NRSG 3320 Nursing Care of Adults 1
PRACTICE QUESTIONS |ORIGINAL
QUESTIONS & ANSWERS |DETAILED
RATIONALES |HINTED COMPLETE
EXAM PREP GRADED A+*INSTANT
DOWNLOAD PDF
1.
A nurse is assessing an older adult admitted with weakness. Which
finding requires the most immediate follow-up?
A. Blood pressure 138/82 mmHg
B. Respiratory rate 18/min
C. New onset confusion
D. Temperature 37.1°C (98.8°F)
Answer: C. New onset confusion
Rationale: Acute confusion may indicate hypoxia, infection, metabolic
disturbance, medication effects, or another acute problem and
requires prompt assessment.
2.
Which assessment finding is most concerning in a hospitalized adult?
A. Heart rate 88/min
B. Oxygen saturation 86%
C. Blood pressure 128/76 mmHg
D. Temperature 36.8°C (98.2°F)
Answer: B. Oxygen saturation 86%
,Rationale: An oxygen saturation of 86% indicates significant
hypoxemia and requires immediate assessment and intervention.
3.
The nurse is caring for a patient at risk for falls. Which intervention is
most appropriate?
A. Keep all four side rails raised
B. Place the call light within reach
C. Keep the room completely dark at night
D. Encourage the patient to ambulate independently
Answer: B. Place the call light within reach
Rationale: Easy access to the call light allows the patient to request
assistance and reduces the likelihood of an unassisted transfer.
4.
Which finding best indicates adequate tissue perfusion?
A. Capillary refill of 4 seconds
B. Cool, mottled extremities
C. Urine output of 35 mL/hr
D. Weak peripheral pulses
Answer: C. Urine output of 35 mL/hr
Rationale: Adequate urine output generally reflects sufficient renal
blood flow and systemic perfusion in an adult.
5.
A patient reports severe pain. Which nursing action should occur
first?
A. Document the pain
B. Administer the prescribed analgesic
C. Determine the location and characteristics of the pain
D. Reassure the patient that the pain will improve
,Answer: C. Determine the location and characteristics of the pain
Rationale: A focused pain assessment guides appropriate treatment
and helps identify potentially serious causes.
6.
Which statement by a patient demonstrates correct understanding
of incentive spirometry?
A. “I should breathe out forcefully into the device.”
B. “I should use it only when I feel short of breath.”
C. “I should inhale slowly and deeply through the mouthpiece.”
D. “I should cough only after using it once.”
Answer: C. “I should inhale slowly and deeply through the
mouthpiece.”
Rationale: Incentive spirometry promotes sustained maximal
inspiration, helping prevent atelectasis.
7.
Which nursing intervention is most effective for preventing pressure
injuries in an immobile patient?
A. Massage reddened areas
B. Reposition the patient regularly
C. Limit protein intake
D. Keep the head of bed elevated continuously
Answer: B. Reposition the patient regularly
Rationale: Regular repositioning relieves prolonged pressure and
supports tissue perfusion.
8.
Which patient is at greatest risk for developing a pressure injury?
, A. Ambulatory adult with hypertension
B. Adult with limited mobility and poor nutrition
C. Adult with seasonal allergies
D. Adult receiving oral antibiotics
Answer: B. Adult with limited mobility and poor nutrition
Rationale: Immobility and inadequate nutrition significantly increase
pressure-injury risk.
9.
Which nursing action best promotes sleep in a hospitalized adult?
A. Perform vital signs every hour regardless of need
B. Cluster nighttime care activities
C. Keep the television on
D. Encourage caffeine before bedtime
Answer: B. Cluster nighttime care activities
Rationale: Clustering care minimizes interruptions and promotes
uninterrupted periods of sleep.
10.
Which finding is most consistent with dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Orthostatic hypotension
D. Peripheral edema
Answer: C. Orthostatic hypotension
Rationale: Volume depletion can reduce circulating volume and cause
a drop in blood pressure when the patient changes position.
