NR341 COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
COMPLETE WITH 100% VERIFIED ANSWERS
1. A nurse is caring for a client with a tracheostomy who suddenly becomes
unable to breathe and is cyanotic. What is the priority nursing action?
A. Call the rapid response team.
B. Remove the inner cannula and suction.
C. Administer oxygen via nasal cannula.
D. Check the tracheostomy tube for obstruction.
Correct Answer: D
Explanation: Airway obstruction is the most likely cause of sudden respiratory
distress in a client with a tracheostomy. The priority is to assess for and clear the
airway obstruction before proceeding to other interventions. Checking for
obstruction is the first and most critical step .
2. A patient with terminal cancer is being admitted to hospice. The spouse visits
daily and cheerfully talks about wedding anniversary plans for the next year.
When the nurse asks about concerns, the spouse says, "I'm busy at work, but
otherwise things are fine." Which issue would the nurse identify as a concern in
working with this spouse?
A. Fear
B. Anxiety
C. Hopelessness
D. Difficulty coping
Correct Answer: D
Explanation: The spouse's behavior and statements indicate an absence of
,anticipatory grieving. This denial and avoidance of the reality of the situation may
lead to impaired adjustment as the patient progresses toward death .
3. An emergency room nurse is triaging victims of a multi-casualty event. Which
client should receive care first?
A. A 30-year-old distraught mother holding her crying child.
B. A 65-year-old conscious male with a head laceration.
C. A 26-year-old male who has pale, cool, clammy skin.
D. A 48-year-old with a simple fracture of the lower leg.
Correct Answer: C
Explanation: Pale, cool, clammy skin is a classic sign of shock, an emergent and
life-threatening condition requiring immediate intervention. This client has the
highest priority .
4. A patient with COPD is admitted with increased shortness of breath and a
respiratory rate of 30. Which nursing intervention is most appropriate?
A. Place the patient in a supine position.
B. Administer high-flow oxygen via non-rebreather mask.
C. Position the patient in high Fowler's and apply oxygen as ordered.
D. Encourage the patient to increase fluid intake to 4 liters per day.
Correct Answer: C
Explanation: High Fowler's position maximizes lung expansion and improves
oxygenation. While oxygen is needed, high-flow oxygen should be used cautiously
in COPD patients to avoid suppressing the hypoxic drive. Upright positioning is
immediately beneficial .
5. A client with heart failure reports a sudden weight gain of 5 pounds in two
days. Which action should the nurse take?
A. Reassure the patient this is normal.
,B. Assess for edema and lung crackles.
C. Increase the patient's fluid intake.
D. Hold all medications until the provider is notified.
Correct Answer: B
Explanation: Rapid weight gain indicates significant fluid retention, a key sign of
worsening heart failure. The nurse should perform a focused assessment (edema,
crackles) to gather data before notifying the provider. This represents acute
decompensation .
6. The emergency department team is performing CPR on a client when the
client's spouse arrives. Which action should the nurse take first?
A. Request that the client's spouse sit in the waiting room.
B. Ask the spouse if he wishes to be present during the resuscitation.
C. Suggest that the spouse begin to pray for the client.
D. Refer the client's spouse to the hospital's crisis team.
Correct Answer: B
Explanation: If resuscitation efforts are still ongoing, the nurse should offer the
spouse the opportunity to be present during the lifesaving procedures. This can
help the spouse begin the closure process .
7. The nurse is providing care for a client with diabetic ketoacidosis (DKA).
Which finding is most important to report to the healthcare provider?
A. Serum potassium level of 3.2 mEq/L.
B. Blood glucose level of 240 mg/dL.
C. Serum sodium level of 135 mEq/L.
D. Urine output of 40 mL/hr.
Correct Answer: A
Explanation: A serum potassium level of 3.2 mEq/L indicates significant
hypokalemia. In DKA, total body potassium is depleted, and insulin therapy can
drive potassium into cells, worsening hypokalemia and increasing the risk of life-
, threatening cardiac dysrhythmias. This is a critical finding requiring immediate
intervention.
8. Which arterial blood gas (ABG) result is consistent with respiratory acidosis?
A. pH 7.48, PaCO2 30, HCO3 24
B. pH 7.30, PaCO2 55, HCO3 25
C. pH 7.35, PaCO2 40, HCO3 24
D. pH 7.50, PaCO2 25, HCO3 20
Correct Answer: B
Explanation: Respiratory acidosis is characterized by a low pH (<7.35) and an
elevated PaCO2 (>45 mm Hg), indicating carbon dioxide retention. The HCO3 may
be normal or elevated if compensation has occurred .
9. An emergency room nurse assesses a client who has been raped. With which
health care team member should the nurse collaborate when planning this
client's care?
A. Emergency medicine physician
B. Case manager
C. Forensic nurse examiner
D. Psychiatric crisis nurse
Correct Answer: C
Explanation: The forensic nurse examiner is specifically educated to obtain client
histories and collect evidence related to sexual assault. This specialist can also
offer the counseling and follow-up needed when caring for the victim of an
assault .
10. A patient with a history of DVT suddenly develops shortness of breath and
chest pain. What is the priority action?
