NSG 3130 EXAM 2 WITH VERIFIED
QUESTIONS & ANSWERS (ACTUAL 2026)
AND DETAILED GRADED A+ ANSWERS
Which nursing diagnosis is appropriate if a patient expresses an interest in learning?
| | | | | | | | | | | |
A. Ready to Learn
| | |
B. Lack of Knowledge
| | |
C. Effective Information Processing
| | |
D. Health-Seeking Behaviors – ANSWER a. Ready to Learn
| | | | | | | |
A patient's expression of an interest in learning would indicate correct use of the
| | | | | | | | | | | | |
nursing diagnosis, Ready to Learn. Lack of Knowledge would indicate the patient has
| | | | | | | | | | | | |
a deficiency of knowledge on a particular subject. Effective Information Processing
| | | | | | | | | | |
is the patient's ability to acquire useful information. Health-Seeking Behaviors is
| | | | | | | | | | |
active seeking by a person of ways to alter habits to enhance health.
| | | | | | | | | | | | |
Which set of cues is most concerning in a patient with deep vein thrombosis (DVT) in
| | | | | | | | | | | | | | |
the left calf?
| | |
A. High blood pressure and low heart rate
| | | | | | |
B. Coughing up blood and chest pain
| | | | | |
C. Low oral intake and urine output
| | | | | |
D. Bruising on the upper arm and torso – ANSWER b. Coughing up blood and chest
| | | | | | | | | | | | | | |
pain |
The patient who is coughing up blood and has chest pain has the most concerning cues.
| | | | | | | | | | | | | | |
A pulmonary embolism (PE) is suspected when a patient has sudden
| | | | | | | | | | |
,shortness of breath, chest pain, dizziness, irregular heartbeat or palpitations, low
| | | | | | | | | |
blood pressure or is coughing up blood. High blood pressure and low heart rate are the
| | | | | | | | | | | | | | | |
opposite of that seen in PE. Fluid intake is important in the prevention of venous
| | | | | | | | | | | | | | |
thrombolytic events but is not the most concerning cue. Bruising might be related to
| | | | | | | | | | | | | |
anticoagulant therapy but is not the most concerning cue.
| | | | | | | | |
After application of sequential compression devices (scds) on a patient, what
| | | | | | | | | |
assessment finding is essential for the nurse to include in documentation?
| | | | | | | | | | |
A. Warmth of bilateral upper extremities
| | | | |
B. Lower extremity circulatory status
| | | |
C. Circumoral cyanosis
| |
D. Altered bowel sounds – ANSWER b. Lower extremity circulatory status
| | | | | | | | | |
The nurse is caring for a patient who states they have not been able to sleep while in
| | | | | | | | | | | | | | | | |
the hospital. Which action would be a priority to implement?
| | | | | | | | | |
A. Administer a sleeping medication with the evening meal.
| | | | | | | |
B. Restrict visitors for the patient in the evening.
| | | | | | | |
C. Decrease noise around the patient during the night.
| | | | | | | |
D. Offer a hot drink of regular tea at bedtime. - ANSWER_c. Decrease noise around
| | | | | | | | | | | | | |
the patient during the night.
| | | | |
Noise is a primary cause for disturbed sleep in the hospital. Administering sleeping
| | | | | | | | | | | |
medications with the evening meal is too early to help the patient sleep throughout
| | | | | | | | | | | | | |
,the night. Restricting visitors may be helpful if the patient requests it, but visitors
| | | | | | | | | | | | |
often provide emotional support and reassurance to the patient, which helps with
| | | | | | | | | | | |
relaxation. Regular tea contains caffeine, which is not helpful in sleep promotion.
| | | | | | | | | | | |
A nurse is working a night shift after several months of working day shift. What action
| | | | | | | | | | | | | | |
does the nurse take to protect patient safety?
| | | | | | | |
A. Take a meal break at midnight.
| | | | | |
B. Plan critical tasks for early in the shift.
| | | | | | | |
C. Ask another nurse to administer all medications.
| | | | | | |
D. Turn up lights on the unit to maintain alertness. - ANSWER_b. Plan critical tasks
| | | | | | | | | | | | | |
for early in the shift.
| | | | |
Critical tasks should be performed early in the shift before the nurse becomes
| | | | | | | | | | | |
fatigued. The 4 a.m. Window is when most people become the sleepiest during a night
| | | | | | | | | | | | | | |
shift. Thus, it is important that noncritical tasks be planned for this time and that extra
| | | | | | | | | | | | | | | |
care be taken with patient care tasks. A meal break at midnight may be too early to
| | | | | | | | | | | | | | | | |
prevent hunger for the entire shift and is not directly related to patient safety. It is not
| | | | | | | | | | | | | | | | |
necessary to have another nurse administer all medications if the nurse is aware of the
| | | | | | | | | | | | | | |
high-risk time for care tasks. Increasing the amount of light is likely to impair the sleep
| | | | | | | | | | | | | | | |
of all patients on the unit.
