NSG 4100 EXAM 3 | QUESTIONS AND ANSWERS | VERIFIED
ANSWERS PLUS RATIONALES | EXAM ALREADY GRADED
A+ | LATEST EXAM
1. A nurse is caring for a patient with congestive heart failure (CHF) who has bilateral
edema. Which intervention is most appropriate?
A. Encourage increased sodium intake
B. Administer diuretics as prescribed
C. Limit fluid intake to 5000 mL/day
D. Elevate head of bed only at night
Answer: B. Administer diuretics as prescribed
Rationale: Diuretics help remove excess fluid, reducing edema and improving cardiac function.
2. A patient with COPD reports increased shortness of breath. Which oxygen delivery
method is most appropriate for initial management?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 2 L/min
C. Venturi mask at 50%
D. Simple face mask at 10 L/min
Answer: B. Nasal cannula at 2 L/min
Rationale: Patients with COPD require low-flow oxygen to prevent CO2 retention and
respiratory depression.
3. A nurse is caring for a patient with type 2 diabetes who is prescribed metformin. Which
statement indicates understanding?
A. "I should stop taking it if I feel tired."
B. "I will take it with meals to reduce stomach upset."
C. "I should double my dose if I forget a dose."
D. "I can take it only when my blood sugar is high."
Answer: B. "I will take it with meals to reduce stomach upset."
Rationale: Metformin should be taken with meals to reduce gastrointestinal side effects.
4. Which lab value is most concerning for a patient on heparin therapy?
A. INR 1.2
B. Platelets 40,000/mm³
C. Hemoglobin 13 g/dL
D. WBC 7,000/mm³
,Answer: B. Platelets 40,000/mm³
Rationale: Low platelets may indicate heparin-induced thrombocytopenia, a serious
complication.
5. A patient with a nasogastric tube reports nausea and abdominal distension. Which
nursing action is priority?
A. Administer antiemetic
B. Check tube placement and patency
C. Increase tube feeding rate
D. Encourage ambulation
Answer: B. Check tube placement and patency
Rationale: Ensuring the NG tube is properly placed and not clogged prevents complications
such as aspiration.
6. A nurse is educating a patient on warfarin therapy. Which instruction is most
important?
A. Avoid green leafy vegetables entirely
B. Take the medication only when feeling unwell
C. Report any unusual bleeding or bruising
D. Stop medication if INR is above 2
Answer: C. Report any unusual bleeding or bruising
Rationale: Warfarin increases bleeding risk; monitoring for signs of bleeding is critical.
7. A patient with hypokalemia is prescribed oral potassium chloride. Which nursing
intervention is essential?
A. Administer undiluted for faster absorption
B. Monitor ECG for dysrhythmias
C. Encourage a low-potassium diet
D. Restrict oral fluids
Answer: B. Monitor ECG for dysrhythmias
Rationale: Hypokalemia can cause dangerous heart rhythm changes; ECG monitoring is
essential during potassium replacement.
8. A nurse is caring for a postoperative patient who develops sudden shortness of breath
and chest pain. What is the priority action?
A. Administer prescribed analgesic
B. Encourage deep breathing exercises
C. Call rapid response or provider immediately
D. Elevate legs and monitor vitals
Answer: C. Call rapid response or provider immediately
Rationale: Sudden chest pain and dyspnea may indicate a pulmonary embolism, requiring
immediate intervention.
,9. A patient is scheduled for surgery and reports a history of penicillin allergy. Which
preoperative action is most appropriate?
A. Administer the prescribed antibiotic
B. Document allergy and notify surgical team
C. Give an antihistamine preoperatively
D. Schedule surgery without adjustments
Answer: B. Document allergy and notify surgical team
Rationale: Proper documentation and communication prevent allergic reactions and ensure safe
perioperative care.
10. A nurse is providing discharge teaching to a patient with newly diagnosed hypertension.
Which instruction is most important?
A. Limit water intake to 1 L/day
B. Avoid all carbohydrates
C. Take antihypertensive medication daily as prescribed
D. Exercise only on weekdays
Answer: C. Take antihypertensive medication daily as prescribed
Rationale: Consistent medication adherence is crucial to control blood pressure and prevent
complications.
1. A nurse is caring for a patient with congestive heart failure (CHF) who has bilateral
edema. Which intervention is most appropriate?
A. Encourage increased sodium intake
B. Administer diuretics as prescribed
C. Limit fluid intake to 5000 mL/day
D. Elevate head of bed only at night
Answer: B. Administer diuretics as prescribed
Rationale: Diuretics help remove excess fluid, reducing edema and improving cardiac function.
