NSG 202 — Adult Health Nursing II exam
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1. A client with acute pulmonary edema is experiencing severe
dyspnea and pink, frothy sputum. Which nursing intervention
should be performed first?
A. Encourage oral fluids
B. Place the client in a supine position
C. Administer oxygen and position the client upright
D. Obtain a routine sputum culture
Answer: C. Administer oxygen and position the client upright
Rationale: Acute pulmonary edema causes severe impairment of
oxygenation because fluid accumulates in the alveoli. Positioning the
client upright decreases venous return and improves lung expansion,
,while supplemental oxygen supports oxygenation. Other interventions
can follow after immediate respiratory support is initiated.
2. A client with chronic heart failure reports a sudden 3-kg weight
gain over several days. What does this finding most likely
indicate?
A. Improved cardiac function
B. Fluid retention
C. Increased muscle mass
D. Dehydration
Answer: B. Fluid retention
Rationale: Rapid weight gain in a client with heart failure is usually
caused by fluid accumulation rather than tissue gain. Daily weights
are an important method for detecting worsening heart failure and
should be obtained under consistent conditions.
3. A client taking digoxin has a serum potassium level of 2.8 mEq/L.
Which action is most appropriate?
A. Administer the digoxin as prescribed
B. Hold the digoxin and notify the provider
C. Restrict dietary potassium
D. Administer an additional dose of digoxin
,Answer: B. Hold the digoxin and notify the provider
Rationale: Hypokalemia increases the risk of digoxin toxicity because
potassium normally competes with digoxin for binding sites. A
potassium level of 2.8 mEq/L is significantly low and requires prompt
intervention. The nurse should withhold digoxin and notify the
provider.
4. Which assessment finding is most characteristic of left-sided heart
failure?
A. Peripheral edema
B. Ascites
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure causes blood to back up into the
pulmonary circulation, producing pulmonary congestion and
potentially pulmonary edema. Crackles, dyspnea, orthopnea, and
decreased oxygen saturation are common manifestations. Peripheral
edema and ascites are more strongly associated with right-sided heart
failure.
, 5. A client with an acute myocardial infarction reports crushing
substernal chest pain. Which medication should the nurse
anticipate administering to reduce platelet aggregation?
A. Aspirin
B. Furosemide
C. Digoxin
D. Acetaminophen
Answer: A. Aspirin
Rationale: Aspirin inhibits platelet aggregation and is a key early
treatment for suspected acute myocardial infarction unless
contraindicated. It helps prevent further thrombus formation and
coronary artery occlusion.
6. A client receiving a heparin infusion has a markedly elevated
aPTT. What should the nurse do?
A. Increase the infusion rate
B. Administer the next dose immediately
C. Follow the protocol for holding or adjusting the infusion
D. Administer vitamin K
Answer: C. Follow the protocol for holding or adjusting the infusion
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A| Instant
Download Pdf
1. A client with acute pulmonary edema is experiencing severe
dyspnea and pink, frothy sputum. Which nursing intervention
should be performed first?
A. Encourage oral fluids
B. Place the client in a supine position
C. Administer oxygen and position the client upright
D. Obtain a routine sputum culture
Answer: C. Administer oxygen and position the client upright
Rationale: Acute pulmonary edema causes severe impairment of
oxygenation because fluid accumulates in the alveoli. Positioning the
client upright decreases venous return and improves lung expansion,
,while supplemental oxygen supports oxygenation. Other interventions
can follow after immediate respiratory support is initiated.
2. A client with chronic heart failure reports a sudden 3-kg weight
gain over several days. What does this finding most likely
indicate?
A. Improved cardiac function
B. Fluid retention
C. Increased muscle mass
D. Dehydration
Answer: B. Fluid retention
Rationale: Rapid weight gain in a client with heart failure is usually
caused by fluid accumulation rather than tissue gain. Daily weights
are an important method for detecting worsening heart failure and
should be obtained under consistent conditions.
3. A client taking digoxin has a serum potassium level of 2.8 mEq/L.
Which action is most appropriate?
A. Administer the digoxin as prescribed
B. Hold the digoxin and notify the provider
C. Restrict dietary potassium
D. Administer an additional dose of digoxin
,Answer: B. Hold the digoxin and notify the provider
Rationale: Hypokalemia increases the risk of digoxin toxicity because
potassium normally competes with digoxin for binding sites. A
potassium level of 2.8 mEq/L is significantly low and requires prompt
intervention. The nurse should withhold digoxin and notify the
provider.
4. Which assessment finding is most characteristic of left-sided heart
failure?
A. Peripheral edema
B. Ascites
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure causes blood to back up into the
pulmonary circulation, producing pulmonary congestion and
potentially pulmonary edema. Crackles, dyspnea, orthopnea, and
decreased oxygen saturation are common manifestations. Peripheral
edema and ascites are more strongly associated with right-sided heart
failure.
, 5. A client with an acute myocardial infarction reports crushing
substernal chest pain. Which medication should the nurse
anticipate administering to reduce platelet aggregation?
A. Aspirin
B. Furosemide
C. Digoxin
D. Acetaminophen
Answer: A. Aspirin
Rationale: Aspirin inhibits platelet aggregation and is a key early
treatment for suspected acute myocardial infarction unless
contraindicated. It helps prevent further thrombus formation and
coronary artery occlusion.
6. A client receiving a heparin infusion has a markedly elevated
aPTT. What should the nurse do?
A. Increase the infusion rate
B. Administer the next dose immediately
C. Follow the protocol for holding or adjusting the infusion
D. Administer vitamin K
Answer: C. Follow the protocol for holding or adjusting the infusion
