NSG 320 EXAM 2
NSG Adult Health Nursing 320 Exam 2
Questions and Correct Answers Brand
New Version 2025 Top Rated A+
1.A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will
the nurse take?
(Select all that apply.)
a. Check for contraindications to the extremity.
b. Start proximally and move distally on the arm.
c. Choose a vein with minimal curvature.
d. Choose the patient's dominant arm.
e. Select a vein that is rigid.
f. Avoid areas of flexion.
ANS: A, C, F
The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an
IV catheter
are conditions such as mastectomy, AV fistula, and central line in the extremity and should be
checked before
initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move
proximally, choosing
the non-dominant arm if possible. The nurse should feel for the best location; a good vein should
feel spongy, arigid vein should be avoided because it might have had previous trauma or
damage.
2. Which assessments will alert the nurse that a patient's IV has inԨltrated? (Select all that apply.)
a. Edema of the extremity near the insertion site
b. Reddish streak proximal to the insertion site
c. Skin discolored or pale in appearance
d. Pain and warmth at the insertion site
A+ TEST BANK 1
, NSG 320 EXAM 2
e. Palpable venous cord
f. Skin cool to the touch
ANS: A, C, F
InԨltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch
and may be pale
or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all
symptoms of
phlebitis.
Infiltration. Infiltration occurs when I.V. fluid or medications leak into the surrounding tissue.
Infiltration can be caused by improper placement or dislodgment of the catheter. Patient
movement can cause the catheter to slip out or through the blood vessel lumen.
3. A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take?
(Select all that
apply.)
a. Wear sterile gloves and a mask.
b. Stop the infusion before removing the IV catheter.
c. Use scissors to remove the IV site dressing and tape.
d. Apply Ԩrm pressure with sterile gauze during removal.
e. Keep the catheter parallel to the skin while removing it.
f. Apply pressure to the site for 2 to 3 minutes after removal.
ANS: B, E, F
The nurse should stop the infusion before removing the IV catheter, so the Ԩuid does not drip on
the patient's
skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and
apply pressure
to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should
not be used
because they may accidentally cut the catheter or tubing or may injure the patient. During
removal of the IV
catheter, light pressure, not Ԩrm pressure, is indicated to prevent trauma. Clean gloves are used
for
discontinuing a peripheral IV access because gloved hands will handle the external dressing,
tubing, and tape,
which are not sterile.
MATCHING
A+ TEST BANK 2
, NSG 320 EXAM 2
A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the
body's regulators to the
function it provides.
a. Increases excretion of sodium and water
b. Reduces excretion of sodium and water
c. Reduces excretion of water
d. Major buffer in the extracellular fluid
e. Vasoconstricts and stimulates aldosterone release
1. Antidiuretic hormone
2. Angiotensin II
3. Aldosterone
4. Atrial natriuretic peptide
5. Bicarbonate
1. Antidiuretic hormone—
-c. Reduces excretion of water
2. Angiotensin II--e. Vasoconstricts and stimulates aldosterone release
3. Aldosterone--b. Reduces excretion of sodium and water
4. Atrial natriuretic peptide--a. Increases excretion of sodium and water
5. Bicarbonate--d. Major buffer in the extracellular fluid
The nurse is developing a plan to minimize the risk of adrenal insufficiency for a patient who is
receiving long-term glucocorticoid therapy. Which outcome should be included?
1
Patient obtains periodic ultrasound scans of adrenal glands.
2
Patient tapers blood pressure medications to avoid hypotension.
3
Patient increases daily intake of sodium for vascular expansion.
4
Patient increases or supplements dosage of glucocorticoid at times of stress.
4
Patient increases or supplements dosage of glucocorticoid at times of stress.
A+ TEST BANK 3
, NSG 320 EXAM 2
Exogenous steroids inhibit the synthesis and release of endogenous steroids by the adrenals, and
recovery is variable, taking from days to a year. Failure to increase or supplement doses at times
of stress may be life-threatening. Increasing sodium intake and tapering blood-pressure
medications could cause harm. Adrenal gland ultrasound scans are not a valid way to minimize
adrenal insufficiency.Test-Taking Tip: When using this program, be sure to note if you guess at an
answer. This will permit you to identify areas that need further review. Also it will help you to see
how correct your guessing can be.
A client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted.
Which finding should the nurse observe for during the immediate hours after insertion?
Beck's triad.
Burns around the site
Hypothermia
Cardiac arrhythmia.
Beck's triad.
Pacemakers and implantable defibrillators both require wires to be placed into the heart muscle
and can cause bleeding into the pericardial sac which causes a high risk for cardiac tamponade.
Signs of Beck's triad include low arterial blood pressure, distended neck veins, and distant,
muffled heart sounds and are indicative of cardiac tamponade.
The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis
diaphoretic and reports lower extremity spasms. The nurse observes respirations that are
uneven and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24
mEq/L, and PaO2 24 mmHg.
Which assessment finding warrants immediate intervention by the nurse?
Increased pulmonary secretions.
Intercostal muscle retraction
Decreased breath sounds.
Bronchovesicular breath sounds.
Intercostal muscle retraction
Intercostal muscle retraction is a critical sign of respiratory muscle fatigue that is likely to lead to
acute respiratory failure, requiringintubation withmechanical ventilation. The ABG results reveal
respiratory alkalosis as evidenced by an increased pH and decreased PaCO2 with a normal HCO3.
The nurse is caring for a client who is receiving mechanical ventilation for acute respiratory
distress syndrome (ARDS). The ventilator is alarming continuously indicating high peak pressures
for the client
A+ TEST BANK 4
NSG Adult Health Nursing 320 Exam 2
Questions and Correct Answers Brand
New Version 2025 Top Rated A+
1.A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will
the nurse take?
