,NR 324 Adult Health I Exam 3 | Chamberlain
College of Nursing | Latest 2026/2027 Update
1. A client is brought to the emergency department with partial thickness burns to the face, neck,
arms, and chest after trying to put out a car fire. Which nursing action should the nurse implement
first?
A) Administer oxygen as prescribed
B) Assess for airway patency
C) Elevate the extremities if no fractures are present
D) Prepare to give oral pain medication as prescribed
Correct Answer: Assess for airway patency
Rationale: The priority in burn care is airway assessment, especially with burns to the face and neck.
Singed nasal hairs, soot in the mouth, and hoarseness indicate potential inhalation injury and airway
compromise. Airway patency must be assessed before oxygen administration, positioning, or pain
management.
2. A client with no history of respiratory disease is admitted with respiratory failure. Which arterial
blood gas result should the nurse expect?
A) PaO2 58 mm Hg, PaCO2 32 mm Hg
B) PaO2 60 mm Hg, PaCO2 45 mm Hg
C) PaO2 49 mm Hg, PaCO2 52 mm Hg
D) PaO2 73 mm Hg, PaCO2 62 mm Hg
Correct Answer: PaO2 49 mm Hg, PaCO2 52 mm Hg
Rationale: Respiratory failure is defined as a PaO2 less than 60 mm Hg and a PaCO2 greater than 50
mm Hg. The combination of hypoxemia and hypercapnia indicates failure of gas exchange. The other
options show either normal values or isolated abnormalities that do not meet the criteria for
respiratory failure.
,3. A client is admitted with chest pain and elevated troponin levels. Heart sounds are normal, but vital
signs reveal hypotension and tachycardia. Which complication should the nurse suspect?
A) Cardiogenic shock
B) Cardiac tamponade
C) Pulmonary embolism
D) Dissecting thoracic aortic aneurysm
Correct Answer: Cardiogenic shock
Rationale: Cardiogenic shock occurs when the heart fails to pump effectively, often after myocardial
infarction. Hypotension and tachycardia with elevated troponin indicate pump failure. Cardiac
tamponade presents with muffled heart sounds, pulmonary embolism with sudden dyspnea, and
aortic dissection with tearing pain.
4. A client in sinus bradycardia with a heart rate of 45 beats per minute complains of dizziness and has
a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate?
A) Defibrillate the client
B) Administer digoxin
C) Continue to monitor the client
D) Prepare for transcutaneous pacing
Correct Answer: Prepare for transcutaneous pacing
Rationale: Symptomatic bradycardia with dizziness and hypotension requires intervention to increase
heart rate. Transcutaneous pacing is indicated for hemodynamically unstable bradycardia.
Defibrillation is for ventricular fibrillation, digoxin further slows heart rate, and monitoring alone is
insufficient for symptomatic bradycardia.
5. A client with heart failure suddenly develops extreme dyspnea, tachycardia, and lung crackles.
Which interventions should the nurse prepare to implement? Select all that apply.
A) Administer oxygen
B) Insert a Foley catheter
, C) Administer furosemide
D) Administer morphine sulfate intravenously
E) Transport the client to the coronary care unit
F) Place the client in a low Fowler's side-lying position
Correct Answer: Administer oxygen, Insert a Foley catheter, Administer furosemide, Administer
morphine sulfate intravenously
Rationale: Pulmonary edema is a medical emergency. Oxygen improves oxygenation, a Foley catheter
monitors urine output, furosemide reduces fluid overload, and morphine reduces anxiety and
preload. The client should be placed in high Fowler's position, not low Fowler's, and transport occurs
after stabilization.
6. A client with myocardial infarction becomes tachycardic, shows signs of air hunger, and coughs
frothy, pink-tinged sputum. Which condition should the nurse suspect?
A) Pulmonary edema
B) Pneumonia
C) Pulmonary embolism
D) Atelectasis
Correct Answer: Pulmonary edema
Rationale: Frothy, pink-tinged sputum is a classic sign of pulmonary edema, which occurs when fluid
accumulates in the alveoli due to left ventricular failure. Tachycardia and air hunger accompany this
condition. Pneumonia produces purulent sputum, pulmonary embolism causes sudden dyspnea
without frothy sputum, and atelectasis causes decreased breath sounds.
7. A nurse is assessing a client with a Type I hypersensitivity reaction. Which manifestation should the
nurse expect?
