6. A client with suspected pulmonary embolism suddenly develops dyspnea, pleuritic chest
pain, and tachycardia. What should the nurse do first?
A. Encourage ambulation.
B. Place the client flat.
C. Administer oxygen and rapidly assess respiratory status.
D. Offer oral fluids.
Answer: C
Pulmonary embolism can cause life-threatening impairment of oxygenation. Immediate
support of airway and breathing is a priority.
7. Which assessment finding is most characteristic of left-sided heart failure?
A. Pulmonary crackles
B. Ascites only
C. Dependent edema without respiratory symptoms
D. Enlarged liver
Answer: A
Left-sided heart failure causes pulmonary congestion, which commonly produces crackles,
dyspnea, and orthopnea.
,8. A client taking furosemide for heart failure has a potassium level of 2.9 mEq/L. Which
action is most appropriate?
A. Administer the medication and document the result.
B. Encourage a low-potassium diet.
C. Notify the healthcare provider and anticipate potassium replacement.
D. Restrict all fluids.
Answer: C
Furosemide can cause potassium loss. A potassium level of 2.9 mEq/L represents significant
hypokalemia and increases the risk of dysrhythmias.
9. Which assessment finding in a client with heart failure most strongly indicates decreased
cardiac output?
A. Warm, flushed skin
B. Bounding peripheral pulses
C. Increased urine output
D. Cool extremities and decreased urine output
Answer: D
Poor cardiac output reduces tissue perfusion, commonly producing cool extremities and
decreased renal perfusion with reduced urine output.
10. A client taking digoxin reports nausea, poor appetite, and seeing yellow halos around
lights. What should the nurse suspect?
A. Digoxin toxicity
B. Hypercalcemia
C. Acute dehydration
D. Iron deficiency
Answer: A
Nausea, anorexia, visual disturbances, and dysrhythmias are classic manifestations
associated with digoxin toxicity.
11. Before administering digoxin, which assessment is most important?
A. Bowel sounds
B. Apical pulse
C. Temperature
D. Pedal pulse only
Answer: B
Digoxin can slow the heart rate. The apical pulse should be assessed before administration
according to prescribed parameters.
, 12. A client with hypertension has been prescribed lisinopril. Which adverse effect requires
immediate medical attention?
A. Mild fatigue
B. Dry cough
C. Angioedema of the lips and tongue
D. Increased appetite
Answer: C
Angioedema can rapidly compromise the airway and is a potentially life-threatening adverse
effect of ACE inhibitors.
13. A client taking hydrochlorothiazide asks why the medication is prescribed. Which
response is best?
A. “It increases sodium and water retention.”
B. “It helps your kidneys excrete sodium and water, reducing fluid volume.”
C. “It directly increases heart contractility.”
D. “It prevents all electrolyte abnormalities.”
Answer: B
Hydrochlorothiazide is a thiazide diuretic that promotes renal sodium and water excretion,
helping reduce blood pressure and fluid volume.
14. A client with peripheral arterial disease reports severe calf pain while walking that
resolves with rest. How should the nurse interpret this finding?
A. Intermittent claudication
B. Venous stasis
C. Neuropathic pain
D. Acute compartment syndrome
Answer: A
Intermittent claudication is ischemic muscle pain caused by inadequate arterial blood flow
during activity and relieved by rest.
15. Which finding is more consistent with chronic venous insufficiency than peripheral
arterial disease?
A. Cool, pale extremity
B. Diminished pedal pulses
C. Brown pigmentation around the ankles
D. Pain worsened by leg elevation
Answer: C
