NSG 3800 Final Exam V3 | NSG 3800 Nursing Practice – Adult Health II
| Actual Q&A with Rationale (NSG3800 Final Exam) | Galen
1. A nurse is caring for a patient with left-sided heart failure. Which of the following
assessment findings should the nurse expect?
A. Peripheral edema and jugular venous distention
B. Hepatomegaly and abdominal girth increase
C. Crackles in the lungs and dyspnea
D. Splenomegaly and dependent edema
Answer: C
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot pump blood effectively to the body, causing backflow into the lungs. This
results in pulmonary congestion, which manifests as crackles, orthopnea, and shortness of
breath. The other options are characteristic of right-sided heart failure, where blood backs
up into the systemic circulation.
2. A patient with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L. Which
medication should the nurse anticipate administering first to stabilize the cardiac membrane?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular insulin and 50% dextrose
D. Calcium gluconate
Answer: D
Rationale: Calcium gluconate is administered in emergency hyperkalemia to protect the
heart from dysrhythmias by stabilizing the cardiac cell membrane. While insulin and
dextrose help shift potassium into the cells, and Kayexalate removes it from the body, they
do not act as quickly to protect the heart. The nurse must prioritize cardiac stability when
potassium levels are critically high.
3. The nurse is monitoring a patient with a chest tube connected to a water-seal drainage
system. Which finding requires immediate intervention?
A. Fluctuation of the water level with respirations (tidaling)
B. Drainage of 50 mL of serosanguinous fluid in the first hour
C. Occasional bubbling in the water-seal chamber during coughing
D. Constant bubbling in the water-seal chamber
,Answer: D
Rationale: Constant bubbling in the water-seal chamber indicates an air leak in the system,
which requires immediate troubleshooting and intervention. Tidaling is a normal finding
that shows the system is patent and responding to intrapleural pressure changes.
Intermittent bubbling during coughing or sneezing is also expected as air is expelled from
the pleural space.
4. A patient is admitted with Diabetic Ketoacidosis (DKA). Which of the following arterial
blood gas (ABG) results is most consistent with this condition?
A. pH 7.48, PaCO2 30, HCO3 22
B. pH 7.32, PaCO2 48, HCO3 26
C. pH 7.50, PaCO2 40, HCO3 32
D. pH 7.28, PaCO2 36, HCO3 16
Answer: D
Rationale: DKA causes metabolic acidosis due to the accumulation of ketones, which are
acidic. A pH below 7.35 and a low bicarbonate level (less than 22) confirm metabolic
acidosis. The partial pressure of CO2 may be normal or low if the patient is compensating
via Kussmaul respirations.
5. A patient diagnosed with cirrhosis is experiencing hepatic encephalopathy. The nurse
should prioritize the administration of which medication?
A. Lactulose
B. Spironolactone
C. Propranolol
D. Vitamin K
Answer: A
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it promotes
the excretion of ammonia through the stool. Ammonia buildup is the neurotoxic culprit
behind the altered mental status seen in cirrhosis patients. The nurse should monitor for
the desired effect of 2-3 soft bowel movements per day.
6. Which clinical manifestation should the nurse recognize as an early sign of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Decreased level of consciousness (LOC)
C. Decerebrate posturing
, D. Fixed and dilated pupils
Answer: B
Rationale: A change in the level of consciousness is the most sensitive and earliest
indicator of increased intracranial pressure. As pressure rises, the brain’s cortical function
is affected before physical signs like pupillary changes or posturing occur. Cushing’s triad
(widening pulse pressure, bradycardia) is a late sign indicating impending herniation.
7. A patient is scheduled for a cardiac catheterization. Which allergy is most critical for the
nurse to assess prior to the procedure?
A. Penicillin
B. Latex
C. Shellfish or Iodine
D. Sulfa drugs
Answer: C
Rationale: Cardiac catheterization uses radiopaque contrast dye, which typically contains
iodine. Patients with an allergy to shellfish or iodine are at high risk for an anaphylactic
reaction during the procedure. The nurse must notify the provider so that premedication
with antihistamines or steroids can be initiated if necessary.
8. During the assessment of a patient with a T4 spinal cord injury, the nurse notes a sudden
onset of severe headache, a BP of 190/100, and diaphoresis above the level of injury. What is
the priority nursing action?
A. Administer an antihypertensive medication
B. Notify the physician immediately
C. Lower the head of the bed to a flat position
D. Check for bladder distention or fecal impaction
Answer: D
Rationale: These symptoms indicate autonomic dysreflexia, a medical emergency
triggered by noxious stimuli below the level of injury. The most common causes are a full
bladder or impacted bowel. The nurse should immediately sit the patient up and then
identify and remove the stimulus to lower the blood pressure.
9. A nurse is caring for a patient post-thyroidectomy. Which assessment finding requires the
most immediate notification of the surgeon?
