NRSG 100 Exam 4 V1 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 4) | Ivy Tech
1. A nurse is assessing a client for early signs of hypoxia. Which of the following clinical
manifestations should the nurse expect to find?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Hypotension
Correct Answer: B
Explanation: Restlessness and agitation are considered early clinical indicators of hypoxia
as the brain is highly sensitive to decreased oxygen levels. Cyanosis and bradycardia are
typically late signs indicating severe oxygen deprivation. The nurse must prioritize early
assessment to prevent further respiratory deterioration.
2. A nurse is caring for a client who is post-operative. Which of the following actions is the
most effective way to prevent deep vein thrombosis (DVT)?
A. Massaging the lower extremities
B. Frequent early ambulation
C. Applying cold compresses
,D. Limiting fluid intake
Correct Answer: B
Explanation: Early ambulation is the most effective nursing intervention to promote
venous return and prevent the formation of blood clots in the lower extremities. Massaging
the legs is contraindicated because it could dislodge an existing clot. The nurse should also
encourage leg exercises and the use of sequential compression devices as ordered.
3. A nurse is monitoring a client’s IV site and notes that the area is cool, pale, and swollen.
Which of the following complications should the nurse document?
A. Phlebitis
B. Infection
C. Infiltration
D. Extravasation
Correct Answer: C
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
tissue, causing the site to become cool, pale, and edematous. Phlebitis, by contrast, is
characterized by warmth, redness, and a palpable cord along the vein. The nurse must stop
the infusion immediately and remove the catheter to prevent further tissue damage.
4. A nurse is preparing to administer oxygen via a nasal cannula to a client. Which of the
following is the maximum recommended flow rate for this device?
A. 6 L/min
, B. 2 L/min
C. 10 L/min
D. 15 L/min
Correct Answer: A
Explanation: A nasal cannula is used to deliver oxygen at flow rates ranging from 1 to 6
liters per minute, providing an FiO2 of approximately 24% to 44%. Flow rates higher than
6 L/min do not significantly increase oxygen concentration and can cause severe mucosal
drying. For higher oxygen needs, the nurse should transition the client to a mask-based
delivery system.
5. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which of the following
findings should the nurse expect?
A. Muscle weakness and dysrhythmias
B. Positive Trousseau’s sign
C. Hypertension
D. Tall peaked T-waves
Correct Answer: A
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, often manifests
as muscle weakness, fatigue, and life-threatening cardiac dysrhythmias. Tall peaked T-
waves are associated with hyperkalemia, not hypokalemia. The nurse should notify the
Nursing | Actual Q&A with Rationale (NRSG100
Exam 4) | Ivy Tech
1. A nurse is assessing a client for early signs of hypoxia. Which of the following clinical
manifestations should the nurse expect to find?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Hypotension
Correct Answer: B
Explanation: Restlessness and agitation are considered early clinical indicators of hypoxia
as the brain is highly sensitive to decreased oxygen levels. Cyanosis and bradycardia are
typically late signs indicating severe oxygen deprivation. The nurse must prioritize early
assessment to prevent further respiratory deterioration.
2. A nurse is caring for a client who is post-operative. Which of the following actions is the
most effective way to prevent deep vein thrombosis (DVT)?
A. Massaging the lower extremities
B. Frequent early ambulation
C. Applying cold compresses
,D. Limiting fluid intake
Correct Answer: B
Explanation: Early ambulation is the most effective nursing intervention to promote
venous return and prevent the formation of blood clots in the lower extremities. Massaging
the legs is contraindicated because it could dislodge an existing clot. The nurse should also
encourage leg exercises and the use of sequential compression devices as ordered.
3. A nurse is monitoring a client’s IV site and notes that the area is cool, pale, and swollen.
Which of the following complications should the nurse document?
A. Phlebitis
B. Infection
C. Infiltration
D. Extravasation
Correct Answer: C
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
tissue, causing the site to become cool, pale, and edematous. Phlebitis, by contrast, is
characterized by warmth, redness, and a palpable cord along the vein. The nurse must stop
the infusion immediately and remove the catheter to prevent further tissue damage.
4. A nurse is preparing to administer oxygen via a nasal cannula to a client. Which of the
following is the maximum recommended flow rate for this device?
A. 6 L/min
, B. 2 L/min
C. 10 L/min
D. 15 L/min
Correct Answer: A
Explanation: A nasal cannula is used to deliver oxygen at flow rates ranging from 1 to 6
liters per minute, providing an FiO2 of approximately 24% to 44%. Flow rates higher than
6 L/min do not significantly increase oxygen concentration and can cause severe mucosal
drying. For higher oxygen needs, the nurse should transition the client to a mask-based
delivery system.
5. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which of the following
findings should the nurse expect?
A. Muscle weakness and dysrhythmias
B. Positive Trousseau’s sign
C. Hypertension
D. Tall peaked T-waves
Correct Answer: A
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, often manifests
as muscle weakness, fatigue, and life-threatening cardiac dysrhythmias. Tall peaked T-
waves are associated with hyperkalemia, not hypokalemia. The nurse should notify the
