NSG 201 — Adult Health Nursing I exam
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1. A nurse is assessing a client admitted with heart failure. Which
finding requires the nurse’s immediate attention?
A. Bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Crackles throughout both lung fields
D. Fatigue with minimal activity
Answer: C. Crackles throughout both lung fields
Rationale: Diffuse crackles can indicate acute pulmonary congestion
and worsening pulmonary edema in a client with heart failure. This can
rapidly impair oxygenation and requires prompt intervention. Peripheral
edema, rapid weight gain, and fatigue are also important findings but
,are generally less immediately life-threatening than respiratory
compromise.
2. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing action is most
appropriate?
A. Administer oxygen at the highest possible flow rate
B. Maintain oxygen according to the prescribed target saturation
C. Discontinue oxygen when the client becomes drowsy
D. Encourage the client to breathe rapidly and deeply
Answer: B. Maintain oxygen according to the prescribed target
saturation
Rationale: Oxygen should be carefully titrated in clients with COPD
according to the prescribed target range and clinical condition.
Excessive oxygen administration can worsen carbon dioxide retention in
some susceptible clients. Oxygen should not be withheld when
hypoxemia is present, and therapy should be individualized rather than
automatically using the highest flow rate.
3. A client with pneumonia has a temperature of 39.2°C (102.6°F),
respiratory rate of 30/min, and oxygen saturation of 88% on room
air. What should the nurse do first?
,A. Encourage oral fluids
B. Administer the prescribed antibiotic
C. Apply supplemental oxygen
D. Obtain a sputum specimen
Answer: C. Apply supplemental oxygen
Rationale: The client is hypoxemic, as demonstrated by an oxygen
saturation of 88%. Airway and breathing are prioritized using the ABC
approach. Supplemental oxygen should be initiated as prescribed or
according to protocol while additional diagnostic and antimicrobial
interventions are carried out.
4. A client with asthma develops wheezing and increasing difficulty
breathing. Which medication should the nurse expect to
administer for rapid relief?
A. Albuterol
B. Montelukast
C. Fluticasone
D. Salmeterol
Answer: A. Albuterol
Rationale: Albuterol is a short-acting beta2-adrenergic agonist that
produces rapid bronchodilation and is commonly used as a rescue
, medication during acute bronchospasm. Inhaled corticosteroids such as
fluticasone are primarily controller medications, while montelukast is a
leukotriene modifier and salmeterol is a long-acting bronchodilator.
5. A nurse is caring for a client with a suspected pulmonary
embolism. Which assessment finding is most concerning?
A. Sudden dyspnea and pleuritic chest pain
B. Mild bilateral ankle edema
C. Productive cough for several days
D. Gradual weight gain
Answer: A. Sudden dyspnea and pleuritic chest pain
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and
hypoxemia are classic findings associated with pulmonary embolism. A
pulmonary embolism can rapidly become life-threatening because it
obstructs pulmonary blood flow and compromises oxygenation and
cardiac function.
6. A client with hypertension asks why blood pressure should be
controlled even when there are no symptoms. Which response is
most appropriate?
A. “Hypertension always causes severe headaches.”
B. “High blood pressure can damage organs over time without causing
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A| Instant
Download Pdf
1. A nurse is assessing a client admitted with heart failure. Which
finding requires the nurse’s immediate attention?
A. Bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Crackles throughout both lung fields
D. Fatigue with minimal activity
Answer: C. Crackles throughout both lung fields
Rationale: Diffuse crackles can indicate acute pulmonary congestion
and worsening pulmonary edema in a client with heart failure. This can
rapidly impair oxygenation and requires prompt intervention. Peripheral
edema, rapid weight gain, and fatigue are also important findings but
,are generally less immediately life-threatening than respiratory
compromise.
2. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing action is most
appropriate?
A. Administer oxygen at the highest possible flow rate
B. Maintain oxygen according to the prescribed target saturation
C. Discontinue oxygen when the client becomes drowsy
D. Encourage the client to breathe rapidly and deeply
Answer: B. Maintain oxygen according to the prescribed target
saturation
Rationale: Oxygen should be carefully titrated in clients with COPD
according to the prescribed target range and clinical condition.
Excessive oxygen administration can worsen carbon dioxide retention in
some susceptible clients. Oxygen should not be withheld when
hypoxemia is present, and therapy should be individualized rather than
automatically using the highest flow rate.
3. A client with pneumonia has a temperature of 39.2°C (102.6°F),
respiratory rate of 30/min, and oxygen saturation of 88% on room
air. What should the nurse do first?
,A. Encourage oral fluids
B. Administer the prescribed antibiotic
C. Apply supplemental oxygen
D. Obtain a sputum specimen
Answer: C. Apply supplemental oxygen
Rationale: The client is hypoxemic, as demonstrated by an oxygen
saturation of 88%. Airway and breathing are prioritized using the ABC
approach. Supplemental oxygen should be initiated as prescribed or
according to protocol while additional diagnostic and antimicrobial
interventions are carried out.
4. A client with asthma develops wheezing and increasing difficulty
breathing. Which medication should the nurse expect to
administer for rapid relief?
A. Albuterol
B. Montelukast
C. Fluticasone
D. Salmeterol
Answer: A. Albuterol
Rationale: Albuterol is a short-acting beta2-adrenergic agonist that
produces rapid bronchodilation and is commonly used as a rescue
, medication during acute bronchospasm. Inhaled corticosteroids such as
fluticasone are primarily controller medications, while montelukast is a
leukotriene modifier and salmeterol is a long-acting bronchodilator.
5. A nurse is caring for a client with a suspected pulmonary
embolism. Which assessment finding is most concerning?
A. Sudden dyspnea and pleuritic chest pain
B. Mild bilateral ankle edema
C. Productive cough for several days
D. Gradual weight gain
Answer: A. Sudden dyspnea and pleuritic chest pain
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and
hypoxemia are classic findings associated with pulmonary embolism. A
pulmonary embolism can rapidly become life-threatening because it
obstructs pulmonary blood flow and compromises oxygenation and
cardiac function.
6. A client with hypertension asks why blood pressure should be
controlled even when there are no symptoms. Which response is
most appropriate?
A. “Hypertension always causes severe headaches.”
B. “High blood pressure can damage organs over time without causing