| | | | | |
At a routine clinic visit, an athlete training for a major sports event reports difficulty
| | | | | | | | | | | | | |
sleeping that is affecting the training schedule. What would be the best
| | | | | | | | | | | |
recommendation by the nurse for this patient to promote sleep?
| | | | | | | | | |
, A. Increase the use of electrolyte-enriched drinks to increase stamina.
| | | | | | | | |
B. Obtain a short-term prescription for sleeping medications.
| | | | | | |
C. Plan to arise later in the morning to accommodate sleep changes.
| | | | | | | | | | |
D. Avoid vigorous exercise for at least 2 hours before bedtime. - ANSWER_d. Avoid
| | | | | | | | | | | | |
vigorous exercise for at least 2 hours before bedtime.
| | | | | | | | |
Vigorous exercise in the hours before bedtime will cause stimulation that prevents
| | | | | | | | | | |
sleep. Adjusting the training schedule to account for this effect is the preferred first
| | | | | | | | | | | | | |
step for improving the athlete's sleep rather than starting medications that may affect
| | | | | | | | | | | | |
alertness during the day. A regular sleep schedule is preferred to maintain sleep
| | | | | | | | | | | | |
promotion, including getting up at the same time each day no matter when bedtime
| | | | | | | | | | | | | |
occurred.
|
The nurse must document the date and time of initiating SCD placement and the
| | | | | | | | | | | | |
results of a skin, circulatory, and neurologic assessment of the lower extremities.
| | | | | | | | | | | |
Scds do not affect the upper extremities, cardiac or respiratory status leading to
| | | | | | | | | | | |
circumoral cyanosis, or altered bowel sounds.
| | | | | |
Spasticity – ANSWER Increased muscle tone | | | | |
Quadriplegia – ANSWER Inability to move all four extremities | | | | | | | |
Necrosis – ANSWER Death of cells, tissues, or organs
| | | | | | | |
Gait – ANSWER Manner of walking
| | | | |
QUESTIONS & ANSWERS (ACTUAL 2026)
AND DETAILED GRADED A+ ANSWERS
Which nursing diagnosis is appropriate if a patient expresses an interest in learning?
| | | | | | | | | | | |
A. Ready to Learn
| | |
B. Lack of Knowledge
| | |
C. Effective Information Processing
| | |
D. Health-Seeking Behaviors – ANSWER a. Ready to Learn
| | | | | | | |
A patient's expression of an interest in learning would indicate correct use of the
| | | | | | | | | | | | |
nursing diagnosis, Ready to Learn. Lack of Knowledge would indicate the patient has
| | | | | | | | | | | | |
a deficiency of knowledge on a particular subject. Effective Information Processing
| | | | | | | | | | |
is the patient's ability to acquire useful information. Health-Seeking Behaviors is
| | | | | | | | | | |
active seeking by a person of ways to alter habits to enhance health.
| | | | | | | | | | | | |
Which set of cues is most concerning in a patient with deep vein thrombosis (DVT) in
| | | | | | | | | | | | | | |
the left calf?
| | |
A. High blood pressure and low heart rate
| | | | | | |
B. Coughing up blood and chest pain
| | | | | |
C. Low oral intake and urine output
| | | | | |
D. Bruising on the upper arm and torso – ANSWER b. Coughing up blood and chest
| | | | | | | | | | | | | | |
pain |
The patient who is coughing up blood and has chest pain has the most concerning cues.
| | | | | | | | | | | | | | |
A pulmonary embolism (PE) is suspected when a patient has sudden
| | | | | | | | | | |
,shortness of breath, chest pain, dizziness, irregular heartbeat or palpitations, low
| | | | | | | | | |
blood pressure or is coughing up blood. High blood pressure and low heart rate are the
| | | | | | | | | | | | | | | |
opposite of that seen in PE. Fluid intake is important in the prevention of venous
| | | | | | | | | | | | | | |
thrombolytic events but is not the most concerning cue. Bruising might be related to
| | | | | | | | | | | | | |
anticoagulant therapy but is not the most concerning cue.
| | | | | | | | |
After application of sequential compression devices (scds) on a patient, what
| | | | | | | | | |
assessment finding is essential for the nurse to include in documentation?