A) Serum sickness
B) Anaphylaxis
C) Rheumatoid arthritis
College of Nursing | Latest 2026/2027 Update
1. A client is brought to the emergency department with partial thickness burns to the face, neck,
arms, and chest after trying to put out a car fire. Which nursing action should the nurse implement
first?
A) Administer oxygen as prescribed
B) Assess for airway patency
C) Elevate the extremities if no fractures are present
D) Prepare to give oral pain medication as prescribed
Correct Answer: Assess for airway patency
Rationale: The priority in burn care is airway assessment, especially with burns to the face and neck.
Singed nasal hairs, soot in the mouth, and hoarseness indicate potential inhalation injury and airway
compromise. Airway patency must be assessed before oxygen administration, positioning, or pain
management.
2. A client with no history of respiratory disease is admitted with respiratory failure. Which arterial
blood gas result should the nurse expect?
A) PaO2 58 mm Hg, PaCO2 32 mm Hg
B) PaO2 60 mm Hg, PaCO2 45 mm Hg
C) PaO2 49 mm Hg, PaCO2 52 mm Hg
D) PaO2 73 mm Hg, PaCO2 62 mm Hg
Correct Answer: PaO2 49 mm Hg, PaCO2 52 mm Hg
Rationale: Respiratory failure is defined as a PaO2 less than 60 mm Hg and a PaCO2 greater than 50
mm Hg. The combination of hypoxemia and hypercapnia indicates failure of gas exchange. The other
options show either normal values or isolated abnormalities that do not meet the criteria for
respiratory failure.
,3. A client is admitted with chest pain and elevated troponin levels. Heart sounds are normal, but vital
signs reveal hypotension and tachycardia. Which complication should the nurse suspect?
A) Cardiogenic shock
B) Cardiac tamponade
C) Pulmonary embolism
D) Dissecting thoracic aortic aneurysm
Correct Answer: Cardiogenic shock
Rationale: Cardiogenic shock occurs when the heart fails to pump effectively, often after myocardial
infarction. Hypotension and tachycardia with elevated troponin indicate pump failure. Cardiac
tamponade presents with muffled heart sounds, pulmonary embolism with sudden dyspnea, and
aortic dissection with tearing pain.
4. A client in sinus bradycardia with a heart rate of 45 beats per minute complains of dizziness and has
a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate?
A) Defibrillate the client
B) Administer digoxin
C) Continue to monitor the client
D) Prepare for transcutaneous pacing
Correct Answer: Prepare for transcutaneous pacing
Rationale: Symptomatic bradycardia with dizziness and hypotension requires intervention to increase
heart rate. Transcutaneous pacing is indicated for hemodynamically unstable bradycardia.
Defibrillation is for ventricular fibrillation, digoxin further slows heart rate, and monitoring alone is
insufficient for symptomatic bradycardia.
5. A client with heart failure suddenly develops extreme dyspnea, tachycardia, and lung crackles.
Which interventions should the nurse prepare to implement? Select all that apply.
A) Administer oxygen
B) Insert a Foley catheter
, C) Administer furosemide
D) Administer morphine sulfate intravenously
E) Transport the client to the coronary care unit
F) Place the client in a low Fowler's side-lying position
Correct Answer: Administer oxygen, Insert a Foley catheter, Administer furosemide, Administer
morphine sulfate intravenously
Rationale: Pulmonary edema is a medical emergency. Oxygen improves oxygenation, a Foley catheter
monitors urine output, furosemide reduces fluid overload, and morphine reduces anxiety and
preload. The client should be placed in high Fowler's position, not low Fowler's, and transport occurs
after stabilization.
6. A client with myocardial infarction becomes tachycardic, shows signs of air hunger, and coughs
frothy, pink-tinged sputum. Which condition should the nurse suspect?
A) Pulmonary edema
B) Pneumonia
C) Pulmonary embolism
D) Atelectasis
Correct Answer: Pulmonary edema
Rationale: Frothy, pink-tinged sputum is a classic sign of pulmonary edema, which occurs when fluid
accumulates in the alveoli due to left ventricular failure. Tachycardia and air hunger accompany this
condition. Pneumonia produces purulent sputum, pulmonary embolism causes sudden dyspnea
without frothy sputum, and atelectasis causes decreased breath sounds.
7. A nurse is assessing a client with a Type I hypersensitivity reaction. Which manifestation should the
nurse expect?
A) Serum sickness
B) Anaphylaxis
C) Rheumatoid arthritis