A. Sore throat when swallowing
B. Hoarseness when speaking
| Actual Q&A with Rationale (NSG3800 Final Exam) | Galen
1. A nurse is caring for a patient with left-sided heart failure. Which of the following
assessment findings should the nurse expect?
A. Peripheral edema and jugular venous distention
B. Hepatomegaly and abdominal girth increase
C. Crackles in the lungs and dyspnea
D. Splenomegaly and dependent edema
Answer: C
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot pump blood effectively to the body, causing backflow into the lungs. This
results in pulmonary congestion, which manifests as crackles, orthopnea, and shortness of
breath. The other options are characteristic of right-sided heart failure, where blood backs
up into the systemic circulation.
2. A patient with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L. Which
medication should the nurse anticipate administering first to stabilize the cardiac membrane?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular insulin and 50% dextrose
D. Calcium gluconate
Answer: D
Rationale: Calcium gluconate is administered in emergency hyperkalemia to protect the
heart from dysrhythmias by stabilizing the cardiac cell membrane. While insulin and
dextrose help shift potassium into the cells, and Kayexalate removes it from the body, they
do not act as quickly to protect the heart. The nurse must prioritize cardiac stability when
potassium levels are critically high.
3. The nurse is monitoring a patient with a chest tube connected to a water-seal drainage
system. Which finding requires immediate intervention?
A. Fluctuation of the water level with respirations (tidaling)
B. Drainage of 50 mL of serosanguinous fluid in the first hour
C. Occasional bubbling in the water-seal chamber during coughing
D. Constant bubbling in the water-seal chamber
,Answer: D
Rationale: Constant bubbling in the water-seal chamber indicates an air leak in the system,
which requires immediate troubleshooting and intervention. Tidaling is a normal finding
that shows the system is patent and responding to intrapleural pressure changes.
Intermittent bubbling during coughing or sneezing is also expected as air is expelled from
the pleural space.
4. A patient is admitted with Diabetic Ketoacidosis (DKA). Which of the following arterial
blood gas (ABG) results is most consistent with this condition?
A. pH 7.48, PaCO2 30, HCO3 22
B. pH 7.32, PaCO2 48, HCO3 26
C. pH 7.50, PaCO2 40, HCO3 32
D. pH 7.28, PaCO2 36, HCO3 16
Answer: D
Rationale: DKA causes metabolic acidosis due to the accumulation of ketones, which are
acidic. A pH below 7.35 and a low bicarbonate level (less than 22) confirm metabolic
acidosis. The partial pressure of CO2 may be normal or low if the patient is compensating
via Kussmaul respirations.
5. A patient diagnosed with cirrhosis is experiencing hepatic encephalopathy. The nurse
should prioritize the administration of which medication?
A. Lactulose
B. Spironolactone
C. Propranolol
D. Vitamin K
Answer: A
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it promotes
the excretion of ammonia through the stool. Ammonia buildup is the neurotoxic culprit
behind the altered mental status seen in cirrhosis patients. The nurse should monitor for
the desired effect of 2-3 soft bowel movements per day.
6. Which clinical manifestation should the nurse recognize as an early sign of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Decreased level of consciousness (LOC)
C. Decerebrate posturing
, D. Fixed and dilated pupils
Answer: B
Rationale: A change in the level of consciousness is the most sensitive and earliest
indicator of increased intracranial pressure. As pressure rises, the brain’s cortical function
is affected before physical signs like pupillary changes or posturing occur. Cushing’s triad
(widening pulse pressure, bradycardia) is a late sign indicating impending herniation.
7. A patient is scheduled for a cardiac catheterization. Which allergy is most critical for the
nurse to assess prior to the procedure?
A. Penicillin
B. Latex
C. Shellfish or Iodine
D. Sulfa drugs
Answer: C
Rationale: Cardiac catheterization uses radiopaque contrast dye, which typically contains
iodine. Patients with an allergy to shellfish or iodine are at high risk for an anaphylactic
reaction during the procedure. The nurse must notify the provider so that premedication
with antihistamines or steroids can be initiated if necessary.
8. During the assessment of a patient with a T4 spinal cord injury, the nurse notes a sudden
onset of severe headache, a BP of 190/100, and diaphoresis above the level of injury. What is
the priority nursing action?
A. Administer an antihypertensive medication
B. Notify the physician immediately
C. Lower the head of the bed to a flat position
D. Check for bladder distention or fecal impaction
Answer: D
Rationale: These symptoms indicate autonomic dysreflexia, a medical emergency
triggered by noxious stimuli below the level of injury. The most common causes are a full
bladder or impacted bowel. The nurse should immediately sit the patient up and then
identify and remove the stimulus to lower the blood pressure.
9. A nurse is caring for a patient post-thyroidectomy. Which assessment finding requires the
most immediate notification of the surgeon?
A. Sore throat when swallowing
B. Hoarseness when speaking
