,NSG 2600 Exam 1 Adult Health Nursing I Questions And Answers
2026/2027 South College
Q1. A 68-year-old client is admitted with increasing fatigue, reduced
appetite, and confusion. The family reports that the client was
independent and fully oriented three days ago. Vital signs reveal
temperature 37.6°C, heart rate 108 beats/minute, respiratory rate
24 breaths/minute, and blood pressure 102/64 mmHg. Which
assessment should the nurse prioritize?
A) Determine the client's preferred daily activities.
B) Assess for acute physiological causes of altered mental status, including
infection, hypoxemia, glucose abnormalities, and impaired perfusion.
C) Assume that confusion is an expected consequence of aging.
D) Delay neurological assessment until the family leaves.
Correct Answer: B) Assess for acute physiological causes of altered mental
status, including infection, hypoxemia, glucose abnormalities, and impaired
perfusion.
Rationale: Acute confusion in an older adult may indicate delirium caused by
infection, hypoxemia, metabolic disturbance, medication effects, or
circulatory compromise. Delirium is not a normal consequence of aging.
Assessment should address immediate physiological threats and identify
reversible causes.
Q2. A 54-year-old client is admitted with generalized weakness and
dizziness. During assessment, the client becomes pale, diaphoretic,
and increasingly difficult to arouse. Blood pressure is 78/42 mmHg,
heart rate is 132 beats/minute, and capillary refill is delayed. Which
nursing action takes priority?
A) Complete a detailed nutritional history.
B) Provide routine discharge education.
C) Encourage the client to walk to improve circulation.
D) Activate emergency assistance, assess airway and breathing, and initiate
appropriate circulatory support.
Correct Answer: D) Activate emergency assistance, assess airway and
breathing, and initiate appropriate circulatory support.
,Rationale: Severe hypotension, tachycardia, altered consciousness, and
delayed capillary refill suggest circulatory shock. Immediate priorities include
airway protection, oxygenation, vascular access, perfusion assessment, and
emergency treatment. Nonurgent assessments must be deferred until the
client is stabilized.
Q3. A 62-year-old client reports sudden shortness of breath while
resting. Respiratory rate is 32 breaths/minute, oxygen saturation is
84% on room air, and the client is using accessory muscles to
breathe. Which intervention should the nurse implement first?
A) Position the client upright, initiate appropriate supplemental oxygen, and
rapidly assess respiratory status.
B) Obtain a detailed family history before intervening.
C) Encourage the client to drink several glasses of water.
D) Ask the client to lie completely flat.
Correct Answer: A) Position the client upright, initiate appropriate
supplemental oxygen, and rapidly assess respiratory status.
Rationale: Acute hypoxemia with increased work of breathing requires
immediate respiratory intervention. Upright positioning supports lung
expansion, while supplemental oxygen improves oxygen availability. The
nurse must rapidly assess breath sounds, respiratory effort, circulation, and
the need for additional support.
Q4. A client hospitalized with pneumonia reports worsening
weakness and states, "I feel like something is seriously wrong." The
nurse observes new restlessness and increasing respiratory rate
despite an unchanged oxygen saturation. Which interpretation is
most appropriate?
A) The client's statement is unrelated to physiological deterioration.
B) Unchanged oxygen saturation excludes respiratory compromise.
C) New restlessness and tachypnea may be early warning signs of clinical
deterioration requiring immediate reassessment.
D) The client should receive a sedative before further assessment.
Correct Answer: C) New restlessness and tachypnea may be early warning
signs of clinical deterioration requiring immediate reassessment.
, Rationale: Changes in mental status, respiratory rate, and behavior may
precede obvious hypoxemia or hypotension. Increasing restlessness can
reflect impaired oxygen delivery, infection progression, or other acute
problems. Recognizing subtle changes is an essential component of clinical
surveillance.
Q5. A 45-year-old client reports abdominal pain rated 8/10. The
nurse observes that the client is smiling while talking with a family
member. Which nursing approach is most appropriate?
A) Document that the client is exaggerating the pain.
B) Accept the client's self-reported pain intensity and complete a
comprehensive pain assessment.
C) Reduce the pain score because the client is smiling.
D) Withhold prescribed analgesics until visible distress develops.
Correct Answer: B) Accept the client's self-reported pain intensity and
complete a comprehensive pain assessment.
Rationale: Pain is a subjective experience, and behavioral appearance does
not reliably indicate pain intensity. The client's report should guide
assessment of location, quality, severity, duration, aggravating factors, and
functional effects. Treatment should be individualized and followed by
reassessment.
Q6. A 70-year-old client with a recent hip fracture becomes restless
and repeatedly attempts to climb out of bed. The client is
disoriented and has a fluctuating level of attention. Which condition
should the nurse suspect?
