NSG 3800 Exam 1 V2 | NSG 3800 Nursing Practice – Adult Health II |
Actual Q&A with Rationale (NSG3800 Exam 1) | Galen
1. A patient with heart failure is prescribed Digoxin. Which of the following assessment
findings would most strongly indicate to the nurse that the patient is experiencing Digoxin
toxicity?
A. Increased urine output and decreased peripheral edema.
B. Visual disturbances such as yellow-green halos around lights.
C. A blood pressure reading of 150/90 mmHg.
D. Occasional premature ventricular contractions (PVCs).
Answer: B
Rationale: Digoxin toxicity commonly manifests as visual changes, including yellow-green
halos or blurred vision. Other classic signs include gastrointestinal distress like nausea,
vomiting, and anorexia. The nurse must also monitor for bradycardia and specific cardiac
dysrhythmias as these are serious adverse effects.
2. A nurse is caring for a patient who just returned from a thyroidectomy. Which assessment
finding should be reported to the provider immediately?
A. Laryngeal stridor and tingling in the fingers.
B. Hoarseness and a weak voice while speaking.
C. Complaints of mild sore throat when swallowing.
D. Pain level of 4 on a scale of 0 to 10 at the incision site.
Answer: A
Rationale: Laryngeal stridor indicates airway obstruction, which is a medical emergency
following neck surgery. Tingling in the fingers (paresthesia) may indicate hypocalcemia
due to accidental parathyroid gland removal. Immediate intervention is required to
maintain the airway and stabilize calcium levels.
3. A client with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
instruction regarding ‘pursed-lip breathing’ should the nurse include in the teaching plan?
A. Inhale through the mouth and exhale quickly through the nose.
B. Exhale through the mouth as if whistling, twice as long as inhalation.
C. Hold the breath for 5 seconds after a deep inhalation.
D. Inhale rapidly to increase the oxygen concentration in the lungs.
,Answer: B
Rationale: Pursed-lip breathing helps prevent airway collapse by maintaining positive
pressure in the bronchioles. The technique involves a slow exhalation that should be
approximately double the duration of the inhalation. This strategy improves gas exchange
and decreases the work of breathing for COPD patients.
4. The nurse is reviewing the Arterial Blood Gas (ABG) results of a patient: pH 7.30, PaCO2 55
mmHg, HCO3 26 mEq/L. Which condition do these results represent?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate (HCO3) is within the normal range (22-26), the
condition is respiratory acidosis. This is commonly seen in patients with hypoventilation or
obstructive lung diseases.
5. A patient is admitted with suspected Diabetic Ketoacidosis (DKA). Which of the following is
the priority nursing intervention?
A. Administration of subcutaneous long-acting insulin.
B. Obtaining a sputum culture to rule out infection.
C. Rapid fluid resuscitation with 0.9% Normal Saline.
D. Teaching the patient about carbohydrate counting.
Answer: C
Rationale: Dehydration is a life-threatening component of DKA due to osmotic diuresis
caused by high blood glucose. The priority is to restore circulatory volume and stabilize the
blood pressure before starting intravenous insulin. Once fluids are running, the nurse will
monitor potassium levels and blood glucose closely.
6. When assessing a patient with right-sided heart failure, the nurse should expect to find
which of the following?
A. Crackles in the lungs and dyspnea on exertion.
B. Pink frothy sputum and orthopnea.
C. Jugular venous distention and peripheral edema.
D. A productive cough and pleuritic chest pain.
, Answer: C
Rationale: Right-sided heart failure causes systemic congestion because the right ventricle
cannot pump blood effectively to the lungs. This leads to backup in the systemic circulation,
causing jugular venous distention (JVD), hepatomegaly, and dependent edema. Lung
sounds are typically clear unless the patient also has left-sided heart failure.
7. A patient with Acute Renal Failure has a serum potassium level of 6.5 mEq/L. What is the
priority nursing assessment?
A. Assessing the patient’s ECG for peaked T-waves.
B. Checking the patient’s bowel sounds.
C. Monitoring the patient for muscle weakness.
D. Evaluating the patient’s daily weight trends.
Answer: A
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) is dangerous because it affects the
electrical conduction of the heart. Peaked T-waves, widened QRS complexes, and
potentially lethal arrhythmias like V-fib can occur. Immediate cardiac monitoring is
essential to ensure patient safety while treatments to lower potassium are initiated.
8. A patient is prescribed Warfarin for atrial fibrillation. Which lab result should the nurse
monitor to determine the effectiveness of this medication?
A. Activated Partial Thromboplastin Time (aPTT)
B. Platelet count
C. International Normalized Ratio (INR)
D. Bleeding time
Answer: C
Rationale: The INR is the standard lab test used to monitor the therapeutic effect of
Warfarin. For most patients on anticoagulation therapy, the goal INR is between 2.0 and
3.0. A high INR indicates a risk for bleeding, while a low INR indicates a risk for clot
formation.
9. Which clinical manifestation is a hallmark sign of SIADH (Syndrome of Inappropriate
Antidiuretic Hormone)?
