BSN 346 Shadow Health Case Study | Nightingale
College BSN 346 Concepts of Nursing III Study Guide &
Case Study Review 2026/2027 | Shadow Health Digital
Clinical Experience, Focused Patient Assessment,
Subjective & Objective Data Collection, Clinical
Reasoning, Nursing Diagnosis, Care Planning,
Therapeutic Communication, Patient Education,
Documentation, Prioritization, Case-Based Practice &
Detailed Explanations
Question 1: A 72-year-old male patient presents with a 2-week history of
progressive shortness of breath, orthopnea, and a dry cough. On auscultation,
you note crackles that are heard late in inspiration and do not clear with
coughing. These findings are most consistent with which of the following
pathophysiological processes?
A. Atelectasis due to airway obstruction
B. Consolidation from a bacterial pneumonia
C. Pulmonary fibrosis with restrictive lung disease
D. Alveolar fluid accumulation from increased hydrostatic pressure
CORRECT ANSWER: D. Alveolar fluid accumulation from increased hydrostatic
pressure
Rationale: Late-inspiratory crackles that do not clear with coughing are classic findings
of pulmonary edema, most commonly cardiogenic in origin. The progressive dyspnea,
orthopnea, and dry cough further support left-sided heart failure, where increased
hydrostatic pressure forces fluid into the alveoli. Atelectasis crackles typically clear after
coughing. Consolidation from pneumonia often presents with more productive cough,
fever, and bronchial breath sounds. Pulmonary fibrosis may present with Velcro-like
crackles, but the clinical history here is more acute and classic for heart failure.
Question 2: When assessing a patient's level of consciousness using the
Glasgow Coma Scale, which of the following components is NOT evaluated?
A. Eye opening
B. Verbal response
C. Motor response
D. Pupillary light reflex
CORRECT ANSWER: D. Pupillary light reflex
Rationale: The Glasgow Coma Scale is a neurological assessment tool that evaluates
three components: eye opening, verbal response, and motor response. The maximum
score is 15, with each component scored independently. Pupillary light reflex is a
,brainstem reflex that is assessed separately as part of a complete neurological
examination but is not a component of the GCS score.
Question 3: A patient with a history of chronic obstructive pulmonary disease
(COPD) is receiving supplemental oxygen at 2 L/min via nasal cannula. The
nurse notes that the patient's respiratory rate has decreased from 22 to 10
breaths per minute and the patient appears drowsy. This change is most likely
due to which of the following?
A. Hyperventilation syndrome
B. Carbon dioxide narcosis
C. Acute asthma exacerbation
D. Paradoxical breathing
CORRECT ANSWER: B. Carbon dioxide narcosis
Rationale: Patients with severe COPD may rely on a hypoxic drive to stimulate
breathing. Administration of high-flow or even moderate-flow oxygen can eliminate this
hypoxic stimulus, leading to hypoventilation, CO2 retention, and subsequent carbon
dioxide narcosis. The classic signs include decreased respiratory rate, drowsiness,
confusion, and potential respiratory acidosis. This is a dangerous situation and would
require careful titration of oxygen.
Question 4: Which of the following findings is the BEST indicator that a
patient's endotracheal tube is correctly positioned in the trachea?
A. Equal breath sounds on both sides of the chest
B. Condensation in the endotracheal tube
C. Presence of a cough reflex
D. Absence of gastric distension
CORRECT ANSWER: A. Equal breath sounds on both sides of the chest
Rationale: Equal bilateral breath sounds are the most reliable initial physical assessment
finding to confirm correct endotracheal tube placement in the trachea, above the carina.
Condensation in the tube is not a reliable indicator of correct placement. While
auscultation over the epigastrium should confirm absence of air entry to rule out
esophageal placement, symmetrical breath sounds are the best physical indicator.
Confirmation is always done via capnography and chest x-ray.
Question 5: A patient is admitted with severe dehydration. The nurse assesses
a thready, rapid pulse, flat neck veins, and poor skin turgor. The nurse
understands that these findings are primarily the result of which
compensatory mechanism?