Section 2: Fluid, Electrolyte, and Acid-Base Balance
PRACTICE QUESTIONS |ORIGINAL
QUESTIONS & ANSWERS |DETAILED
RATIONALES |HINTED COMPLETE
EXAM PREP GRADED A+*INSTANT
DOWNLOAD PDF
1.
A nurse is assessing an older adult admitted with weakness. Which
finding requires the most immediate follow-up?
A. Blood pressure 138/82 mmHg
B. Respiratory rate 18/min
C. New onset confusion
D. Temperature 37.1°C (98.8°F)
Answer: C. New onset confusion
Rationale: Acute confusion may indicate hypoxia, infection, metabolic
disturbance, medication effects, or another acute problem and
requires prompt assessment.
2.
Which assessment finding is most concerning in a hospitalized adult?
A. Heart rate 88/min
B. Oxygen saturation 86%
C. Blood pressure 128/76 mmHg
D. Temperature 36.8°C (98.2°F)
Answer: B. Oxygen saturation 86%
,Rationale: An oxygen saturation of 86% indicates significant
hypoxemia and requires immediate assessment and intervention.
3.
The nurse is caring for a patient at risk for falls. Which intervention is
most appropriate?
A. Keep all four side rails raised
B. Place the call light within reach
C. Keep the room completely dark at night
D. Encourage the patient to ambulate independently
Answer: B. Place the call light within reach
Rationale: Easy access to the call light allows the patient to request
assistance and reduces the likelihood of an unassisted transfer.
4.
Which finding best indicates adequate tissue perfusion?
A. Capillary refill of 4 seconds
B. Cool, mottled extremities
C. Urine output of 35 mL/hr
D. Weak peripheral pulses
Answer: C. Urine output of 35 mL/hr
Rationale: Adequate urine output generally reflects sufficient renal
blood flow and systemic perfusion in an adult.
5.
A patient reports severe pain. Which nursing action should occur
first?
A. Document the pain
B. Administer the prescribed analgesic
C. Determine the location and characteristics of the pain
D. Reassure the patient that the pain will improve
,Answer: C. Determine the location and characteristics of the pain
Rationale: A focused pain assessment guides appropriate treatment
and helps identify potentially serious causes.
6.
Which statement by a patient demonstrates correct understanding
of incentive spirometry?
A. “I should breathe out forcefully into the device.”
B. “I should use it only when I feel short of breath.”
C. “I should inhale slowly and deeply through the mouthpiece.”
D. “I should cough only after using it once.”
Answer: C. “I should inhale slowly and deeply through the
mouthpiece.”
Rationale: Incentive spirometry promotes sustained maximal
inspiration, helping prevent atelectasis.
7.
Which nursing intervention is most effective for preventing pressure
injuries in an immobile patient?
A. Massage reddened areas
B. Reposition the patient regularly
C. Limit protein intake
D. Keep the head of bed elevated continuously
Answer: B. Reposition the patient regularly
Rationale: Regular repositioning relieves prolonged pressure and
supports tissue perfusion.
8.
Which patient is at greatest risk for developing a pressure injury?
, A. Ambulatory adult with hypertension
B. Adult with limited mobility and poor nutrition
C. Adult with seasonal allergies
D. Adult receiving oral antibiotics
Answer: B. Adult with limited mobility and poor nutrition
Rationale: Immobility and inadequate nutrition significantly increase
pressure-injury risk.
9.
Which nursing action best promotes sleep in a hospitalized adult?
A. Perform vital signs every hour regardless of need
B. Cluster nighttime care activities
C. Keep the television on
D. Encourage caffeine before bedtime
Answer: B. Cluster nighttime care activities
Rationale: Clustering care minimizes interruptions and promotes
uninterrupted periods of sleep.
10.
Which finding is most consistent with dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Orthostatic hypotension
D. Peripheral edema
Answer: C. Orthostatic hypotension
Rationale: Volume depletion can reduce circulating volume and cause
a drop in blood pressure when the patient changes position.
Section 2: Fluid, Electrolyte, and Acid-Base Balance
