Adult Health Nursing I – Unit 3 Exam Practice
Questions & Answers
Question 1:
A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% while receiving oxygen at 2 L/min by nasal cannula. Which
action should the nurse take first?
A. Increase oxygen to 10 L/min
B. Assess the client's respiratory effort and mental status
C. Place the client flat in bed
D. Discontinue oxygen therapy
Correct Answer: B. Assess the client's respiratory effort and mental status
Rationale: The nurse should first assess respiratory effort, level of consciousness,
breath sounds, and overall clinical condition. Oxygen should be carefully titrated in
COPD rather than automatically increased to high concentrations. Positioning and
further assessment help determine whether the client is experiencing worsening
respiratory compromise.
Question 2:
A client with heart failure reports gaining 2.5 kg over the past three days. Which
finding is most concerning?
A. Increased appetite
B. Mild fatigue after walking
,C. Bilateral crackles and increasing dyspnea
D. Heart rate of 78 beats/minute
Correct Answer: C. Bilateral crackles and increasing dyspnea
Rationale: Rapid weight gain indicates fluid retention, and crackles with
worsening dyspnea suggest pulmonary congestion. These findings can indicate an
acute exacerbation of heart failure. The nurse should promptly assess respiratory
status and notify the provider as appropriate while implementing prescribed
interventions.
Question 3:
A client taking furosemide for heart failure reports muscle weakness and
palpitations. Which laboratory value should the nurse review first?
A. Potassium
B. Sodium
C. Calcium
D. Hemoglobin
Correct Answer: A. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary potassium loss.
Hypokalemia can cause muscle weakness, palpitations, and potentially life-
threatening dysrhythmias. The nurse should review the potassium level and ECG
findings and report significant abnormalities promptly.
Question 4:
A client with asthma develops severe wheezing and increasing respiratory distress.
,Suddenly, the wheezing disappears, but the client's respiratory effort worsens.
What does this finding suggest?
A. Resolution of bronchospasm
B. Improved airway clearance
C. Development of pulmonary edema
D. Severe airway obstruction with minimal airflow
Correct Answer: D. Severe airway obstruction with minimal airflow
Rationale: A sudden absence of wheezing in a client with worsening asthma is
dangerous. Severe bronchoconstriction can reduce airflow so significantly that
wheezing becomes inaudible. A silent chest may indicate impending respiratory
failure and requires immediate intervention.
Question 5:
Which instruction should the nurse give a client with COPD about pursed-lip
breathing?
A. Inhale rapidly through the mouth and exhale through the nose
B. Inhale through the nose and exhale slowly through pursed lips
C. Hold the breath for 20 seconds after each inhalation
D. Breathe rapidly to eliminate carbon dioxide
Correct Answer: B. Inhale through the nose and exhale slowly through pursed lips
Rationale: Pursed-lip breathing prolongs exhalation and helps prevent premature
airway collapse. The client inhales through the nose and slowly exhales through
partially closed lips. This technique can reduce air trapping and improve
ventilation during dyspnea.
, Question 6:
A client with pneumonia has a temperature of 39°C, productive cough, respiratory
rate of 28/minute, and oxygen saturation of 89%. Which intervention has the
highest priority?
A. Encourage oral fluids
B. Administer prescribed antipyretic medication
C. Apply supplemental oxygen as prescribed
D. Encourage ambulation
Correct Answer: C. Apply supplemental oxygen as prescribed
Rationale: The oxygen saturation of 89% indicates impaired oxygenation. Airway
and breathing take priority over comfort measures and activity. Supplemental
oxygen should be administered according to the prescription or protocol while the
nurse continues assessing respiratory status and underlying deterioration.
Question 7:
A client with pulmonary embolism suddenly develops severe dyspnea, chest pain,
and tachycardia. Which action should the nurse take first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position and administer oxygen
C. Assist the client to ambulate
D. Apply a warm compress to the chest
Correct Answer: B. Place the client in high-Fowler's position and administer
oxygen
Questions & Answers
Question 1:
A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% while receiving oxygen at 2 L/min by nasal cannula. Which
action should the nurse take first?