,A. Increased sympathetic nervous system activity
B. Decreased antidiuretic hormone secretion
C. Increased parasympathetic nervous system activity
D. Decreased renin-angiotensin-aldosterone system activation
CORRECT ANSWER: A. Increased sympathetic nervous system activity
Rationale: In response to hypovolemia, the body activates the sympathetic nervous
system, leading to increased heart rate (tachycardia) and peripheral vasoconstriction to
maintain blood pressure. This results in a rapid, thready pulse. The decreased circulating
volume also leads to flat neck veins and poor skin turgor. ADH and aldosterone are
actually increased in dehydration to conserve water, not decreased. The sympathetic
response is the primary compensatory mechanism.
Question 6: The nurse is caring for a patient with a chest tube attached to a
water-seal drainage system. Which of the following observations indicates that
the chest tube system is functioning correctly?
A. Continuous bubbling in the water-seal chamber
B. Fluctuation (tidaling) of the water level in the water-seal chamber with respirations
C. No drainage in the collection chamber
D. The chest tube is disconnected from the suction source
CORRECT ANSWER: B. Fluctuation (tidaling) of the water level in the water-
seal chamber with respirations
Rationale: Tidaling, or fluctuation of the water level in the water-seal chamber with
inspiration and expiration, is a normal finding that indicates the chest tube is patent and
functioning correctly. Continuous bubbling in the water-seal chamber indicates an air
leak. No drainage in the collection chamber may be normal, but it depends on the
indication for the chest tube. If a patient had a pneumothorax without significant
bleeding, this is fine; however, tidaling is the key indicator of correct system function.
Question 7: A patient with type 1 diabetes mellitus is brought to the
emergency department with a blood glucose level of 650 mg/dL. Arterial blood
gas results reveal a pH of 7.20, HCO3- of 12 mEq/L, and PaCO2 of 28 mmHg.
The nurse interprets these results as:
A. Uncompensated metabolic acidosis
B. Uncompensated respiratory alkalosis
C. Partially compensated metabolic acidosis
D. Fully compensated metabolic acidosis
CORRECT ANSWER: C. Partially compensated metabolic acidosis
, Rationale: The primary disturbance is metabolic acidosis, as indicated by a low pH and
low HCO3-. The PaCO2 is low, indicating that the lungs are attempting to compensate
by blowing off CO2 (respiratory alkalosis). The pH is still below normal, meaning the
compensation is not yet complete, so this is considered a partially compensated
metabolic acidosis. If the pH were normal, it would be fully compensated.
Question 8: The nurse is performing a focused assessment on a patient who
had a hip replacement surgery 12 hours ago. Which of the following findings
would be of most concern?
A. Pain rated 4 out of 10 at the surgical site
B. Mild erythema around the incision
C. The patient's foot on the operative side is cool and pale with a diminished pulse
D. A low-grade fever of 99.8°F
CORRECT ANSWER: C. The patient's foot on the operative side is cool and pale
with a diminished pulse
Rationale: A cool, pale extremity with a diminished pulse on the operative side is a sign
of possible vascular compromise. This is an emergent situation that could indicate
damage to the femoral artery during surgery or the development of a thrombus. The
neurovascular assessment of the operative extremity is a priority. Pain, erythema, and
low-grade fever are expected postoperative findings.
Question 9: A patient has an order for a 24-hour urine collection. Which of the
following actions by the nursing assistant indicates a need for further
teaching?
A. Starting the collection with an empty bladder at the start time
B. Placing the collection container on ice
C. Discarding a urine specimen voided at the 24-hour mark
D. Placing a sign in the patient's bathroom to save all urine
CORRECT ANSWER: C. Discarding a urine specimen voided at the 24-hour
mark
Rationale: For a 24-hour urine collection, the collection period is started after the patient
voids and discards the first specimen. All subsequent urine over the next 24 hours is
saved, including the last specimen voided at the end of the 24-hour period. Discarding
the final specimen is incorrect and would result in an incomplete collection, invalidating
the test.
Question 10: A patient with an indwelling urinary catheter has cloudy, foul-
smelling urine. What is the nurse's priority action?