| | | | | | | | | | |
A. Warmth of bilateral upper extremities
| | | | |
B. Lower extremity circulatory status
| | | |
C. Circumoral cyanosis
| |
D. Altered bowel sounds – ANSWER b. Lower extremity circulatory status
| | | | | | | | | |
The nurse is caring for a patient who states they have not been able to sleep while in
| | | | | | | | | | | | | | | | |
the hospital. Which action would be a priority to implement?
| | | | | | | | | |
A. Administer a sleeping medication with the evening meal.
| | | | | | | |
B. Restrict visitors for the patient in the evening.
| | | | | | | |
C. Decrease noise around the patient during the night.
| | | | | | | |
D. Offer a hot drink of regular tea at bedtime. - ANSWER_c. Decrease noise around
| | | | | | | | | | | | | |
the patient during the night.
| | | | |
Noise is a primary cause for disturbed sleep in the hospital. Administering sleeping
| | | | | | | | | | | |
medications with the evening meal is too early to help the patient sleep throughout
| | | | | | | | | | | | | |
,the night. Restricting visitors may be helpful if the patient requests it, but visitors
| | | | | | | | | | | | |
often provide emotional support and reassurance to the patient, which helps with
| | | | | | | | | | | |
relaxation. Regular tea contains caffeine, which is not helpful in sleep promotion.
| | | | | | | | | | | |
A nurse is working a night shift after several months of working day shift. What action
| | | | | | | | | | | | | | |
does the nurse take to protect patient safety?
| | | | | | | |
A. Take a meal break at midnight.
| | | | | |
B. Plan critical tasks for early in the shift.
| | | | | | | |
C. Ask another nurse to administer all medications.
| | | | | | |
D. Turn up lights on the unit to maintain alertness. - ANSWER_b. Plan critical tasks
| | | | | | | | | | | | | |
for early in the shift.
| | | | |
Critical tasks should be performed early in the shift before the nurse becomes
| | | | | | | | | | | |
fatigued. The 4 a.m. Window is when most people become the sleepiest during a night
| | | | | | | | | | | | | | |
shift. Thus, it is important that noncritical tasks be planned for this time and that extra
| | | | | | | | | | | | | | | |
care be taken with patient care tasks. A meal break at midnight may be too early to
| | | | | | | | | | | | | | | | |
prevent hunger for the entire shift and is not directly related to patient safety. It is not
| | | | | | | | | | | | | | | | |
necessary to have another nurse administer all medications if the nurse is aware of the
| | | | | | | | | | | | | | |
high-risk time for care tasks. Increasing the amount of light is likely to impair the sleep
| | | | | | | | | | | | | | | |
of all patients on the unit.
| | | | | |
At a routine clinic visit, an athlete training for a major sports event reports difficulty
| | | | | | | | | | | | | |
sleeping that is affecting the training schedule. What would be the best
| | | | | | | | | | | |
recommendation by the nurse for this patient to promote sleep?
| | | | | | | | | |
, A. Increase the use of electrolyte-enriched drinks to increase stamina.
| | | | | | | | |
B. Obtain a short-term prescription for sleeping medications.
| | | | | | |
C. Plan to arise later in the morning to accommodate sleep changes.
| | | | | | | | | | |
D. Avoid vigorous exercise for at least 2 hours before bedtime. - ANSWER_d. Avoid
| | | | | | | | | | | | |
vigorous exercise for at least 2 hours before bedtime.
| | | | | | | | |
Vigorous exercise in the hours before bedtime will cause stimulation that prevents
| | | | | | | | | | |
sleep. Adjusting the training schedule to account for this effect is the preferred first
| | | | | | | | | | | | | |
step for improving the athlete's sleep rather than starting medications that may affect
| | | | | | | | | | | | |
alertness during the day. A regular sleep schedule is preferred to maintain sleep
| | | | | | | | | | | | |
promotion, including getting up at the same time each day no matter when bedtime
| | | | | | | | | | | | | |
occurred.
|
The nurse must document the date and time of initiating SCD placement and the
| | | | | | | | | | | | |
results of a skin, circulatory, and neurologic assessment of the lower extremities.
| | | | | | | | | | | |
Scds do not affect the upper extremities, cardiac or respiratory status leading to
| | | | | | | | | | | |
circumoral cyanosis, or altered bowel sounds.
| | | | | |
Spasticity – ANSWER Increased muscle tone | | | | |
Quadriplegia – ANSWER Inability to move all four extremities | | | | | | | |
Necrosis – ANSWER Death of cells, tissues, or organs
| | | | | | | |
Gait – ANSWER Manner of walking
| | | | |
