NSG 3100 Exam 2 — Exam Questions with
Correct Answers (VerifiedAnswers) Plus
Rationales 2026 Q&A Instant Download PDF
Question 1
A nurse is assessing a client who has developed hypovolemia
following prolonged vomiting and diarrhea. Which finding
would the nurse expect?
A. Bounding peripheral pulses
B. Increased urine output
C. Decreased blood pressure
D. Bradycardia
Correct Answer: C. Decreased blood pressure
Rationale: Hypovolemia occurs when there is an inadequate
circulating blood volume, commonly because of fluid loss from
vomiting, diarrhea, hemorrhage, burns, or excessive diuresis. As
circulating volume decreases, venous return and cardiac output
decline, which can result in hypotension. The body initially
attempts to compensate through sympathetic stimulation,
producing tachycardia, peripheral vasoconstriction, and
decreased urine output. Bounding pulses and increased urine
output are inconsistent with significant hypovolemia.
,Question 2
A client with heart failure reports increasing shortness of breath
and difficulty breathing when lying flat. Which additional
finding would most strongly support worsening left-sided heart
failure?
A. Dependent peripheral edema
B. Jugular venous distention
C. Enlarged liver
D. Crackles on auscultation
Correct Answer: D. Crackles on auscultation
Rationale: Left-sided heart failure causes inadequate pumping
of blood from the left ventricle, resulting in blood backing up
into the pulmonary circulation. Increased pulmonary vascular
pressure promotes movement of fluid into the lung interstitium
and alveoli, producing pulmonary congestion and crackles.
Orthopnea and dyspnea are also common manifestations.
Peripheral edema, jugular venous distention, and hepatomegaly
are more characteristic of systemic venous congestion
associated with right-sided heart failure.
Question 3
,A nurse is caring for a client experiencing an acute asthma
exacerbation. Which assessment finding requires the most
immediate attention?
A. Respiratory rate of 24/min
B. Anxiety and restlessness
C. Expiratory wheezing
D. Sudden absence of wheezing with worsening respiratory
distress
Correct Answer: D. Sudden absence of wheezing with
worsening respiratory distress
Rationale: A sudden decrease or disappearance of wheezing in a
client who is becoming increasingly distressed can indicate
extremely limited airflow rather than improvement. Severe
bronchoconstriction may prevent enough air from moving
through the airways to produce wheezing. This finding can
indicate impending respiratory failure and requires immediate
intervention. Mild tachypnea, anxiety, and wheezing are
common during an asthma exacerbation but are not as ominous
as a "silent chest."
Question 4
, A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing intervention is most
appropriate?
A. Administer oxygen at the highest possible flow rate
B. Discontinue oxygen if the respiratory rate decreases
C. Administer oxygen at the prescribed flow rate and monitor
respiratory status
D. Encourage the client to breathe rapidly to increase oxygen
intake
Correct Answer: C. Administer oxygen at the prescribed flow
rate and monitor respiratory status
Rationale: Oxygen therapy is used in COPD to correct
hypoxemia, but it should be administered according to the
prescribed target and carefully monitored. Excessive oxygen
administration can worsen hypercapnia in some clients with
chronic CO₂ retention through several physiologic mechanisms.
The nurse should monitor oxygen saturation, respiratory rate,
mental status, work of breathing, and other clinical indicators
rather than withholding necessary oxygen. Rapid breathing is
not an appropriate strategy because it can increase fatigue and
reduce ventilatory efficiency.
Question 5
Correct Answers (VerifiedAnswers) Plus
Rationales 2026 Q&A Instant Download PDF
Question 1
A nurse is assessing a client who has developed hypovolemia
following prolonged vomiting and diarrhea. Which finding
would the nurse expect?
A. Bounding peripheral pulses
B. Increased urine output
C. Decreased blood pressure
D. Bradycardia
Correct Answer: C. Decreased blood pressure
Rationale: Hypovolemia occurs when there is an inadequate
circulating blood volume, commonly because of fluid loss from
vomiting, diarrhea, hemorrhage, burns, or excessive diuresis. As
circulating volume decreases, venous return and cardiac output
decline, which can result in hypotension. The body initially
attempts to compensate through sympathetic stimulation,
producing tachycardia, peripheral vasoconstriction, and
decreased urine output. Bounding pulses and increased urine
output are inconsistent with significant hypovolemia.
,Question 2
A client with heart failure reports increasing shortness of breath
and difficulty breathing when lying flat. Which additional
finding would most strongly support worsening left-sided heart
failure?
A. Dependent peripheral edema
B. Jugular venous distention
C. Enlarged liver
D. Crackles on auscultation
Correct Answer: D. Crackles on auscultation
Rationale: Left-sided heart failure causes inadequate pumping
of blood from the left ventricle, resulting in blood backing up
into the pulmonary circulation. Increased pulmonary vascular
pressure promotes movement of fluid into the lung interstitium
and alveoli, producing pulmonary congestion and crackles.
Orthopnea and dyspnea are also common manifestations.
Peripheral edema, jugular venous distention, and hepatomegaly
are more characteristic of systemic venous congestion
associated with right-sided heart failure.
Question 3
,A nurse is caring for a client experiencing an acute asthma
exacerbation. Which assessment finding requires the most
immediate attention?
A. Respiratory rate of 24/min
B. Anxiety and restlessness
C. Expiratory wheezing
D. Sudden absence of wheezing with worsening respiratory
distress
Correct Answer: D. Sudden absence of wheezing with
worsening respiratory distress
Rationale: A sudden decrease or disappearance of wheezing in a
client who is becoming increasingly distressed can indicate
extremely limited airflow rather than improvement. Severe
bronchoconstriction may prevent enough air from moving
through the airways to produce wheezing. This finding can
indicate impending respiratory failure and requires immediate
intervention. Mild tachypnea, anxiety, and wheezing are
common during an asthma exacerbation but are not as ominous
as a "silent chest."
Question 4
, A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing intervention is most
appropriate?
A. Administer oxygen at the highest possible flow rate
B. Discontinue oxygen if the respiratory rate decreases
C. Administer oxygen at the prescribed flow rate and monitor
respiratory status
D. Encourage the client to breathe rapidly to increase oxygen
intake
Correct Answer: C. Administer oxygen at the prescribed flow
rate and monitor respiratory status
Rationale: Oxygen therapy is used in COPD to correct
hypoxemia, but it should be administered according to the
prescribed target and carefully monitored. Excessive oxygen
administration can worsen hypercapnia in some clients with
chronic CO₂ retention through several physiologic mechanisms.
The nurse should monitor oxygen saturation, respiratory rate,
mental status, work of breathing, and other clinical indicators
rather than withholding necessary oxygen. Rapid breathing is
not an appropriate strategy because it can increase fatigue and
reduce ventilatory efficiency.
Question 5