A) Delirium
B) Normal age-related forgetfulness
C) Stable chronic dementia without further evaluation
D) Expected postoperative independence
Correct Answer: A) Delirium
Rationale: Delirium is characterized by acute onset, fluctuating attention,
altered awareness, and cognitive changes. Common triggers include
infection, medications, pain, dehydration, sleep disruption, and metabolic
2026/2027 South College
Q1. A 68-year-old client is admitted with increasing fatigue, reduced
appetite, and confusion. The family reports that the client was
independent and fully oriented three days ago. Vital signs reveal
temperature 37.6°C, heart rate 108 beats/minute, respiratory rate
24 breaths/minute, and blood pressure 102/64 mmHg. Which
assessment should the nurse prioritize?
A) Determine the client's preferred daily activities.
B) Assess for acute physiological causes of altered mental status, including
infection, hypoxemia, glucose abnormalities, and impaired perfusion.
C) Assume that confusion is an expected consequence of aging.
D) Delay neurological assessment until the family leaves.
Correct Answer: B) Assess for acute physiological causes of altered mental
status, including infection, hypoxemia, glucose abnormalities, and impaired
perfusion.
Rationale: Acute confusion in an older adult may indicate delirium caused by
infection, hypoxemia, metabolic disturbance, medication effects, or
circulatory compromise. Delirium is not a normal consequence of aging.
Assessment should address immediate physiological threats and identify
reversible causes.
Q2. A 54-year-old client is admitted with generalized weakness and
dizziness. During assessment, the client becomes pale, diaphoretic,
and increasingly difficult to arouse. Blood pressure is 78/42 mmHg,
heart rate is 132 beats/minute, and capillary refill is delayed. Which
nursing action takes priority?
A) Complete a detailed nutritional history.
B) Provide routine discharge education.
C) Encourage the client to walk to improve circulation.
D) Activate emergency assistance, assess airway and breathing, and initiate
appropriate circulatory support.
Correct Answer: D) Activate emergency assistance, assess airway and
breathing, and initiate appropriate circulatory support.
,Rationale: Severe hypotension, tachycardia, altered consciousness, and
delayed capillary refill suggest circulatory shock. Immediate priorities include
airway protection, oxygenation, vascular access, perfusion assessment, and
emergency treatment. Nonurgent assessments must be deferred until the
client is stabilized.
Q3. A 62-year-old client reports sudden shortness of breath while
resting. Respiratory rate is 32 breaths/minute, oxygen saturation is
84% on room air, and the client is using accessory muscles to
breathe. Which intervention should the nurse implement first?
A) Position the client upright, initiate appropriate supplemental oxygen, and
rapidly assess respiratory status.
B) Obtain a detailed family history before intervening.
C) Encourage the client to drink several glasses of water.
D) Ask the client to lie completely flat.
Correct Answer: A) Position the client upright, initiate appropriate
supplemental oxygen, and rapidly assess respiratory status.
Rationale: Acute hypoxemia with increased work of breathing requires
immediate respiratory intervention. Upright positioning supports lung
expansion, while supplemental oxygen improves oxygen availability. The
nurse must rapidly assess breath sounds, respiratory effort, circulation, and
the need for additional support.
Q4. A client hospitalized with pneumonia reports worsening
weakness and states, "I feel like something is seriously wrong." The
nurse observes new restlessness and increasing respiratory rate
despite an unchanged oxygen saturation. Which interpretation is
most appropriate?
A) The client's statement is unrelated to physiological deterioration.
B) Unchanged oxygen saturation excludes respiratory compromise.
C) New restlessness and tachypnea may be early warning signs of clinical
deterioration requiring immediate reassessment.
D) The client should receive a sedative before further assessment.
Correct Answer: C) New restlessness and tachypnea may be early warning
signs of clinical deterioration requiring immediate reassessment.
, Rationale: Changes in mental status, respiratory rate, and behavior may
precede obvious hypoxemia or hypotension. Increasing restlessness can
reflect impaired oxygen delivery, infection progression, or other acute
problems. Recognizing subtle changes is an essential component of clinical
surveillance.
Q5. A 45-year-old client reports abdominal pain rated 8/10. The
nurse observes that the client is smiling while talking with a family
member. Which nursing approach is most appropriate?
A) Document that the client is exaggerating the pain.
B) Accept the client's self-reported pain intensity and complete a
comprehensive pain assessment.
C) Reduce the pain score because the client is smiling.
D) Withhold prescribed analgesics until visible distress develops.
Correct Answer: B) Accept the client's self-reported pain intensity and
complete a comprehensive pain assessment.
Rationale: Pain is a subjective experience, and behavioral appearance does
not reliably indicate pain intensity. The client's report should guide
assessment of location, quality, severity, duration, aggravating factors, and
functional effects. Treatment should be individualized and followed by
reassessment.
Q6. A 70-year-old client with a recent hip fracture becomes restless
and repeatedly attempts to climb out of bed. The client is
disoriented and has a fluctuating level of attention. Which condition
should the nurse suspect?
A) Delirium
B) Normal age-related forgetfulness
C) Stable chronic dementia without further evaluation
D) Expected postoperative independence
Correct Answer: A) Delirium
Rationale: Delirium is characterized by acute onset, fluctuating attention,
altered awareness, and cognitive changes. Common triggers include
infection, medications, pain, dehydration, sleep disruption, and metabolic
