NSG 3160 Exam 1 questions verified with correct answers and rationales
2026/2027 version
1. Which action should the nurse perform first when
entering a patient's room?
A. Review laboratory results
B. Perform hand hygiene
C. Administer medications
D. Assess pain level
Correct Answer: B
Rationale: Hand hygiene is the single most effective intervention to prevent healthcare-
associated infections.
2. Which assessment finding requires the nurse's immediate
intervention?
A. Blood pressure 128/76 mmHg
B. Oxygen saturation 86% on room air
C. Temperature 37.2°C (99°F)
D. Heart rate 82 beats/minute
Correct Answer: B
Rationale: An oxygen saturation of 86% indicates hypoxemia and requires immediate
assessment and intervention using the ABC (Airway, Breathing, Circulation) priority framework.
3. Which electrolyte imbalance commonly causes muscle
weakness, cardiac dysrhythmias, and constipation?
A. Hyperkalemia
B. Hypokalemia
C. Hyponatremia
D. Hypermagnesemia
Correct Answer: B
,Rationale: Hypokalemia decreases neuromuscular excitability, causing muscle weakness,
constipation, and potentially life-threatening cardiac dysrhythmias.
4. Which intravenous solution is considered isotonic?
A. 0.9% Normal Saline
B. 3% Sodium Chloride
C. 0.45% Normal Saline
D. D5W after metabolism
Correct Answer: A
Rationale: 0.9% Normal Saline is isotonic and remains within the intravascular space, making it
useful for fluid volume replacement.
5. Which patient is at greatest risk for developing fluid
volume deficit?
A. Patient with persistent vomiting and diarrhea
B. Patient receiving IV fluids
C. Patient with hypertension only
D. Patient on bed rest
Correct Answer: A
Rationale: Gastrointestinal losses can rapidly lead to dehydration and electrolyte imbalances.
6. Which clinical finding is most consistent with fluid volume
overload?
A. Crackles in the lungs and peripheral edema
B. Dry mucous membranes
C. Decreased skin turgor
D. Hypotension and tachycardia
Correct Answer: A
,Rationale: Fluid overload commonly presents with pulmonary congestion, edema, weight gain,
and elevated blood pressure.
7. Which assessment finding is most concerning in a
postoperative patient?
A. Respiratory rate of 8 breaths/minute after opioid administration
B. Pain rating of 4/10
C. Temperature 37.3°C (99.1°F)
D. Blood pressure 130/78 mmHg
Correct Answer: A
Rationale: Opioid-induced respiratory depression is a medical emergency requiring immediate
intervention.
8. Which medication reverses opioid-induced respiratory
depression?
A. Naloxone
B. Flumazenil
C. Protamine sulfate
D. Vitamin K
Correct Answer: A
Rationale: Naloxone rapidly reverses opioid effects by competitively binding opioid receptors.
9. Which nursing action is the priority when administering
blood products?
A. Verify patient identity with another licensed professional according to facility policy
B. Warm the blood in hot water
C. Infuse blood with dextrose solution
D. Administer medications through the same IV line routinely
Correct Answer: A
, Rationale: Proper patient identification is the most important step in preventing fatal transfusion
errors.
10. Which symptom suggests a blood transfusion reaction?
A. Fever, chills, and back pain
B. Increased appetite
C. Mild drowsiness
D. Dry skin
Correct Answer: A
Rationale: Fever, chills, flank/back pain, dyspnea, and hypotension are classic signs of an acute
transfusion reaction.
11. Which laboratory value is most important to monitor
before administering insulin?
A. Blood glucose level
B. Platelet count
C. Hemoglobin level
D. White blood cell count
Correct Answer: A
Rationale: Blood glucose determines the need for insulin and helps prevent hypoglycemia.
12. Which symptom is most consistent with hypoglycemia?
A. Sweating, shakiness, and confusion
B. Polyuria and excessive thirst only
C. Warm, dry skin
D. Bradycardia only
Correct Answer: A
Rationale: Hypoglycemia commonly presents with adrenergic and neuroglycopenic symptoms,
including tremors, diaphoresis, confusion, and irritability.