College BSN 346 Concepts of Nursing III Study Guide &
Case Study Review 2026/2027 | Shadow Health Digital
Clinical Experience, Focused Patient Assessment,
Subjective & Objective Data Collection, Clinical
Reasoning, Nursing Diagnosis, Care Planning,
Therapeutic Communication, Patient Education,
Documentation, Prioritization, Case-Based Practice &
Detailed Explanations
Question 1: A 72-year-old male patient presents with a 2-week history of
progressive shortness of breath, orthopnea, and a dry cough. On auscultation,
you note crackles that are heard late in inspiration and do not clear with
coughing. These findings are most consistent with which of the following
pathophysiological processes?
A. Atelectasis due to airway obstruction
B. Consolidation from a bacterial pneumonia
C. Pulmonary fibrosis with restrictive lung disease
D. Alveolar fluid accumulation from increased hydrostatic pressure
CORRECT ANSWER: D. Alveolar fluid accumulation from increased hydrostatic
pressure
Rationale: Late-inspiratory crackles that do not clear with coughing are classic findings
of pulmonary edema, most commonly cardiogenic in origin. The progressive dyspnea,
orthopnea, and dry cough further support left-sided heart failure, where increased
hydrostatic pressure forces fluid into the alveoli. Atelectasis crackles typically clear after
coughing. Consolidation from pneumonia often presents with more productive cough,
fever, and bronchial breath sounds. Pulmonary fibrosis may present with Velcro-like
crackles, but the clinical history here is more acute and classic for heart failure.
Question 2: When assessing a patient's level of consciousness using the
Glasgow Coma Scale, which of the following components is NOT evaluated?
A. Eye opening
B. Verbal response
C. Motor response
D. Pupillary light reflex
CORRECT ANSWER: D. Pupillary light reflex
Rationale: The Glasgow Coma Scale is a neurological assessment tool that evaluates
three components: eye opening, verbal response, and motor response. The maximum
score is 15, with each component scored independently. Pupillary light reflex is a
,brainstem reflex that is assessed separately as part of a complete neurological
examination but is not a component of the GCS score.
Question 3: A patient with a history of chronic obstructive pulmonary disease
(COPD) is receiving supplemental oxygen at 2 L/min via nasal cannula. The
nurse notes that the patient's respiratory rate has decreased from 22 to 10
breaths per minute and the patient appears drowsy. This change is most likely
due to which of the following?
A. Hyperventilation syndrome
B. Carbon dioxide narcosis
C. Acute asthma exacerbation
D. Paradoxical breathing
CORRECT ANSWER: B. Carbon dioxide narcosis
Rationale: Patients with severe COPD may rely on a hypoxic drive to stimulate
breathing. Administration of high-flow or even moderate-flow oxygen can eliminate this
hypoxic stimulus, leading to hypoventilation, CO2 retention, and subsequent carbon
dioxide narcosis. The classic signs include decreased respiratory rate, drowsiness,
confusion, and potential respiratory acidosis. This is a dangerous situation and would
require careful titration of oxygen.
Question 4: Which of the following findings is the BEST indicator that a
patient's endotracheal tube is correctly positioned in the trachea?
A. Equal breath sounds on both sides of the chest
B. Condensation in the endotracheal tube
C. Presence of a cough reflex
D. Absence of gastric distension
CORRECT ANSWER: A. Equal breath sounds on both sides of the chest
Rationale: Equal bilateral breath sounds are the most reliable initial physical assessment
finding to confirm correct endotracheal tube placement in the trachea, above the carina.
Condensation in the tube is not a reliable indicator of correct placement. While
auscultation over the epigastrium should confirm absence of air entry to rule out
esophageal placement, symmetrical breath sounds are the best physical indicator.
Confirmation is always done via capnography and chest x-ray.
Question 5: A patient is admitted with severe dehydration. The nurse assesses
a thready, rapid pulse, flat neck veins, and poor skin turgor. The nurse
understands that these findings are primarily the result of which
compensatory mechanism?