A. Place the patient in Trendelenburg position.
COMPLETE WITH 100% VERIFIED ANSWERS
1. A nurse is caring for a client with a tracheostomy who suddenly becomes
unable to breathe and is cyanotic. What is the priority nursing action?
A. Call the rapid response team.
B. Remove the inner cannula and suction.
C. Administer oxygen via nasal cannula.
D. Check the tracheostomy tube for obstruction.
Correct Answer: D
Explanation: Airway obstruction is the most likely cause of sudden respiratory
distress in a client with a tracheostomy. The priority is to assess for and clear the
airway obstruction before proceeding to other interventions. Checking for
obstruction is the first and most critical step .
2. A patient with terminal cancer is being admitted to hospice. The spouse visits
daily and cheerfully talks about wedding anniversary plans for the next year.
When the nurse asks about concerns, the spouse says, "I'm busy at work, but
otherwise things are fine." Which issue would the nurse identify as a concern in
working with this spouse?
A. Fear
B. Anxiety
C. Hopelessness
D. Difficulty coping
Correct Answer: D
Explanation: The spouse's behavior and statements indicate an absence of
,anticipatory grieving. This denial and avoidance of the reality of the situation may
lead to impaired adjustment as the patient progresses toward death .
3. An emergency room nurse is triaging victims of a multi-casualty event. Which
client should receive care first?
A. A 30-year-old distraught mother holding her crying child.
B. A 65-year-old conscious male with a head laceration.
C. A 26-year-old male who has pale, cool, clammy skin.
D. A 48-year-old with a simple fracture of the lower leg.
Correct Answer: C
Explanation: Pale, cool, clammy skin is a classic sign of shock, an emergent and
life-threatening condition requiring immediate intervention. This client has the
highest priority .
4. A patient with COPD is admitted with increased shortness of breath and a
respiratory rate of 30. Which nursing intervention is most appropriate?
A. Place the patient in a supine position.
B. Administer high-flow oxygen via non-rebreather mask.
C. Position the patient in high Fowler's and apply oxygen as ordered.
D. Encourage the patient to increase fluid intake to 4 liters per day.
Correct Answer: C
Explanation: High Fowler's position maximizes lung expansion and improves
oxygenation. While oxygen is needed, high-flow oxygen should be used cautiously
in COPD patients to avoid suppressing the hypoxic drive. Upright positioning is
immediately beneficial .
5. A client with heart failure reports a sudden weight gain of 5 pounds in two
days. Which action should the nurse take?
A. Reassure the patient this is normal.
,B. Assess for edema and lung crackles.
C. Increase the patient's fluid intake.
D. Hold all medications until the provider is notified.
Correct Answer: B
Explanation: Rapid weight gain indicates significant fluid retention, a key sign of
worsening heart failure. The nurse should perform a focused assessment (edema,
crackles) to gather data before notifying the provider. This represents acute
decompensation .
6. The emergency department team is performing CPR on a client when the
client's spouse arrives. Which action should the nurse take first?
A. Request that the client's spouse sit in the waiting room.
B. Ask the spouse if he wishes to be present during the resuscitation.
C. Suggest that the spouse begin to pray for the client.
D. Refer the client's spouse to the hospital's crisis team.
Correct Answer: B
Explanation: If resuscitation efforts are still ongoing, the nurse should offer the
spouse the opportunity to be present during the lifesaving procedures. This can
help the spouse begin the closure process .
7. The nurse is providing care for a client with diabetic ketoacidosis (DKA).
Which finding is most important to report to the healthcare provider?
A. Serum potassium level of 3.2 mEq/L.
B. Blood glucose level of 240 mg/dL.
C. Serum sodium level of 135 mEq/L.
D. Urine output of 40 mL/hr.
Correct Answer: A
Explanation: A serum potassium level of 3.2 mEq/L indicates significant
hypokalemia. In DKA, total body potassium is depleted, and insulin therapy can
drive potassium into cells, worsening hypokalemia and increasing the risk of life-
, threatening cardiac dysrhythmias. This is a critical finding requiring immediate
intervention.
8. Which arterial blood gas (ABG) result is consistent with respiratory acidosis?
A. pH 7.48, PaCO2 30, HCO3 24
B. pH 7.30, PaCO2 55, HCO3 25
C. pH 7.35, PaCO2 40, HCO3 24
D. pH 7.50, PaCO2 25, HCO3 20
Correct Answer: B
Explanation: Respiratory acidosis is characterized by a low pH (<7.35) and an
elevated PaCO2 (>45 mm Hg), indicating carbon dioxide retention. The HCO3 may
be normal or elevated if compensation has occurred .
9. An emergency room nurse assesses a client who has been raped. With which
health care team member should the nurse collaborate when planning this
client's care?
A. Emergency medicine physician
B. Case manager
C. Forensic nurse examiner
D. Psychiatric crisis nurse
Correct Answer: C
Explanation: The forensic nurse examiner is specifically educated to obtain client
histories and collect evidence related to sexual assault. This specialist can also
offer the counseling and follow-up needed when caring for the victim of an
assault .
10. A patient with a history of DVT suddenly develops shortness of breath and
chest pain. What is the priority action?
A. Place the patient in Trendelenburg position.