2026/2027 version
1. Which action should the nurse perform first when
entering a patient's room?
A. Review laboratory results
B. Perform hand hygiene
C. Administer medications
D. Assess pain level
Correct Answer: B
Rationale: Hand hygiene is the single most effective intervention to prevent healthcare-
associated infections.
2. Which assessment finding requires the nurse's immediate
intervention?
A. Blood pressure 128/76 mmHg
B. Oxygen saturation 86% on room air
C. Temperature 37.2°C (99°F)
D. Heart rate 82 beats/minute
Correct Answer: B
Rationale: An oxygen saturation of 86% indicates hypoxemia and requires immediate
assessment and intervention using the ABC (Airway, Breathing, Circulation) priority framework.
3. Which electrolyte imbalance commonly causes muscle
weakness, cardiac dysrhythmias, and constipation?
A. Hyperkalemia
B. Hypokalemia
C. Hyponatremia
D. Hypermagnesemia
Correct Answer: B
,Rationale: Hypokalemia decreases neuromuscular excitability, causing muscle weakness,
constipation, and potentially life-threatening cardiac dysrhythmias.
4. Which intravenous solution is considered isotonic?
A. 0.9% Normal Saline
B. 3% Sodium Chloride
C. 0.45% Normal Saline
D. D5W after metabolism
Correct Answer: A
Rationale: 0.9% Normal Saline is isotonic and remains within the intravascular space, making it
useful for fluid volume replacement.
5. Which patient is at greatest risk for developing fluid
volume deficit?
A. Patient with persistent vomiting and diarrhea
B. Patient receiving IV fluids
C. Patient with hypertension only
D. Patient on bed rest
Correct Answer: A
Rationale: Gastrointestinal losses can rapidly lead to dehydration and electrolyte imbalances.
6. Which clinical finding is most consistent with fluid volume
overload?
A. Crackles in the lungs and peripheral edema
B. Dry mucous membranes
C. Decreased skin turgor
D. Hypotension and tachycardia
Correct Answer: A
,Rationale: Fluid overload commonly presents with pulmonary congestion, edema, weight gain,
and elevated blood pressure.
7. Which assessment finding is most concerning in a
postoperative patient?
A. Respiratory rate of 8 breaths/minute after opioid administration
B. Pain rating of 4/10
C. Temperature 37.3°C (99.1°F)
D. Blood pressure 130/78 mmHg
Correct Answer: A
Rationale: Opioid-induced respiratory depression is a medical emergency requiring immediate
intervention.
8. Which medication reverses opioid-induced respiratory
depression?
A. Naloxone
B. Flumazenil
C. Protamine sulfate
D. Vitamin K
Correct Answer: A
Rationale: Naloxone rapidly reverses opioid effects by competitively binding opioid receptors.
9. Which nursing action is the priority when administering
blood products?
A. Verify patient identity with another licensed professional according to facility policy
B. Warm the blood in hot water
C. Infuse blood with dextrose solution
D. Administer medications through the same IV line routinely
Correct Answer: A
, Rationale: Proper patient identification is the most important step in preventing fatal transfusion
errors.
10. Which symptom suggests a blood transfusion reaction?
A. Fever, chills, and back pain
B. Increased appetite
C. Mild drowsiness
D. Dry skin
Correct Answer: A
Rationale: Fever, chills, flank/back pain, dyspnea, and hypotension are classic signs of an acute
transfusion reaction.
11. Which laboratory value is most important to monitor
before administering insulin?
A. Blood glucose level
B. Platelet count
C. Hemoglobin level
D. White blood cell count
Correct Answer: A
Rationale: Blood glucose determines the need for insulin and helps prevent hypoglycemia.
12. Which symptom is most consistent with hypoglycemia?
A. Sweating, shakiness, and confusion
B. Polyuria and excessive thirst only
C. Warm, dry skin
D. Bradycardia only
Correct Answer: A
Rationale: Hypoglycemia commonly presents with adrenergic and neuroglycopenic symptoms,
including tremors, diaphoresis, confusion, and irritability.
