NSG 430 Exam 3 Adult Health Nursing II
Review 2026/2027 | Questions & Answers
with Rationales
Question 1
A client with chronic heart failure reports increasing shortness of breath, a 3-kg
weight gain over the past week, and swelling of both ankles. Which assessment
finding requires the nurse's immediate attention?
A. Fatigue after walking
B. Bilateral ankle edema
C. Crackles throughout both lung fields
D. Increased appetite
Answer: _C. Crackles throughout both lung fields_
Rationale: Diffuse crackles indicate pulmonary congestion, which can occur with
acute worsening of heart failure and impaired gas exchange. The nurse should
prioritize respiratory status and oxygenation.
Question 2
A nurse is caring for a client with acute myocardial infarction who suddenly
develops severe dyspnea and pink, frothy sputum. Which complication should the
nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Pleural effusion
D. Pulmonary embolism
Answer: _A. Pulmonary edema_
Rationale: Sudden dyspnea accompanied by pink, frothy sputum is characteristic
of acute pulmonary edema caused by severe left ventricular dysfunction.
,Question 3
A client receiving warfarin therapy for atrial fibrillation has an INR of 5.8. Which
action should the nurse anticipate?
A. Administer the next dose as scheduled
B. Hold the warfarin and notify the provider
C. Administer aspirin
D. Encourage foods high in vitamin K immediately
Answer: _B. Hold the warfarin and notify the provider_
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased risk
of bleeding. The nurse should hold the medication and notify the provider for
further management.
Question 4
A client with peripheral arterial disease reports severe calf pain when walking that
improves with rest. How should the nurse document this finding?
A. Venous claudication
B. Intermittent arterial claudication
C. Dependent edema
D. Neuropathic pain
Answer: _B. Intermittent arterial claudication_
Rationale: Intermittent claudication is ischemic muscle pain caused by inadequate
arterial blood flow during activity. It typically improves when the activity stops.
Question 5
Which finding is most concerning in a client with a suspected pulmonary
embolism?
A. Respiratory rate of 28/min
B. Sudden onset of dyspnea
C. Oxygen saturation of 86%
D. Mild anxiety
,Answer: _C. Oxygen saturation of 86%_
Rationale: Severe hypoxemia represents impaired oxygenation and requires
immediate intervention. The nurse should support oxygenation while rapidly
addressing the suspected pulmonary embolism.
Question 6
A client with chronic obstructive pulmonary disease is receiving oxygen therapy.
Which oxygen saturation target is generally appropriate for a client at risk for
chronic carbon dioxide retention?
A. 70%–75%
B. 80%–85%
C. 88%–92%
D. 98%–100%
Answer: _C. 88%–92%_
Rationale: For many clients with COPD who are at risk for hypercapnic
respiratory failure, controlled oxygen therapy targeting approximately 88%–92%
helps improve oxygenation while reducing the risk of excessive oxygen
administration.
Question 7
A client with pneumonia becomes confused and restless. The oxygen saturation is
82% despite oxygen therapy. What should the nurse do first?
A. Obtain a urine specimen
B. Increase oral fluids
C. Assess and support airway and breathing
D. Administer a sedative
Answer: _C. Assess and support airway and breathing_
Rationale: Confusion and restlessness may be manifestations of severe hypoxemia.
Airway and breathing take priority according to the ABC approach.
Question 8
, A client with asthma develops wheezing and chest tightness. Which medication
should the nurse expect to administer for rapid relief?
A. Albuterol
B. Fluticasone
C. Montelukast
D. Salmeterol
Answer: _A. Albuterol_
Rationale: Albuterol is a short-acting beta₂-adrenergic agonist that produces rapid
bronchodilation and is commonly used as a rescue medication during acute
bronchospasm.
Question 9
A client with a chest tube has continuous bubbling in the water-seal chamber.
What does this finding most likely indicate?
A. Normal lung re-expansion
B. An air leak
C. Adequate suction pressure
D. Complete chest-tube obstruction
Answer: _B. An air leak_
Rationale: Continuous bubbling in the water-seal chamber generally indicates an
air leak somewhere in the system. The nurse should assess the tubing and
connections.
Question 10
A client with a chest tube accidentally becomes disconnected from the drainage
system. Which action should the nurse take first?
