NSG 4100 Assessment 3 – Adult Health
III with Complete Solutions
Respiratory System
Neurological System
Endocrine & Metabolic
Gastrointestinal & Hepatic
Musculoskeletal
Lab & Diagnostics
Question 1
A 64-year-old patient with COPD is admitted with worsening dyspnea. Which nursing
intervention is most appropriate to promote effective breathing?
A. Encourage the patient to lie flat in bed B. Teach pursed-lip breathing techniques C. Restrict
fluid intake to prevent pulmonary edema D. Administer high-flow oxygen at 10 L/min
Answer: B. Teach pursed-lip breathing techniques
Rationale: Pursed-lip breathing helps prevent airway collapse, promotes CO₂ elimination, and
improves ventilation. Lying flat worsens breathing, fluid restriction is not indicated unless
cardiac issues coexist, and high-flow oxygen can suppress hypoxic drive in COPD patients.
Question 2
A patient with heart failure is prescribed furosemide. Which lab value requires the nurse’s
immediate attention?
A. Sodium 138 mEq/L B. Potassium 2.9 mEq/L C. Hemoglobin 13 g/dL D. Creatinine 1.0
mg/dL
Answer: B. Potassium 2.9 mEq/L
,Rationale: Furosemide can cause hypokalemia, which increases the risk of life-threatening
arrhythmias. Normal potassium is 3.5–5.0 mEq/L. The other values are within normal ranges.
Question 3
A patient with type 2 diabetes reports numbness and tingling in both feet. What is the priority
nursing action?
A. Encourage daily foot inspection B. Increase insulin dosage C. Apply warm compresses to feet
D. Recommend high-protein diet
Answer: A. Encourage daily foot inspection
Rationale: Peripheral neuropathy increases risk for unnoticed injuries and infections. Daily foot
care and inspection are essential to prevent complications. Insulin adjustment requires provider
input, warm compresses may cause burns, and diet changes do not directly address neuropathy.
Question 4
A patient recovering from abdominal surgery suddenly develops shortness of breath and chest
pain. What is the nurse’s first action?
A. Notify the surgeon immediately B. Assess oxygen saturation and apply oxygen C.
Administer prescribed analgesics D. Encourage ambulation
Answer: B. Assess oxygen saturation and apply oxygen
Rationale: Sudden dyspnea and chest pain may indicate pulmonary embolism. The nurse must
first assess and stabilize oxygenation before notifying the provider. Analgesics and ambulation
are inappropriate until the patient is stabilized.
Question 5
A patient with chronic kidney disease is scheduled for hemodialysis. Which finding should the
nurse report before treatment?
A. Blood pressure 150/88 mmHg B. Serum potassium 6.2 mEq/L C. Hemoglobin 11 g/dL D.
Weight gain of 2 lbs since yesterday
Answer: B. Serum potassium 6.2 mEq/L
Rationale: Severe hyperkalemia is life-threatening and requires urgent dialysis. Elevated BP and
mild anemia are common in CKD, and small weight gain reflects fluid retention but is not
immediately critical.
Question 6
, A patient with pneumonia is receiving IV antibiotics. Which finding indicates the treatment is
effective?
A. WBC count decreases from 15,000 to 8,000/mm³ B. Respiratory rate increases from 20 to
28/min C. Oxygen saturation drops from 95% to 90% D. Temperature rises from 99°F to 101°F
Answer: A. WBC count decreases from 15,000 to 8,000/mm³
Rationale: A declining WBC count reflects resolution of infection. Increased respiratory rate,
decreased oxygen saturation, and rising temperature suggest worsening condition.
Question 7
A patient with cirrhosis develops ascites. Which nursing intervention is most appropriate?
A. Encourage high-sodium diet B. Measure abdominal girth daily C. Restrict protein intake
completely D. Position patient flat in bed
Answer: B. Measure abdominal girth daily
Rationale: Monitoring abdominal girth helps track fluid accumulation. Sodium should be
restricted, protein is not eliminated unless encephalopathy worsens, and lying flat impairs
breathing.
Question 8
A patient with a chest tube accidentally disconnects the drainage system. What is the nurse’s
immediate action?
A. Clamp the chest tube B. Place the tube in sterile water C. Call the physician immediately D.
Apply high-flow oxygen
Answer: B. Place the tube in sterile water
Rationale: Submerging the tube in sterile water creates a temporary water seal to prevent air
entry. Clamping can cause tension pneumothorax, and oxygen does not address the problem
directly.
Question 9
A patient with Parkinson’s disease is at risk for falls. Which intervention is most appropriate?