2. A patient with COPD reports increased shortness of breath. Which oxygen delivery
method is most appropriate for initial management?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 2 L/min
C. Venturi mask at 50%
D. Simple face mask at 10 L/min
Answer: B. Nasal cannula at 2 L/min
Rationale: Patients with COPD require low-flow oxygen to prevent CO2 retention and
respiratory depression.
3. A nurse is caring for a patient with type 2 diabetes who is prescribed metformin. Which
statement indicates understanding?
A. "I should stop taking it if I feel tired."
, B. "I will take it with meals to reduce stomach upset."
C. "I should double my dose if I forget a dose."
D. "I can take it only when my blood sugar is high."
Answer: B. "I will take it with meals to reduce stomach upset."
Rationale: Metformin should be taken with meals to reduce gastrointestinal side effects.
4. Which lab value is most concerning for a patient on heparin therapy?
A. INR 1.2
B. Platelets 40,000/mm³
C. Hemoglobin 13 g/dL
D. WBC 7,000/mm³
Answer: B. Platelets 40,000/mm³
Rationale: Low platelets may indicate heparin-induced thrombocytopenia, a serious
complication.
5. A patient with a nasogastric tube reports nausea and abdominal distension. Which
nursing action is priority?
A. Administer antiemetic
B. Check tube placement and patency
C. Increase tube feeding rate
D. Encourage ambulation
Answer: B. Check tube placement and patency
Rationale: Ensuring the NG tube is properly placed and not clogged prevents complications
such as aspiration.
6. A nurse is educating a patient on warfarin therapy. Which instruction is most
important?
A. Avoid green leafy vegetables entirely
B. Take the medication only when feeling unwell
C. Report any unusual bleeding or bruising
D. Stop medication if INR is above 2
Answer: C. Report any unusual bleeding or bruising
Rationale: Warfarin increases bleeding risk; monitoring for signs of bleeding is critical.
7. A patient with hypokalemia is prescribed oral potassium chloride. Which nursing
intervention is essential?
A. Administer undiluted for faster absorption
B. Monitor ECG for dysrhythmias
C. Encourage a low-potassium diet
D. Restrict oral fluids
ANSWERS PLUS RATIONALES | EXAM ALREADY GRADED
A+ | LATEST EXAM
1. A nurse is caring for a patient with congestive heart failure (CHF) who has bilateral
edema. Which intervention is most appropriate?
A. Encourage increased sodium intake
B. Administer diuretics as prescribed
C. Limit fluid intake to 5000 mL/day
D. Elevate head of bed only at night
Answer: B. Administer diuretics as prescribed
Rationale: Diuretics help remove excess fluid, reducing edema and improving cardiac function.
2. A patient with COPD reports increased shortness of breath. Which oxygen delivery
method is most appropriate for initial management?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 2 L/min
C. Venturi mask at 50%
D. Simple face mask at 10 L/min
Answer: B. Nasal cannula at 2 L/min
Rationale: Patients with COPD require low-flow oxygen to prevent CO2 retention and
respiratory depression.
3. A nurse is caring for a patient with type 2 diabetes who is prescribed metformin. Which
statement indicates understanding?
A. "I should stop taking it if I feel tired."
B. "I will take it with meals to reduce stomach upset."
C. "I should double my dose if I forget a dose."
D. "I can take it only when my blood sugar is high."
Answer: B. "I will take it with meals to reduce stomach upset."
Rationale: Metformin should be taken with meals to reduce gastrointestinal side effects.
4. Which lab value is most concerning for a patient on heparin therapy?
A. INR 1.2
B. Platelets 40,000/mm³
C. Hemoglobin 13 g/dL
D. WBC 7,000/mm³
,Answer: B. Platelets 40,000/mm³
Rationale: Low platelets may indicate heparin-induced thrombocytopenia, a serious
complication.
5. A patient with a nasogastric tube reports nausea and abdominal distension. Which
nursing action is priority?
A. Administer antiemetic
B. Check tube placement and patency
C. Increase tube feeding rate
D. Encourage ambulation
Answer: B. Check tube placement and patency
Rationale: Ensuring the NG tube is properly placed and not clogged prevents complications
such as aspiration.
6. A nurse is educating a patient on warfarin therapy. Which instruction is most
important?
