RNSG 1517 Exam 5 Questions and Correct
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client who has developed shortness of
breath and restlessness. Which finding requires the nurse's
immediate attention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 89%
C. Temperature of 37.2°C (99°F)
D. Heart rate of 82/min
Answer: B. Oxygen saturation of 89%
Rationale: An oxygen saturation of 89% indicates hypoxemia and
requires prompt assessment and intervention. The nurse should first
assess airway and breathing, apply oxygen as prescribed or according
to protocol, and determine the underlying cause. The other findings
are within expected ranges for many adult clients.
, 2. A client with heart failure is receiving furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of potassium. Hypokalemia can cause muscle weakness and
potentially dangerous cardiac dysrhythmias. Potassium levels should
therefore be monitored closely during therapy.
3. A nurse is caring for a client with diabetes mellitus who is
receiving insulin. Which finding is most consistent with
hypoglycemia?
A. Warm, dry skin
B. Bradycardia and hypertension
C. Trembling and diaphoresis
D. Increased thirst and polyuria
Answer: C. Trembling and diaphoresis
,Rationale: Hypoglycemia commonly produces adrenergic
manifestations such as sweating, tremors, palpitations, anxiety, and
hunger. Polyuria and increased thirst are more characteristic of
hyperglycemia.
4. Which assessment finding should the nurse expect in a client
experiencing dehydration?
A. Bounding pulse
B. Increased urine output
C. Poor skin turgor
D. Moist mucous membranes
Answer: C. Poor skin turgor
Rationale: Dehydration decreases intravascular and interstitial fluid
volume. Expected findings include poor skin turgor, dry mucous
membranes, concentrated urine, hypotension, tachycardia, and
decreased urine output.
5. A client receiving oxygen through a nasal cannula reports dryness
of the nasal passages. Which intervention is appropriate?
A. Discontinue oxygen immediately
B. Apply petroleum jelly inside the nostrils
, C. Provide humidification as appropriate
D. Increase the oxygen flow rate
Answer: C. Provide humidification as appropriate
Rationale: Humidification can help relieve dryness associated with
oxygen therapy, particularly when oxygen is administered at higher
flow rates. Petroleum-based products should not be used around
oxygen because they can increase fire risk.
6. A nurse is assessing a client with pneumonia. Which finding is
most concerning?
A. Productive cough
B. Temperature of 38.1°C (100.6°F)
C. Respiratory rate of 32/min
D. Fatigue
Answer: C. Respiratory rate of 32/min
Rationale: A respiratory rate of 32/min indicates significant
tachypnea and may signal respiratory distress or impaired gas
exchange. The nurse should assess oxygen saturation, work of
breathing, breath sounds, and other signs of deterioration.
7. A client has a prescription for potassium chloride. Which action
should the nurse take?
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client who has developed shortness of
breath and restlessness. Which finding requires the nurse's
immediate attention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 89%
C. Temperature of 37.2°C (99°F)
D. Heart rate of 82/min
Answer: B. Oxygen saturation of 89%
Rationale: An oxygen saturation of 89% indicates hypoxemia and
requires prompt assessment and intervention. The nurse should first
assess airway and breathing, apply oxygen as prescribed or according
to protocol, and determine the underlying cause. The other findings
are within expected ranges for many adult clients.
, 2. A client with heart failure is receiving furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of potassium. Hypokalemia can cause muscle weakness and
potentially dangerous cardiac dysrhythmias. Potassium levels should
therefore be monitored closely during therapy.
3. A nurse is caring for a client with diabetes mellitus who is
receiving insulin. Which finding is most consistent with
hypoglycemia?
A. Warm, dry skin
B. Bradycardia and hypertension
C. Trembling and diaphoresis
D. Increased thirst and polyuria
Answer: C. Trembling and diaphoresis
,Rationale: Hypoglycemia commonly produces adrenergic
manifestations such as sweating, tremors, palpitations, anxiety, and
hunger. Polyuria and increased thirst are more characteristic of
hyperglycemia.
4. Which assessment finding should the nurse expect in a client
experiencing dehydration?
A. Bounding pulse
B. Increased urine output
C. Poor skin turgor
D. Moist mucous membranes
Answer: C. Poor skin turgor
Rationale: Dehydration decreases intravascular and interstitial fluid
volume. Expected findings include poor skin turgor, dry mucous
membranes, concentrated urine, hypotension, tachycardia, and
decreased urine output.
5. A client receiving oxygen through a nasal cannula reports dryness
of the nasal passages. Which intervention is appropriate?
A. Discontinue oxygen immediately
B. Apply petroleum jelly inside the nostrils
, C. Provide humidification as appropriate
D. Increase the oxygen flow rate
Answer: C. Provide humidification as appropriate
Rationale: Humidification can help relieve dryness associated with
oxygen therapy, particularly when oxygen is administered at higher
flow rates. Petroleum-based products should not be used around
oxygen because they can increase fire risk.
6. A nurse is assessing a client with pneumonia. Which finding is
most concerning?
A. Productive cough
B. Temperature of 38.1°C (100.6°F)
C. Respiratory rate of 32/min
D. Fatigue
Answer: C. Respiratory rate of 32/min
Rationale: A respiratory rate of 32/min indicates significant
tachypnea and may signal respiratory distress or impaired gas
exchange. The nurse should assess oxygen saturation, work of
breathing, breath sounds, and other signs of deterioration.
7. A client has a prescription for potassium chloride. Which action
should the nurse take?
