NSG 3800 Exam 2 V1 | NSG 3800 Nursing Practice – Adult Health II |
Actual Q&A with Rationale (NSG3800 Exam 2) | Galen
1. A client is admitted with left-sided heart failure. Which clinical manifestation should the
nurse expect to find during the assessment?
A. Jugular venous distention
B. Peripheral edema
C. Hepatomegaly
D. Dyspnea and crackles
Answer: D
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot pump blood efficiently to the body, causing fluid to back up into the lungs.
Symptoms like dyspnea, crackles, and orthopnea are common respiratory findings. Options
A, B, and D are typically associated with right-sided heart failure where fluid backs up into
the systemic circulation.
2. A nurse is preparing to administer Digoxin to a client with heart failure. Which action is
most important before administration?
A. Check the client’s blood pressure
B. Monitor the client’s respiratory rate
C. Assess the apical pulse for one full minute
D. Measure the client’s urinary output
Answer: C
Rationale: Digoxin is a cardiac glycoside that slows the heart rate and increases the force
of contraction. The nurse must assess the apical pulse for a full minute and withhold the
medication if the rate is below 60 beats per minute in an adult. This safety measure
prevents further bradycardia and potential digoxin toxicity.
3. A client presents to the emergency department with chest pain that is relieved by rest. The
nurse recognizes this as which condition?
A. Stable angina
B. Myocardial infarction
C. Unstable angina
D. Prinzmetal’s angina
,Answer: A
Rationale: Stable angina is characterized by chest pain that occurs with exertion and is
predictable in nature. It is typically relieved by rest or nitroglycerin within a few minutes.
Unstable angina and myocardial infarction involve pain that is more severe and not
necessarily relieved by rest.
4. Which laboratory value is most specific for diagnosing a myocardial infarction (MI)?
A. Creatine kinase (CK)
B. C-reactive protein
C. Myoglobin
D. Troponin I
Answer: D
Rationale: Troponin I is a highly specific cardiac marker that rises within a few hours of
myocardial injury. It remains elevated for several days, making it the gold standard for
diagnosing an MI. While other markers like CK-MB exist, Troponin provides the most
accurate evidence of cardiac muscle damage.
5. A client is prescribed Warfarin for atrial fibrillation. Which laboratory test should the nurse
monitor to evaluate the effectiveness of this medication?
A. aPTT
B. Platelet count
C. Hemoglobin
D. PT/INR
Answer: D
Rationale: Warfarin (Coumadin) therapy is monitored using the Prothrombin Time (PT)
and the International Normalized Ratio (INR). The goal is typically to maintain an INR
between 2.0 and 3.0 for conditions like atrial fibrillation. The aPTT is used to monitor
heparin therapy, not warfarin.
6. A nurse is teaching a client about the use of sublingual nitroglycerin. Which statement by
the client indicates a need for further teaching?
A. I will swallow the tablet with a full glass of water
B. I can take up to three tablets 5 minutes apart if pain continues
C. I should call 911 if pain is not relieved after the first tablet
D. I will keep the tablets in the original dark glass bottle
Answer: A
, Rationale: Sublingual nitroglycerin must be placed under the tongue to be absorbed
directly into the bloodstream through the oral mucosa. Swallowing the tablet will result in
the medication being inactivated by the liver (first-pass effect). The client should be taught
to let it dissolve completely without drinking water immediately.
7. A client with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is most appropriate for this client?
A. 12-15 L/min
B. 6-10 L/min
C. 1-2 L/min
D. Oxygen should not be given to COPD clients
Answer: C
Rationale: Clients with COPD often rely on a hypoxic drive to stimulate breathing due to
chronic carbon dioxide retention. High concentrations of oxygen can suppress this drive,
leading to respiratory depression. Therefore, low-flow oxygen, typically 1-2 L/min, is used
to maintain adequate saturation without removing the stimulus to breathe.
8. A nurse is assessing a client with a suspected pneumothorax. Which finding is characteristic
of this condition?
A. Increased breath sounds on the affected side
B. Absence of breath sounds on the affected side
C. Dullness on percussion of the affected side
D. Bilateral chest expansion
Answer: B
Rationale: A pneumothorax occurs when air enters the pleural space, causing the lung to
collapse. This results in an absence of breath sounds on the affected side because the lung
is no longer ventilating. The nurse would also observe asymmetrical chest expansion and
hyperresonance upon percussion.