A. Avoid green leafy vegetables entirely
B. Take the medication only when feeling unwell
C. Report any unusual bleeding or bruising
D. Stop medication if INR is above 2
Answer: C. Report any unusual bleeding or bruising
Rationale: Warfarin increases bleeding risk; monitoring for signs of bleeding is critical.
7. A patient with hypokalemia is prescribed oral potassium chloride. Which nursing
intervention is essential?
A. Administer undiluted for faster absorption
B. Monitor ECG for dysrhythmias
C. Encourage a low-potassium diet
D. Restrict oral fluids
Answer: B. Monitor ECG for dysrhythmias
Rationale: Hypokalemia can cause dangerous heart rhythm changes; ECG monitoring is
essential during potassium replacement.
8. A nurse is caring for a postoperative patient who develops sudden shortness of breath
and chest pain. What is the priority action?
A. Administer prescribed analgesic
B. Encourage deep breathing exercises
C. Call rapid response or provider immediately
D. Elevate legs and monitor vitals
Answer: C. Call rapid response or provider immediately
Rationale: Sudden chest pain and dyspnea may indicate a pulmonary embolism, requiring
immediate intervention.
,9. A patient is scheduled for surgery and reports a history of penicillin allergy. Which
preoperative action is most appropriate?
A. Administer the prescribed antibiotic
B. Document allergy and notify surgical team
C. Give an antihistamine preoperatively
D. Schedule surgery without adjustments
Answer: B. Document allergy and notify surgical team
Rationale: Proper documentation and communication prevent allergic reactions and ensure safe
perioperative care.
10. A nurse is providing discharge teaching to a patient with newly diagnosed hypertension.
Which instruction is most important?
A. Limit water intake to 1 L/day
B. Avoid all carbohydrates
C. Take antihypertensive medication daily as prescribed
D. Exercise only on weekdays
Answer: C. Take antihypertensive medication daily as prescribed
Rationale: Consistent medication adherence is crucial to control blood pressure and prevent
complications.
1. A nurse is caring for a patient with congestive heart failure (CHF) who has bilateral
edema. Which intervention is most appropriate?
A. Encourage increased sodium intake
B. Administer diuretics as prescribed
C. Limit fluid intake to 5000 mL/day
D. Elevate head of bed only at night
Answer: B. Administer diuretics as prescribed
Rationale: Diuretics help remove excess fluid, reducing edema and improving cardiac function.
2. A patient with COPD reports increased shortness of breath. Which oxygen delivery
method is most appropriate for initial management?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 2 L/min
C. Venturi mask at 50%
D. Simple face mask at 10 L/min
Answer: B. Nasal cannula at 2 L/min
Rationale: Patients with COPD require low-flow oxygen to prevent CO2 retention and
respiratory depression.
3. A nurse is caring for a patient with type 2 diabetes who is prescribed metformin. Which
statement indicates understanding?
A. "I should stop taking it if I feel tired."
, B. "I will take it with meals to reduce stomach upset."
C. "I should double my dose if I forget a dose."
D. "I can take it only when my blood sugar is high."
Answer: B. "I will take it with meals to reduce stomach upset."
Rationale: Metformin should be taken with meals to reduce gastrointestinal side effects.
4. Which lab value is most concerning for a patient on heparin therapy?
A. INR 1.2
B. Platelets 40,000/mm³
C. Hemoglobin 13 g/dL
D. WBC 7,000/mm³
Answer: B. Platelets 40,000/mm³
Rationale: Low platelets may indicate heparin-induced thrombocytopenia, a serious
complication.
5. A patient with a nasogastric tube reports nausea and abdominal distension. Which
nursing action is priority?
A. Administer antiemetic
B. Check tube placement and patency
C. Increase tube feeding rate
D. Encourage ambulation
Answer: B. Check tube placement and patency
Rationale: Ensuring the NG tube is properly placed and not clogged prevents complications
such as aspiration.
6. A nurse is educating a patient on warfarin therapy. Which instruction is most
important?
A. Avoid green leafy vegetables entirely
B. Take the medication only when feeling unwell
C. Report any unusual bleeding or bruising
D. Stop medication if INR is above 2
Answer: C. Report any unusual bleeding or bruising
Rationale: Warfarin increases bleeding risk; monitoring for signs of bleeding is critical.
7. A patient with hypokalemia is prescribed oral potassium chloride. Which nursing
intervention is essential?
A. Administer undiluted for faster absorption
B. Monitor ECG for dysrhythmias
C. Encourage a low-potassium diet
D. Restrict oral fluids