,A. Increased sympathetic nervous system activity
B. Decreased antidiuretic hormone secretion
C. Increased parasympathetic nervous system activity
D. Decreased renin-angiotensin-aldosterone system activation
CORRECT ANSWER: A. Increased sympathetic nervous system activity
Rationale: In response to hypovolemia, the body activates the sympathetic nervous
system, leading to increased heart rate (tachycardia) and peripheral vasoconstriction to
maintain blood pressure. This results in a rapid, thready pulse. The decreased circulating
volume also leads to flat neck veins and poor skin turgor. ADH and aldosterone are
actually increased in dehydration to conserve water, not decreased. The sympathetic
response is the primary compensatory mechanism.
Question 6: The nurse is caring for a patient with a chest tube attached to a
water-seal drainage system. Which of the following observations indicates that
the chest tube system is functioning correctly?
A. Continuous bubbling in the water-seal chamber
B. Fluctuation (tidaling) of the water level in the water-seal chamber with respirations
C. No drainage in the collection chamber
D. The chest tube is disconnected from the suction source
CORRECT ANSWER: B. Fluctuation (tidaling) of the water level in the water-
seal chamber with respirations
Rationale: Tidaling, or fluctuation of the water level in the water-seal chamber with
inspiration and expiration, is a normal finding that indicates the chest tube is patent and
functioning correctly. Continuous bubbling in the water-seal chamber indicates an air
leak. No drainage in the collection chamber may be normal, but it depends on the
indication for the chest tube. If a patient had a pneumothorax without significant
bleeding, this is fine; however, tidaling is the key indicator of correct system function.
Question 7: A patient with type 1 diabetes mellitus is brought to the
emergency department with a blood glucose level of 650 mg/dL. Arterial blood
gas results reveal a pH of 7.20, HCO3- of 12 mEq/L, and PaCO2 of 28 mmHg.
The nurse interprets these results as:
A. Uncompensated metabolic acidosis
B. Uncompensated respiratory alkalosis
C. Partially compensated metabolic acidosis
D. Fully compensated metabolic acidosis
CORRECT ANSWER: C. Partially compensated metabolic acidosis
, Rationale: The primary disturbance is metabolic acidosis, as indicated by a low pH and
low HCO3-. The PaCO2 is low, indicating that the lungs are attempting to compensate
by blowing off CO2 (respiratory alkalosis). The pH is still below normal, meaning the
compensation is not yet complete, so this is considered a partially compensated
metabolic acidosis. If the pH were normal, it would be fully compensated.
Question 8: The nurse is performing a focused assessment on a patient who
had a hip replacement surgery 12 hours ago. Which of the following findings
would be of most concern?
A. Pain rated 4 out of 10 at the surgical site
B. Mild erythema around the incision
C. The patient's foot on the operative side is cool and pale with a diminished pulse
D. A low-grade fever of 99.8°F
CORRECT ANSWER: C. The patient's foot on the operative side is cool and pale
with a diminished pulse
Rationale: A cool, pale extremity with a diminished pulse on the operative side is a sign
of possible vascular compromise. This is an emergent situation that could indicate
damage to the femoral artery during surgery or the development of a thrombus. The
neurovascular assessment of the operative extremity is a priority. Pain, erythema, and
low-grade fever are expected postoperative findings.
Question 9: A patient has an order for a 24-hour urine collection. Which of the
following actions by the nursing assistant indicates a need for further
teaching?
A. Starting the collection with an empty bladder at the start time
B. Placing the collection container on ice
C. Discarding a urine specimen voided at the 24-hour mark
D. Placing a sign in the patient's bathroom to save all urine
CORRECT ANSWER: C. Discarding a urine specimen voided at the 24-hour
mark
Rationale: For a 24-hour urine collection, the collection period is started after the patient
voids and discards the first specimen. All subsequent urine over the next 24 hours is
saved, including the last specimen voided at the end of the 24-hour period. Discarding
the final specimen is incorrect and would result in an incomplete collection, invalidating
the test.
Question 10: A patient with an indwelling urinary catheter has cloudy, foul-
smelling urine. What is the nurse's priority action?