9. What is the primary goal of treatment for a client experiencing an acute asthma attack?
A. Promoting long-term lifestyle changes
B. Relieving airway obstruction and inflammation
C. Identifying triggers for the attack
D. Improving peak flow meter readings
Answer: B
Actual Q&A with Rationale (NSG3800 Exam 2) | Galen
1. A client is admitted with left-sided heart failure. Which clinical manifestation should the
nurse expect to find during the assessment?
A. Jugular venous distention
B. Peripheral edema
C. Hepatomegaly
D. Dyspnea and crackles
Answer: D
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot pump blood efficiently to the body, causing fluid to back up into the lungs.
Symptoms like dyspnea, crackles, and orthopnea are common respiratory findings. Options
A, B, and D are typically associated with right-sided heart failure where fluid backs up into
the systemic circulation.
2. A nurse is preparing to administer Digoxin to a client with heart failure. Which action is
most important before administration?
A. Check the client’s blood pressure
B. Monitor the client’s respiratory rate
C. Assess the apical pulse for one full minute
D. Measure the client’s urinary output
Answer: C
Rationale: Digoxin is a cardiac glycoside that slows the heart rate and increases the force
of contraction. The nurse must assess the apical pulse for a full minute and withhold the
medication if the rate is below 60 beats per minute in an adult. This safety measure
prevents further bradycardia and potential digoxin toxicity.
3. A client presents to the emergency department with chest pain that is relieved by rest. The
nurse recognizes this as which condition?
A. Stable angina
B. Myocardial infarction
C. Unstable angina
D. Prinzmetal’s angina
,Answer: A
Rationale: Stable angina is characterized by chest pain that occurs with exertion and is
predictable in nature. It is typically relieved by rest or nitroglycerin within a few minutes.
Unstable angina and myocardial infarction involve pain that is more severe and not
necessarily relieved by rest.
4. Which laboratory value is most specific for diagnosing a myocardial infarction (MI)?
A. Creatine kinase (CK)
B. C-reactive protein
C. Myoglobin
D. Troponin I
Answer: D
Rationale: Troponin I is a highly specific cardiac marker that rises within a few hours of
myocardial injury. It remains elevated for several days, making it the gold standard for
diagnosing an MI. While other markers like CK-MB exist, Troponin provides the most
accurate evidence of cardiac muscle damage.
5. A client is prescribed Warfarin for atrial fibrillation. Which laboratory test should the nurse
monitor to evaluate the effectiveness of this medication?
A. aPTT
B. Platelet count
C. Hemoglobin
D. PT/INR
Answer: D
Rationale: Warfarin (Coumadin) therapy is monitored using the Prothrombin Time (PT)
and the International Normalized Ratio (INR). The goal is typically to maintain an INR
between 2.0 and 3.0 for conditions like atrial fibrillation. The aPTT is used to monitor
heparin therapy, not warfarin.
6. A nurse is teaching a client about the use of sublingual nitroglycerin. Which statement by
the client indicates a need for further teaching?
A. I will swallow the tablet with a full glass of water
B. I can take up to three tablets 5 minutes apart if pain continues
C. I should call 911 if pain is not relieved after the first tablet
D. I will keep the tablets in the original dark glass bottle
Answer: A
, Rationale: Sublingual nitroglycerin must be placed under the tongue to be absorbed
directly into the bloodstream through the oral mucosa. Swallowing the tablet will result in
the medication being inactivated by the liver (first-pass effect). The client should be taught
to let it dissolve completely without drinking water immediately.
7. A client with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is most appropriate for this client?
A. 12-15 L/min
B. 6-10 L/min
C. 1-2 L/min
D. Oxygen should not be given to COPD clients
Answer: C
Rationale: Clients with COPD often rely on a hypoxic drive to stimulate breathing due to
chronic carbon dioxide retention. High concentrations of oxygen can suppress this drive,
leading to respiratory depression. Therefore, low-flow oxygen, typically 1-2 L/min, is used
to maintain adequate saturation without removing the stimulus to breathe.
8. A nurse is assessing a client with a suspected pneumothorax. Which finding is characteristic
of this condition?
A. Increased breath sounds on the affected side
B. Absence of breath sounds on the affected side
C. Dullness on percussion of the affected side
D. Bilateral chest expansion
Answer: B
Rationale: A pneumothorax occurs when air enters the pleural space, causing the lung to
collapse. This results in an absence of breath sounds on the affected side because the lung
is no longer ventilating. The nurse would also observe asymmetrical chest expansion and
hyperresonance upon percussion.
9. What is the primary goal of treatment for a client experiencing an acute asthma attack?
A. Promoting long-term lifestyle changes
B. Relieving airway obstruction and inflammation
C. Identifying triggers for the attack
D. Improving peak flow meter readings
Answer: B