(Select all that apply.)
a. Check for contraindications to the extremity.
b. Start proximally and move distally on the arm.
c. Choose a vein with minimal curvature.
d. Choose the patient's dominant arm.
e. Select a vein that is rigid.
f. Avoid areas of flexion.
ANS: A, C, F
The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an
IV catheter
are conditions such as mastectomy, AV fistula, and central line in the extremity and should be
checked before
initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move
proximally, choosing
the non-dominant arm if possible. The nurse should feel for the best location; a good vein should
feel spongy, arigid vein should be avoided because it might have had previous trauma or
damage.
2. Which assessments will alert the nurse that a patient's IV has inԨltrated? (Select all that apply.)
a. Edema of the extremity near the insertion site
b. Reddish streak proximal to the insertion site
c. Skin discolored or pale in appearance
d. Pain and warmth at the insertion site
A+ TEST BANK 1
, NSG 320 EXAM 2
e. Palpable venous cord
f. Skin cool to the touch
ANS: A, C, F
InԨltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch
and may be pale
or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all
symptoms of
phlebitis.
Infiltration. Infiltration occurs when I.V. fluid or medications leak into the surrounding tissue.
Infiltration can be caused by improper placement or dislodgment of the catheter. Patient
movement can cause the catheter to slip out or through the blood vessel lumen.
3. A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take?
(Select all that
apply.)
a. Wear sterile gloves and a mask.
b. Stop the infusion before removing the IV catheter.
c. Use scissors to remove the IV site dressing and tape.
d. Apply Ԩrm pressure with sterile gauze during removal.
e. Keep the catheter parallel to the skin while removing it.
f. Apply pressure to the site for 2 to 3 minutes after removal.
ANS: B, E, F
The nurse should stop the infusion before removing the IV catheter, so the Ԩuid does not drip on
the patient's
skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and
apply pressure
to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should
not be used
because they may accidentally cut the catheter or tubing or may injure the patient. During
removal of the IV
catheter, light pressure, not Ԩrm pressure, is indicated to prevent trauma. Clean gloves are used
for
discontinuing a peripheral IV access because gloved hands will handle the external dressing,
tubing, and tape,
which are not sterile.
MATCHING
A+ TEST BANK 2
, NSG 320 EXAM 2
A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the
body's regulators to the
function it provides.
a. Increases excretion of sodium and water
b. Reduces excretion of sodium and water
c. Reduces excretion of water
d. Major buffer in the extracellular fluid
e. Vasoconstricts and stimulates aldosterone release
1. Antidiuretic hormone
2. Angiotensin II
3. Aldosterone
4. Atrial natriuretic peptide
5. Bicarbonate
1. Antidiuretic hormone—
-c. Reduces excretion of water
2. Angiotensin II--e. Vasoconstricts and stimulates aldosterone release
3. Aldosterone--b. Reduces excretion of sodium and water
4. Atrial natriuretic peptide--a. Increases excretion of sodium and water
5. Bicarbonate--d. Major buffer in the extracellular fluid
The nurse is developing a plan to minimize the risk of adrenal insufficiency for a patient who is
receiving long-term glucocorticoid therapy. Which outcome should be included?
1
Patient obtains periodic ultrasound scans of adrenal glands.
2
Patient tapers blood pressure medications to avoid hypotension.
3
Patient increases daily intake of sodium for vascular expansion.
4
Patient increases or supplements dosage of glucocorticoid at times of stress.
4
Patient increases or supplements dosage of glucocorticoid at times of stress.
A+ TEST BANK 3
, NSG 320 EXAM 2
Exogenous steroids inhibit the synthesis and release of endogenous steroids by the adrenals, and
recovery is variable, taking from days to a year. Failure to increase or supplement doses at times
of stress may be life-threatening. Increasing sodium intake and tapering blood-pressure
medications could cause harm. Adrenal gland ultrasound scans are not a valid way to minimize
adrenal insufficiency.Test-Taking Tip: When using this program, be sure to note if you guess at an
answer. This will permit you to identify areas that need further review. Also it will help you to see
how correct your guessing can be.
A client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted.
Which finding should the nurse observe for during the immediate hours after insertion?
Beck's triad.
Burns around the site
Hypothermia
Cardiac arrhythmia.
Beck's triad.
Pacemakers and implantable defibrillators both require wires to be placed into the heart muscle
and can cause bleeding into the pericardial sac which causes a high risk for cardiac tamponade.
Signs of Beck's triad include low arterial blood pressure, distended neck veins, and distant,
muffled heart sounds and are indicative of cardiac tamponade.
The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis
diaphoretic and reports lower extremity spasms. The nurse observes respirations that are
uneven and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24
mEq/L, and PaO2 24 mmHg.
Which assessment finding warrants immediate intervention by the nurse?
Increased pulmonary secretions.
Intercostal muscle retraction
Decreased breath sounds.
Bronchovesicular breath sounds.
Intercostal muscle retraction
Intercostal muscle retraction is a critical sign of respiratory muscle fatigue that is likely to lead to
acute respiratory failure, requiringintubation withmechanical ventilation. The ABG results reveal
respiratory alkalosis as evidenced by an increased pH and decreased PaCO2 with a normal HCO3.
The nurse is caring for a client who is receiving mechanical ventilation for acute respiratory
distress syndrome (ARDS). The ventilator is alarming continuously indicating high peak pressures
for the client
A+ TEST BANK 4