A. Hypernatremia and excessive polyuria.
B. Hyponatremia and high urine specific gravity.
C. Hypokalemia and hypotension.
D. Polydipsia and dilute urine.
Actual Q&A with Rationale (NSG3800 Exam 1) | Galen
1. A patient with heart failure is prescribed Digoxin. Which of the following assessment
findings would most strongly indicate to the nurse that the patient is experiencing Digoxin
toxicity?
A. Increased urine output and decreased peripheral edema.
B. Visual disturbances such as yellow-green halos around lights.
C. A blood pressure reading of 150/90 mmHg.
D. Occasional premature ventricular contractions (PVCs).
Answer: B
Rationale: Digoxin toxicity commonly manifests as visual changes, including yellow-green
halos or blurred vision. Other classic signs include gastrointestinal distress like nausea,
vomiting, and anorexia. The nurse must also monitor for bradycardia and specific cardiac
dysrhythmias as these are serious adverse effects.
2. A nurse is caring for a patient who just returned from a thyroidectomy. Which assessment
finding should be reported to the provider immediately?
A. Laryngeal stridor and tingling in the fingers.
B. Hoarseness and a weak voice while speaking.
C. Complaints of mild sore throat when swallowing.
D. Pain level of 4 on a scale of 0 to 10 at the incision site.
Answer: A
Rationale: Laryngeal stridor indicates airway obstruction, which is a medical emergency
following neck surgery. Tingling in the fingers (paresthesia) may indicate hypocalcemia
due to accidental parathyroid gland removal. Immediate intervention is required to
maintain the airway and stabilize calcium levels.
3. A client with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
instruction regarding ‘pursed-lip breathing’ should the nurse include in the teaching plan?
A. Inhale through the mouth and exhale quickly through the nose.
B. Exhale through the mouth as if whistling, twice as long as inhalation.
C. Hold the breath for 5 seconds after a deep inhalation.
D. Inhale rapidly to increase the oxygen concentration in the lungs.
,Answer: B
Rationale: Pursed-lip breathing helps prevent airway collapse by maintaining positive
pressure in the bronchioles. The technique involves a slow exhalation that should be
approximately double the duration of the inhalation. This strategy improves gas exchange
and decreases the work of breathing for COPD patients.
4. The nurse is reviewing the Arterial Blood Gas (ABG) results of a patient: pH 7.30, PaCO2 55
mmHg, HCO3 26 mEq/L. Which condition do these results represent?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate (HCO3) is within the normal range (22-26), the
condition is respiratory acidosis. This is commonly seen in patients with hypoventilation or
obstructive lung diseases.
5. A patient is admitted with suspected Diabetic Ketoacidosis (DKA). Which of the following is
the priority nursing intervention?
A. Administration of subcutaneous long-acting insulin.
B. Obtaining a sputum culture to rule out infection.
C. Rapid fluid resuscitation with 0.9% Normal Saline.
D. Teaching the patient about carbohydrate counting.
Answer: C
Rationale: Dehydration is a life-threatening component of DKA due to osmotic diuresis
caused by high blood glucose. The priority is to restore circulatory volume and stabilize the
blood pressure before starting intravenous insulin. Once fluids are running, the nurse will
monitor potassium levels and blood glucose closely.
6. When assessing a patient with right-sided heart failure, the nurse should expect to find
which of the following?
A. Crackles in the lungs and dyspnea on exertion.
B. Pink frothy sputum and orthopnea.
C. Jugular venous distention and peripheral edema.
D. A productive cough and pleuritic chest pain.
, Answer: C
Rationale: Right-sided heart failure causes systemic congestion because the right ventricle
cannot pump blood effectively to the lungs. This leads to backup in the systemic circulation,
causing jugular venous distention (JVD), hepatomegaly, and dependent edema. Lung
sounds are typically clear unless the patient also has left-sided heart failure.
7. A patient with Acute Renal Failure has a serum potassium level of 6.5 mEq/L. What is the
priority nursing assessment?
A. Assessing the patient’s ECG for peaked T-waves.
B. Checking the patient’s bowel sounds.
C. Monitoring the patient for muscle weakness.
D. Evaluating the patient’s daily weight trends.
Answer: A
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) is dangerous because it affects the
electrical conduction of the heart. Peaked T-waves, widened QRS complexes, and
potentially lethal arrhythmias like V-fib can occur. Immediate cardiac monitoring is
essential to ensure patient safety while treatments to lower potassium are initiated.
8. A patient is prescribed Warfarin for atrial fibrillation. Which lab result should the nurse
monitor to determine the effectiveness of this medication?
A. Activated Partial Thromboplastin Time (aPTT)
B. Platelet count
C. International Normalized Ratio (INR)
D. Bleeding time
Answer: C
Rationale: The INR is the standard lab test used to monitor the therapeutic effect of
Warfarin. For most patients on anticoagulation therapy, the goal INR is between 2.0 and
3.0. A high INR indicates a risk for bleeding, while a low INR indicates a risk for clot
formation.
9. Which clinical manifestation is a hallmark sign of SIADH (Syndrome of Inappropriate
Antidiuretic Hormone)?
A. Hypernatremia and excessive polyuria.
B. Hyponatremia and high urine specific gravity.
C. Hypokalemia and hypotension.
D. Polydipsia and dilute urine.
