Adult Health Nursing I – Comprehensive Final
Exam Question Bank
Question 1: A patient with acute left-sided heart failure develops severe
dyspnea, crackles, and pink, frothy sputum. Which action should the
nurse take first?
A. Place the patient in high-Fowler’s position and administer oxygen as
prescribed
B. Encourage oral fluids
C. Place the patient supine
D. Encourage ambulation
Correct Answer: A. Place the patient in high-Fowler’s position and
administer oxygen as prescribed.
Rationale: Pink, frothy sputum and crackles indicate acute pulmonary
edema, a life-threatening complication of left-sided heart failure. High-
Fowler’s positioning improves lung expansion and reduces venous return.
Oxygen supports gas exchange. The nurse should also notify the provider
and prepare prescribed emergency medications.
Question 2
,Question 2: A patient with heart failure gains 3 pounds in two days and
reports worsening orthopnea. Which finding best explains these
symptoms?
A. Fluid retention
B. Dehydration
C. Hypoglycemia
D. Acute blood loss
Correct Answer: A. Fluid retention.
Rationale: Rapid weight gain and orthopnea commonly indicate fluid
accumulation associated with worsening heart failure. Increased
intravascular volume raises cardiac workload and promotes pulmonary
congestion. The nurse should monitor daily weight, lung sounds,
oxygenation, edema, intake and output, and response to prescribed
diuretics.
Question 3
Question 3: A patient taking digoxin has nausea, visual halos, and an
apical pulse of 54 beats per minute. What should the nurse do?
A. Administer the dose with food
B. Withhold the medication and notify the provider
C. Encourage vigorous exercise
D. Give an additional dose
,Correct Answer: B. Withhold the medication and notify the provider.
Rationale: Nausea, visual disturbances, and bradycardia suggest digoxin
toxicity. The nurse should withhold the medication, assess the apical
pulse, review potassium and renal-function results, and notify the
provider. Toxicity may cause life-threatening cardiac dysrhythmias.
Question 4
Question 4: Which electrolyte imbalance increases the risk of digoxin
toxicity?
A. Hypernatremia
B. Hypokalemia
C. Hyperchloremia
D. Hypermagnesemia
Correct Answer: B. Hypokalemia.
Rationale: Potassium competes with digoxin for binding sites on cardiac
muscle. Low potassium allows more digoxin to bind, increasing toxicity
risk. Patients receiving digoxin, particularly those taking diuretics, require
regular monitoring of potassium, renal function, apical pulse, and toxicity
symptoms.
Question 5
, Question 5: A patient receiving furosemide reports weakness and muscle
cramps. Which laboratory result should the nurse review first?
A. Serum potassium
B. Serum amylase
C. Hemoglobin A1c
D. Platelet count
Correct Answer: A. Serum potassium.
Rationale: Furosemide increases urinary potassium loss. Hypokalemia
can cause weakness, muscle cramps, constipation, ileus, and cardiac
dysrhythmias. The nurse should review potassium and renal-function
values, assess cardiac rhythm, and notify the provider if the level is
significantly abnormal.
Question 6
Question 6: A patient presents with crushing chest pain radiating to the
jaw and left arm. Which action should occur first?
A. Obtain a 12-lead ECG
B. Offer a meal
C. Encourage ambulation
D. Apply a heating pad
Correct Answer: A. Obtain a 12-lead ECG.
Exam Question Bank
Question 1: A patient with acute left-sided heart failure develops severe
dyspnea, crackles, and pink, frothy sputum. Which action should the
nurse take first?
A. Place the patient in high-Fowler’s position and administer oxygen as
prescribed
B. Encourage oral fluids
C. Place the patient supine
D. Encourage ambulation
Correct Answer: A. Place the patient in high-Fowler’s position and
administer oxygen as prescribed.
Rationale: Pink, frothy sputum and crackles indicate acute pulmonary
edema, a life-threatening complication of left-sided heart failure. High-
Fowler’s positioning improves lung expansion and reduces venous return.
Oxygen supports gas exchange. The nurse should also notify the provider
and prepare prescribed emergency medications.
Question 2
,Question 2: A patient with heart failure gains 3 pounds in two days and
reports worsening orthopnea. Which finding best explains these
symptoms?
A. Fluid retention
B. Dehydration
C. Hypoglycemia
D. Acute blood loss
Correct Answer: A. Fluid retention.
Rationale: Rapid weight gain and orthopnea commonly indicate fluid
accumulation associated with worsening heart failure. Increased
intravascular volume raises cardiac workload and promotes pulmonary
congestion. The nurse should monitor daily weight, lung sounds,
oxygenation, edema, intake and output, and response to prescribed
diuretics.
Question 3
Question 3: A patient taking digoxin has nausea, visual halos, and an
apical pulse of 54 beats per minute. What should the nurse do?
A. Administer the dose with food
B. Withhold the medication and notify the provider
C. Encourage vigorous exercise
D. Give an additional dose
,Correct Answer: B. Withhold the medication and notify the provider.
Rationale: Nausea, visual disturbances, and bradycardia suggest digoxin
toxicity. The nurse should withhold the medication, assess the apical
pulse, review potassium and renal-function results, and notify the
provider. Toxicity may cause life-threatening cardiac dysrhythmias.
Question 4
Question 4: Which electrolyte imbalance increases the risk of digoxin
toxicity?
A. Hypernatremia
B. Hypokalemia
C. Hyperchloremia
D. Hypermagnesemia
Correct Answer: B. Hypokalemia.
Rationale: Potassium competes with digoxin for binding sites on cardiac
muscle. Low potassium allows more digoxin to bind, increasing toxicity
risk. Patients receiving digoxin, particularly those taking diuretics, require
regular monitoring of potassium, renal function, apical pulse, and toxicity
symptoms.
Question 5
, Question 5: A patient receiving furosemide reports weakness and muscle
cramps. Which laboratory result should the nurse review first?
A. Serum potassium
B. Serum amylase
C. Hemoglobin A1c
D. Platelet count
Correct Answer: A. Serum potassium.
Rationale: Furosemide increases urinary potassium loss. Hypokalemia
can cause weakness, muscle cramps, constipation, ileus, and cardiac
dysrhythmias. The nurse should review potassium and renal-function
values, assess cardiac rhythm, and notify the provider if the level is
significantly abnormal.
Question 6
Question 6: A patient presents with crushing chest pain radiating to the
jaw and left arm. Which action should occur first?
A. Obtain a 12-lead ECG
B. Offer a meal
C. Encourage ambulation
D. Apply a heating pad
Correct Answer: A. Obtain a 12-lead ECG.
