NSG 4100 Exam 4 Final exam Questions and
Correct Answers (Verified Answers) Plus
Rationale 2027 Q&A| Instant Download Pdf
1. A nurse is caring for a patient who reports sudden onset of severe
shortness of breath and chest pain. Which assessment finding
requires the nurse's immediate attention?
A. Respiratory rate of 20 breaths/min
B. Oxygen saturation of 96%
C. Oxygen saturation of 84%
D. Temperature of 37.2°C
Rationale: An oxygen saturation of 84% indicates significant hypoxemia
and requires immediate intervention. The nurse should assess airway
and breathing, administer oxygen as prescribed, and rapidly evaluate
the underlying cause.
2. A patient with heart failure is prescribed furosemide. Which
assessment finding best indicates that the medication is
producing the desired effect?
,A. Increased peripheral edema
B. Increased blood pressure
C. Decreased peripheral edema and improved breathing
D. Increased heart rate
Rationale: Furosemide promotes sodium and water excretion, reducing
fluid overload. Decreased edema, improved lung sounds, reduced
dyspnea, and weight loss from excess fluid indicate therapeutic
effectiveness.
3. Which laboratory value should the nurse monitor most closely in a
patient receiving high-dose furosemide?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelets
Rationale: Loop diuretics such as furosemide can cause significant
potassium loss. Hypokalemia can lead to muscle weakness and
potentially dangerous cardiac dysrhythmias.
4. A patient with chronic obstructive pulmonary disease is receiving
oxygen therapy. Which nursing intervention is appropriate?
,A. Maintain oxygen saturation at 100% at all times
B. Avoid monitoring respiratory status
C. Administer oxygen at the prescribed low-flow rate and monitor the
patient's response
D. Discontinue oxygen whenever the patient becomes dyspneic
Rationale: Some patients with COPD require carefully titrated oxygen
therapy. Oxygen should be administered according to the prescribed
target range while respiratory status and clinical response are
continuously assessed.
5. A nurse is teaching a patient with asthma about using a short-
acting beta2-agonist inhaler. Which statement indicates correct
understanding?
A. "I should use this medication every morning whether I have
symptoms or not."
B. "This medication prevents all future asthma attacks."
C. "I can use this medication for quick relief of acute bronchospasm."
D. "I should stop using my controller medication when I use this
inhaler."
Rationale: Short-acting beta2-agonists such as albuterol provide rapid
bronchodilation and are commonly used as rescue medications for
acute bronchospasm. They do not replace long-term controller therapy.
, 6. A patient with pneumonia has a productive cough. Which
intervention best promotes secretion clearance?
A. Restrict oral fluids
B. Encourage prolonged bed rest
C. Encourage adequate hydration if not contraindicated
D. Administer cough suppressants routinely
Rationale: Adequate hydration helps thin respiratory secretions, making
them easier to expectorate. Mobilization, coughing and deep breathing,
and appropriate respiratory treatments may also assist secretion
clearance.
7. A patient with diabetes mellitus is diaphoretic, trembling, and
confused. The blood glucose level is 48 mg/dL. Which action
should the nurse take first if the patient is conscious and able to
swallow?
A. Administer long-acting insulin
B. Encourage exercise
C. Give approximately 15 g of rapid-acting carbohydrate
D. Restrict oral intake
Rationale: A conscious patient with symptomatic hypoglycemia should
receive approximately 15 g of rapidly absorbed carbohydrate, followed
Correct Answers (Verified Answers) Plus
Rationale 2027 Q&A| Instant Download Pdf
1. A nurse is caring for a patient who reports sudden onset of severe
shortness of breath and chest pain. Which assessment finding
requires the nurse's immediate attention?
A. Respiratory rate of 20 breaths/min
B. Oxygen saturation of 96%
C. Oxygen saturation of 84%
D. Temperature of 37.2°C
Rationale: An oxygen saturation of 84% indicates significant hypoxemia
and requires immediate intervention. The nurse should assess airway
and breathing, administer oxygen as prescribed, and rapidly evaluate
the underlying cause.
2. A patient with heart failure is prescribed furosemide. Which
assessment finding best indicates that the medication is
producing the desired effect?
,A. Increased peripheral edema
B. Increased blood pressure
C. Decreased peripheral edema and improved breathing
D. Increased heart rate
Rationale: Furosemide promotes sodium and water excretion, reducing
fluid overload. Decreased edema, improved lung sounds, reduced
dyspnea, and weight loss from excess fluid indicate therapeutic
effectiveness.
3. Which laboratory value should the nurse monitor most closely in a
patient receiving high-dose furosemide?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelets
Rationale: Loop diuretics such as furosemide can cause significant
potassium loss. Hypokalemia can lead to muscle weakness and
potentially dangerous cardiac dysrhythmias.
4. A patient with chronic obstructive pulmonary disease is receiving
oxygen therapy. Which nursing intervention is appropriate?
,A. Maintain oxygen saturation at 100% at all times
B. Avoid monitoring respiratory status
C. Administer oxygen at the prescribed low-flow rate and monitor the
patient's response
D. Discontinue oxygen whenever the patient becomes dyspneic
Rationale: Some patients with COPD require carefully titrated oxygen
therapy. Oxygen should be administered according to the prescribed
target range while respiratory status and clinical response are
continuously assessed.
5. A nurse is teaching a patient with asthma about using a short-
acting beta2-agonist inhaler. Which statement indicates correct
understanding?
A. "I should use this medication every morning whether I have
symptoms or not."
B. "This medication prevents all future asthma attacks."
C. "I can use this medication for quick relief of acute bronchospasm."
D. "I should stop using my controller medication when I use this
inhaler."
Rationale: Short-acting beta2-agonists such as albuterol provide rapid
bronchodilation and are commonly used as rescue medications for
acute bronchospasm. They do not replace long-term controller therapy.
, 6. A patient with pneumonia has a productive cough. Which
intervention best promotes secretion clearance?
A. Restrict oral fluids
B. Encourage prolonged bed rest
C. Encourage adequate hydration if not contraindicated
D. Administer cough suppressants routinely
Rationale: Adequate hydration helps thin respiratory secretions, making
them easier to expectorate. Mobilization, coughing and deep breathing,
and appropriate respiratory treatments may also assist secretion
clearance.
7. A patient with diabetes mellitus is diaphoretic, trembling, and
confused. The blood glucose level is 48 mg/dL. Which action
should the nurse take first if the patient is conscious and able to
swallow?
A. Administer long-acting insulin
B. Encourage exercise
C. Give approximately 15 g of rapid-acting carbohydrate
D. Restrict oral intake
Rationale: A conscious patient with symptomatic hypoglycemia should
receive approximately 15 g of rapidly absorbed carbohydrate, followed
