NSG 4100 Exam 2 — Practice Questions
,Ques on 1. A pa ent is admi ed with acute respiratory distress. Which assessment finding
requires the nurse's immediate interven on?
A. Respiratory rate of 24/min
B. Oxygen satura on of 88%
C. Produc ve cough with clear sputum
D. Temperature of 37.4°C (99.3°F)
Answer: B. Oxygen satura on of 88%
Ra onale: An oxygen satura on of 88% indicates significant hypoxemia and requires prompt
interven on. The nurse should first address airway and breathing and administer oxygen as
indicated.
Ques on 2. A nurse is caring for a pa ent receiving IV fluids. Which finding most strongly
suggests fluid overload?
A. Dry mucous membranes
B. Flat neck veins
C. Bilateral crackles in the lungs
D. Decreased blood pressure
Answer: C. Bilateral crackles in the lungs
Ra onale: Crackles may indicate pulmonary fluid accumula on, which is a common
manifesta on of fluid volume excess. The nurse should assess respiratory status and no fy the
provider as appropriate.
Ques on 3. A pa ent with diabetes mellitus becomes pale, diaphore c, and confused. What
should the nurse do first?
A. Administer the scheduled insulin
B. Check the pa ent's blood glucose level
C. Encourage the pa ent to ambulate
D. Restrict oral fluids
Answer: B. Check the pa ent's blood glucose level
Ra onale: Pallor, diaphoresis, and confusion are classic manifesta ons of hypoglycemia. Blood
glucose should be assessed promptly, followed by treatment based on the result and the
pa ent's ability to swallow.
,Ques on 4. Which assessment finding is most concerning in a pa ent receiving opioid
analgesia?
A. Pain ra ng of 4/10
B. Respiratory rate of 8/min
C. Blood pressure of 132/78 mmHg
D. Mild nausea
Answer: B. Respiratory rate of 8/min
Ra onale: Opioids can cause respiratory depression. A respiratory rate of 8/min is dangerously
low and requires immediate assessment and interven on.
Ques on 5. The nurse is teaching a pa ent how to use an incen ve spirometer. Which
instruc on is correct?
A. “Blow forcefully into the device.”
B. “Use the device once every 8 hours.”
C. “Inhale slowly and deeply through the mouthpiece.”
D. “Use it only when you feel short of breath.”
Answer: C. “Inhale slowly and deeply through the mouthpiece.”
Ra onale: Incen ve spirometry promotes lung expansion by encouraging slow, deep inhala on.
It is commonly used regularly while awake to help prevent atelectasis.
Ques on 6. A pa ent has a potassium level of 2.8 mEq/L. Which finding should the nurse
an cipate?
A. Muscle weakness
B. Hyperac ve reflexes
C. Peaked T waves
D. Severe hypertension
Answer: A. Muscle weakness
Ra onale: Hypokalemia can cause muscle weakness, fa gue, cons pa on, and cardiac
dysrhythmias. Peaked T waves are more characteris c of hyperkalemia.
, Ques on 7. Which pa ent should the nurse assess first?
A. Pa ent reques ng a sleeping medica on
B. Pa ent with chronic arthri s repor ng pain of 6/10
C. Pa ent with chest pain and diaphoresis
D. Pa ent wai ng for discharge instruc ons
Answer: C. Pa ent with chest pain and diaphoresis
Ra onale: Chest pain accompanied by diaphoresis may indicate acute myocardial ischemia or
infarc on. Using the ABCs and priority principles, this pa ent requires immediate assessment.
Ques on 8. A pa ent taking furosemide should be monitored closely for which electrolyte
imbalance?
A. Hypernatremia
B. Hypokalemia
C. Hypermagnesemia
D. Hypercalcemia
Answer: B. Hypokalemia
Ra onale: Furosemide is a loop diure c that increases urinary excre on of potassium. The nurse
should monitor serum potassium and assess for manifesta ons of hypokalemia.
Ques on 9. Which statement by a pa ent taking warfarin indicates a need for further teaching?
A. “I will have my INR checked as ordered.”
B. “I will report unusual bleeding.”
C. “I can take aspirin whenever I have a headache.”
D. “I will try to keep my vitamin K intake consistent.”
Answer: C. “I can take aspirin whenever I have a headache.”
Ra onale: Aspirin can increase bleeding risk when taken with warfarin. Pa ents should consult
their healthcare provider before taking medica ons that can affect coagula on.
Ques on 10. A nurse is assessing a pa ent with suspected hypovolemia. Which finding is most
consistent with this condi on?
