Latest 2026/2027 NSG 3160 Exam 2 questions verified with correct answers and rationales
/instant pdf
1. A nurse is caring for a client with chest pain. Which action should the nurse
perform first?
A. Administer prescribed pain medication.
B. Assess the client's airway, breathing, circulation, and obtain vital signs.
C. Encourage the client to ambulate.
D. Document the complaint.
Correct Answer: B
Rationale: Initial assessment using the ABC (Airway, Breathing, Circulation) framework is the
priority for any client with chest pain.
2. Which assessment finding is most consistent with left-sided heart failure?
A. Crackles in the lungs and dyspnea
B. Hepatomegaly and ascites
C. Peripheral edema only
D. Jugular venous distention only
Correct Answer: A
Rationale: Left-sided heart failure leads to pulmonary congestion, causing crackles, dyspnea,
orthopnea, and reduced oxygenation.
3. Which assessment finding is most consistent with right-sided heart failure?
A. Peripheral edema and jugular venous distention
B. Persistent dry cough only
C. Hemoptysis only
D. Cyanosis only
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, resulting in edema, JVD,
hepatomegaly, and ascites.
,4. A client with heart failure is prescribed furosemide. Which laboratory value
requires the closest monitoring?
A. Serum potassium
B. White blood cell count
C. Platelet count
D. Hemoglobin
Correct Answer: A
Rationale: Furosemide is a loop diuretic that may cause potassium loss, increasing the risk of
hypokalemia and dysrhythmias.
5. Which ECG finding is commonly associated with hyperkalemia?
A. Peaked T waves
B. Flattened T waves
C. Shortened PR interval
D. Absent P waves only
Correct Answer: A
Rationale: Hyperkalemia typically produces tall, peaked T waves and may progress to widened
QRS complexes and life-threatening dysrhythmias.
6. Which assessment finding suggests hypokalemia?
A. Muscle weakness and flattened T waves
B. Peaked T waves
C. Bradycardia with hypertension
D. Bounding pulses
Correct Answer: A
Rationale: Hypokalemia commonly causes muscle weakness, constipation, and flattened T waves
on ECG.
,7. A client has an oxygen saturation of 84% while receiving oxygen by nasal
cannula. What is the nurse's priority action?
A. Assess the client's respiratory status and notify the provider while implementing appropriate
oxygenation interventions.
B. Remove the oxygen.
C. Encourage the client to walk.
D. Delay reassessment for one hour.
Correct Answer: A
Rationale: Persistent hypoxemia requires immediate assessment and intervention to improve
oxygenation.
8. Which intervention best prevents postoperative atelectasis?
A. Encourage incentive spirometry and deep-breathing exercises.
B. Restrict oral fluids.
C. Maintain strict bed rest.
D. Discourage coughing.
Correct Answer: A
Rationale: Incentive spirometry promotes alveolar expansion and reduces postoperative
pulmonary complications.
9. Which client should the nurse assess first?
A. Client with sudden shortness of breath and oxygen saturation of 82%
B. Client requesting pain medication rated 4/10
C. Client waiting for discharge instructions
D. Client asking for water
Correct Answer: A
Rationale: Airway and breathing problems are the highest priority according to the ABC
framework.
, 10. Which assessment finding is most consistent with diabetic ketoacidosis
(DKA)?
A. Fruity breath odor, Kussmaul respirations, and hyperglycemia
B. Bradycardia and hypoglycemia
C. Hypertension with hypoglycemia
D. Peripheral edema only
Correct Answer: A
Rationale: DKA is characterized by hyperglycemia, metabolic acidosis, dehydration, fruity
breath, and deep, rapid respirations.
11. Which symptom is most consistent with hypoglycemia?
A. Sweating, tremors, confusion, and tachycardia
B. Polyuria and polydipsia only
C. Warm, dry skin only
D. Slow pulse
Correct Answer: A
Rationale: Adrenergic activation during hypoglycemia produces sweating, tremors, hunger, and
tachycardia.
12. A conscious client has a blood glucose level of 55 mg/dL. What is the nurse's
priority action?
A. Administer 15 g of fast-acting carbohydrate and recheck the glucose in 15 minutes.
B. Administer long-acting insulin.
C. Restrict fluids.
D. Encourage exercise.
Correct Answer: A
Rationale: The "15-15 Rule" is appropriate for treating conscious clients with mild to moderate
hypoglycemia.