A. Clamp the chest tube permanently
B. Place the end of the tube in sterile water
C. Remove the chest tube
D. Apply a dry dressing to the insertion site
Answer: _B. Place the end of the tube in sterile water_
Review 2026/2027 | Questions & Answers
with Rationales
Question 1
A client with chronic heart failure reports increasing shortness of breath, a 3-kg
weight gain over the past week, and swelling of both ankles. Which assessment
finding requires the nurse's immediate attention?
A. Fatigue after walking
B. Bilateral ankle edema
C. Crackles throughout both lung fields
D. Increased appetite
Answer: _C. Crackles throughout both lung fields_
Rationale: Diffuse crackles indicate pulmonary congestion, which can occur with
acute worsening of heart failure and impaired gas exchange. The nurse should
prioritize respiratory status and oxygenation.
Question 2
A nurse is caring for a client with acute myocardial infarction who suddenly
develops severe dyspnea and pink, frothy sputum. Which complication should the
nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Pleural effusion
D. Pulmonary embolism
Answer: _A. Pulmonary edema_
Rationale: Sudden dyspnea accompanied by pink, frothy sputum is characteristic
of acute pulmonary edema caused by severe left ventricular dysfunction.
,Question 3
A client receiving warfarin therapy for atrial fibrillation has an INR of 5.8. Which
action should the nurse anticipate?
A. Administer the next dose as scheduled
B. Hold the warfarin and notify the provider
C. Administer aspirin
D. Encourage foods high in vitamin K immediately
Answer: _B. Hold the warfarin and notify the provider_
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased risk
of bleeding. The nurse should hold the medication and notify the provider for
further management.
Question 4
A client with peripheral arterial disease reports severe calf pain when walking that
improves with rest. How should the nurse document this finding?
A. Venous claudication
B. Intermittent arterial claudication
C. Dependent edema
D. Neuropathic pain
Answer: _B. Intermittent arterial claudication_
Rationale: Intermittent claudication is ischemic muscle pain caused by inadequate
arterial blood flow during activity. It typically improves when the activity stops.
Question 5
Which finding is most concerning in a client with a suspected pulmonary
embolism?
A. Respiratory rate of 28/min
B. Sudden onset of dyspnea
C. Oxygen saturation of 86%
D. Mild anxiety
,Answer: _C. Oxygen saturation of 86%_
Rationale: Severe hypoxemia represents impaired oxygenation and requires
immediate intervention. The nurse should support oxygenation while rapidly
addressing the suspected pulmonary embolism.
Question 6
A client with chronic obstructive pulmonary disease is receiving oxygen therapy.
Which oxygen saturation target is generally appropriate for a client at risk for
chronic carbon dioxide retention?
A. 70%–75%
B. 80%–85%
C. 88%–92%
D. 98%–100%
Answer: _C. 88%–92%_
Rationale: For many clients with COPD who are at risk for hypercapnic
respiratory failure, controlled oxygen therapy targeting approximately 88%–92%
helps improve oxygenation while reducing the risk of excessive oxygen
administration.
Question 7
A client with pneumonia becomes confused and restless. The oxygen saturation is
82% despite oxygen therapy. What should the nurse do first?
A. Obtain a urine specimen
B. Increase oral fluids
C. Assess and support airway and breathing
D. Administer a sedative
Answer: _C. Assess and support airway and breathing_
Rationale: Confusion and restlessness may be manifestations of severe hypoxemia.
Airway and breathing take priority according to the ABC approach.
Question 8
, A client with asthma develops wheezing and chest tightness. Which medication
should the nurse expect to administer for rapid relief?
A. Albuterol
B. Fluticasone
C. Montelukast
D. Salmeterol
Answer: _A. Albuterol_
Rationale: Albuterol is a short-acting beta₂-adrenergic agonist that produces rapid
bronchodilation and is commonly used as a rescue medication during acute
bronchospasm.
Question 9
A client with a chest tube has continuous bubbling in the water-seal chamber.
What does this finding most likely indicate?
A. Normal lung re-expansion
B. An air leak
C. Adequate suction pressure
D. Complete chest-tube obstruction
Answer: _B. An air leak_
Rationale: Continuous bubbling in the water-seal chamber generally indicates an
air leak somewhere in the system. The nurse should assess the tubing and
connections.
Question 10
A client with a chest tube accidentally becomes disconnected from the drainage
system. Which action should the nurse take first?
A. Clamp the chest tube permanently
B. Place the end of the tube in sterile water
C. Remove the chest tube
D. Apply a dry dressing to the insertion site
Answer: _B. Place the end of the tube in sterile water_