,Ques on 1. A pa ent is admi ed with acute respiratory distress. Which assessment finding
requires the nurse's immediate interven on?
A. Respiratory rate of 24/min
B. Oxygen satura on of 88%
C. Produc ve cough with clear sputum
D. Temperature of 37.4°C (99.3°F)
Answer: B. Oxygen satura on of 88%
Ra onale: An oxygen satura on of 88% indicates significant hypoxemia and requires prompt
interven on. The nurse should first address airway and breathing and administer oxygen as
indicated.
Ques on 2. A nurse is caring for a pa ent receiving IV fluids. Which finding most strongly
suggests fluid overload?
A. Dry mucous membranes
B. Flat neck veins
C. Bilateral crackles in the lungs
D. Decreased blood pressure
Answer: C. Bilateral crackles in the lungs
Ra onale: Crackles may indicate pulmonary fluid accumula on, which is a common
manifesta on of fluid volume excess. The nurse should assess respiratory status and no fy the
provider as appropriate.
Ques on 3. A pa ent with diabetes mellitus becomes pale, diaphore c, and confused. What
should the nurse do first?
A. Administer the scheduled insulin
B. Check the pa ent's blood glucose level
C. Encourage the pa ent to ambulate
D. Restrict oral fluids
Answer: B. Check the pa ent's blood glucose level
Ra onale: Pallor, diaphoresis, and confusion are classic manifesta ons of hypoglycemia. Blood
glucose should be assessed promptly, followed by treatment based on the result and the
pa ent's ability to swallow.
,Ques on 4. Which assessment finding is most concerning in a pa ent receiving opioid
analgesia?
A. Pain ra ng of 4/10
B. Respiratory rate of 8/min
C. Blood pressure of 132/78 mmHg
D. Mild nausea
Answer: B. Respiratory rate of 8/min
Ra onale: Opioids can cause respiratory depression. A respiratory rate of 8/min is dangerously
low and requires immediate assessment and interven on.
Ques on 5. The nurse is teaching a pa ent how to use an incen ve spirometer. Which
instruc on is correct?
A. “Blow forcefully into the device.”
B. “Use the device once every 8 hours.”
C. “Inhale slowly and deeply through the mouthpiece.”
D. “Use it only when you feel short of breath.”
Answer: C. “Inhale slowly and deeply through the mouthpiece.”
Ra onale: Incen ve spirometry promotes lung expansion by encouraging slow, deep inhala on.
It is commonly used regularly while awake to help prevent atelectasis.
Ques on 6. A pa ent has a potassium level of 2.8 mEq/L. Which finding should the nurse
an cipate?
A. Muscle weakness
B. Hyperac ve reflexes
C. Peaked T waves
D. Severe hypertension
Answer: A. Muscle weakness
Ra onale: Hypokalemia can cause muscle weakness, fa gue, cons pa on, and cardiac
dysrhythmias. Peaked T waves are more characteris c of hyperkalemia.
, Ques on 7. Which pa ent should the nurse assess first?
A. Pa ent reques ng a sleeping medica on
B. Pa ent with chronic arthri s repor ng pain of 6/10
C. Pa ent with chest pain and diaphoresis
D. Pa ent wai ng for discharge instruc ons
Answer: C. Pa ent with chest pain and diaphoresis
Ra onale: Chest pain accompanied by diaphoresis may indicate acute myocardial ischemia or
infarc on. Using the ABCs and priority principles, this pa ent requires immediate assessment.
Ques on 8. A pa ent taking furosemide should be monitored closely for which electrolyte
imbalance?
A. Hypernatremia
B. Hypokalemia
C. Hypermagnesemia
D. Hypercalcemia
Answer: B. Hypokalemia
Ra onale: Furosemide is a loop diure c that increases urinary excre on of potassium. The nurse
should monitor serum potassium and assess for manifesta ons of hypokalemia.
Ques on 9. Which statement by a pa ent taking warfarin indicates a need for further teaching?
A. “I will have my INR checked as ordered.”
B. “I will report unusual bleeding.”
C. “I can take aspirin whenever I have a headache.”
D. “I will try to keep my vitamin K intake consistent.”
Answer: C. “I can take aspirin whenever I have a headache.”
Ra onale: Aspirin can increase bleeding risk when taken with warfarin. Pa ents should consult
their healthcare provider before taking medica ons that can affect coagula on.
Ques on 10. A nurse is assessing a pa ent with suspected hypovolemia. Which finding is most
consistent with this condi on?