13. Which laboratory value indicates impaired kidney function?
/instant pdf
1. A nurse is caring for a client with chest pain. Which action should the nurse
perform first?
A. Administer prescribed pain medication.
B. Assess the client's airway, breathing, circulation, and obtain vital signs.
C. Encourage the client to ambulate.
D. Document the complaint.
Correct Answer: B
Rationale: Initial assessment using the ABC (Airway, Breathing, Circulation) framework is the
priority for any client with chest pain.
2. Which assessment finding is most consistent with left-sided heart failure?
A. Crackles in the lungs and dyspnea
B. Hepatomegaly and ascites
C. Peripheral edema only
D. Jugular venous distention only
Correct Answer: A
Rationale: Left-sided heart failure leads to pulmonary congestion, causing crackles, dyspnea,
orthopnea, and reduced oxygenation.
3. Which assessment finding is most consistent with right-sided heart failure?
A. Peripheral edema and jugular venous distention
B. Persistent dry cough only
C. Hemoptysis only
D. Cyanosis only
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, resulting in edema, JVD,
hepatomegaly, and ascites.
,4. A client with heart failure is prescribed furosemide. Which laboratory value
requires the closest monitoring?
A. Serum potassium
B. White blood cell count
C. Platelet count
D. Hemoglobin
Correct Answer: A
Rationale: Furosemide is a loop diuretic that may cause potassium loss, increasing the risk of
hypokalemia and dysrhythmias.
5. Which ECG finding is commonly associated with hyperkalemia?
A. Peaked T waves
B. Flattened T waves
C. Shortened PR interval
D. Absent P waves only
Correct Answer: A
Rationale: Hyperkalemia typically produces tall, peaked T waves and may progress to widened
QRS complexes and life-threatening dysrhythmias.
6. Which assessment finding suggests hypokalemia?
A. Muscle weakness and flattened T waves
B. Peaked T waves
C. Bradycardia with hypertension
D. Bounding pulses
Correct Answer: A
Rationale: Hypokalemia commonly causes muscle weakness, constipation, and flattened T waves
on ECG.
,7. A client has an oxygen saturation of 84% while receiving oxygen by nasal
cannula. What is the nurse's priority action?
A. Assess the client's respiratory status and notify the provider while implementing appropriate
oxygenation interventions.
B. Remove the oxygen.
C. Encourage the client to walk.
D. Delay reassessment for one hour.
Correct Answer: A
Rationale: Persistent hypoxemia requires immediate assessment and intervention to improve
oxygenation.
8. Which intervention best prevents postoperative atelectasis?
A. Encourage incentive spirometry and deep-breathing exercises.
B. Restrict oral fluids.
C. Maintain strict bed rest.
D. Discourage coughing.
Correct Answer: A
Rationale: Incentive spirometry promotes alveolar expansion and reduces postoperative
pulmonary complications.
9. Which client should the nurse assess first?
A. Client with sudden shortness of breath and oxygen saturation of 82%
B. Client requesting pain medication rated 4/10
C. Client waiting for discharge instructions
D. Client asking for water
Correct Answer: A
Rationale: Airway and breathing problems are the highest priority according to the ABC
framework.
, 10. Which assessment finding is most consistent with diabetic ketoacidosis
(DKA)?
A. Fruity breath odor, Kussmaul respirations, and hyperglycemia
B. Bradycardia and hypoglycemia
C. Hypertension with hypoglycemia
D. Peripheral edema only
Correct Answer: A
Rationale: DKA is characterized by hyperglycemia, metabolic acidosis, dehydration, fruity
breath, and deep, rapid respirations.
11. Which symptom is most consistent with hypoglycemia?
A. Sweating, tremors, confusion, and tachycardia
B. Polyuria and polydipsia only
C. Warm, dry skin only
D. Slow pulse
Correct Answer: A
Rationale: Adrenergic activation during hypoglycemia produces sweating, tremors, hunger, and
tachycardia.
12. A conscious client has a blood glucose level of 55 mg/dL. What is the nurse's
priority action?
A. Administer 15 g of fast-acting carbohydrate and recheck the glucose in 15 minutes.
B. Administer long-acting insulin.
C. Restrict fluids.
D. Encourage exercise.
Correct Answer: A
Rationale: The "15-15 Rule" is appropriate for treating conscious clients with mild to moderate
hypoglycemia.
13. Which laboratory value indicates impaired kidney function?