A. Increase oxygen to 10 L/min
B. Assess the client's respiratory effort and mental status
C. Place the client flat in bed
D. Discontinue oxygen therapy
Correct Answer: B. Assess the client's respiratory effort and mental status
Rationale: The nurse should first assess respiratory effort, level of consciousness,
breath sounds, and overall clinical condition. Oxygen should be carefully titrated in
COPD rather than automatically increased to high concentrations. Positioning and
further assessment help determine whether the client is experiencing worsening
respiratory compromise.
Question 2:
A client with heart failure reports gaining 2.5 kg over the past three days. Which
finding is most concerning?
A. Increased appetite
B. Mild fatigue after walking
,C. Bilateral crackles and increasing dyspnea
D. Heart rate of 78 beats/minute
Correct Answer: C. Bilateral crackles and increasing dyspnea
Rationale: Rapid weight gain indicates fluid retention, and crackles with
worsening dyspnea suggest pulmonary congestion. These findings can indicate an
acute exacerbation of heart failure. The nurse should promptly assess respiratory
status and notify the provider as appropriate while implementing prescribed
interventions.
Question 3:
A client taking furosemide for heart failure reports muscle weakness and
palpitations. Which laboratory value should the nurse review first?
A. Potassium
B. Sodium
C. Calcium
D. Hemoglobin
Correct Answer: A. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary potassium loss.
Hypokalemia can cause muscle weakness, palpitations, and potentially life-
threatening dysrhythmias. The nurse should review the potassium level and ECG
findings and report significant abnormalities promptly.
Question 4:
A client with asthma develops severe wheezing and increasing respiratory distress.
,Suddenly, the wheezing disappears, but the client's respiratory effort worsens.
What does this finding suggest?
A. Resolution of bronchospasm
B. Improved airway clearance
C. Development of pulmonary edema
D. Severe airway obstruction with minimal airflow
Correct Answer: D. Severe airway obstruction with minimal airflow
Rationale: A sudden absence of wheezing in a client with worsening asthma is
dangerous. Severe bronchoconstriction can reduce airflow so significantly that
wheezing becomes inaudible. A silent chest may indicate impending respiratory
failure and requires immediate intervention.
Question 5:
Which instruction should the nurse give a client with COPD about pursed-lip
breathing?
A. Inhale rapidly through the mouth and exhale through the nose
B. Inhale through the nose and exhale slowly through pursed lips
C. Hold the breath for 20 seconds after each inhalation
D. Breathe rapidly to eliminate carbon dioxide
Correct Answer: B. Inhale through the nose and exhale slowly through pursed lips
Rationale: Pursed-lip breathing prolongs exhalation and helps prevent premature
airway collapse. The client inhales through the nose and slowly exhales through
partially closed lips. This technique can reduce air trapping and improve
ventilation during dyspnea.
, Question 6:
A client with pneumonia has a temperature of 39°C, productive cough, respiratory
rate of 28/minute, and oxygen saturation of 89%. Which intervention has the
highest priority?
A. Encourage oral fluids
B. Administer prescribed antipyretic medication
C. Apply supplemental oxygen as prescribed
D. Encourage ambulation
Correct Answer: C. Apply supplemental oxygen as prescribed
Rationale: The oxygen saturation of 89% indicates impaired oxygenation. Airway
and breathing take priority over comfort measures and activity. Supplemental
oxygen should be administered according to the prescription or protocol while the
nurse continues assessing respiratory status and underlying deterioration.
Question 7:
A client with pulmonary embolism suddenly develops severe dyspnea, chest pain,
and tachycardia. Which action should the nurse take first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position and administer oxygen
C. Assist the client to ambulate
D. Apply a warm compress to the chest
Correct Answer: B. Place the client in high-Fowler's position and administer
oxygen