A. Encourage rapid movements to maintain strength B. Provide a cane and teach proper use C.
Restrict ambulation to prevent injury D. Place bed in high position for easy exit
Answer: B. Provide a cane and teach proper use
III with Complete Solutions
Respiratory System
Neurological System
Endocrine & Metabolic
Gastrointestinal & Hepatic
Musculoskeletal
Lab & Diagnostics
Question 1
A 64-year-old patient with COPD is admitted with worsening dyspnea. Which nursing
intervention is most appropriate to promote effective breathing?
A. Encourage the patient to lie flat in bed B. Teach pursed-lip breathing techniques C. Restrict
fluid intake to prevent pulmonary edema D. Administer high-flow oxygen at 10 L/min
Answer: B. Teach pursed-lip breathing techniques
Rationale: Pursed-lip breathing helps prevent airway collapse, promotes CO₂ elimination, and
improves ventilation. Lying flat worsens breathing, fluid restriction is not indicated unless
cardiac issues coexist, and high-flow oxygen can suppress hypoxic drive in COPD patients.
Question 2
A patient with heart failure is prescribed furosemide. Which lab value requires the nurse’s
immediate attention?
A. Sodium 138 mEq/L B. Potassium 2.9 mEq/L C. Hemoglobin 13 g/dL D. Creatinine 1.0
mg/dL
Answer: B. Potassium 2.9 mEq/L
,Rationale: Furosemide can cause hypokalemia, which increases the risk of life-threatening
arrhythmias. Normal potassium is 3.5–5.0 mEq/L. The other values are within normal ranges.
Question 3
A patient with type 2 diabetes reports numbness and tingling in both feet. What is the priority
nursing action?
A. Encourage daily foot inspection B. Increase insulin dosage C. Apply warm compresses to feet
D. Recommend high-protein diet
Answer: A. Encourage daily foot inspection
Rationale: Peripheral neuropathy increases risk for unnoticed injuries and infections. Daily foot
care and inspection are essential to prevent complications. Insulin adjustment requires provider
input, warm compresses may cause burns, and diet changes do not directly address neuropathy.
Question 4
A patient recovering from abdominal surgery suddenly develops shortness of breath and chest
pain. What is the nurse’s first action?
A. Notify the surgeon immediately B. Assess oxygen saturation and apply oxygen C.
Administer prescribed analgesics D. Encourage ambulation
Answer: B. Assess oxygen saturation and apply oxygen
Rationale: Sudden dyspnea and chest pain may indicate pulmonary embolism. The nurse must
first assess and stabilize oxygenation before notifying the provider. Analgesics and ambulation
are inappropriate until the patient is stabilized.
Question 5
A patient with chronic kidney disease is scheduled for hemodialysis. Which finding should the
nurse report before treatment?
A. Blood pressure 150/88 mmHg B. Serum potassium 6.2 mEq/L C. Hemoglobin 11 g/dL D.
Weight gain of 2 lbs since yesterday
Answer: B. Serum potassium 6.2 mEq/L
Rationale: Severe hyperkalemia is life-threatening and requires urgent dialysis. Elevated BP and
mild anemia are common in CKD, and small weight gain reflects fluid retention but is not
immediately critical.
Question 6
, A patient with pneumonia is receiving IV antibiotics. Which finding indicates the treatment is
effective?
A. WBC count decreases from 15,000 to 8,000/mm³ B. Respiratory rate increases from 20 to
28/min C. Oxygen saturation drops from 95% to 90% D. Temperature rises from 99°F to 101°F
Answer: A. WBC count decreases from 15,000 to 8,000/mm³
Rationale: A declining WBC count reflects resolution of infection. Increased respiratory rate,
decreased oxygen saturation, and rising temperature suggest worsening condition.
Question 7
A patient with cirrhosis develops ascites. Which nursing intervention is most appropriate?
A. Encourage high-sodium diet B. Measure abdominal girth daily C. Restrict protein intake
completely D. Position patient flat in bed
Answer: B. Measure abdominal girth daily
Rationale: Monitoring abdominal girth helps track fluid accumulation. Sodium should be
restricted, protein is not eliminated unless encephalopathy worsens, and lying flat impairs
breathing.
Question 8
A patient with a chest tube accidentally disconnects the drainage system. What is the nurse’s
immediate action?
A. Clamp the chest tube B. Place the tube in sterile water C. Call the physician immediately D.
Apply high-flow oxygen
Answer: B. Place the tube in sterile water
Rationale: Submerging the tube in sterile water creates a temporary water seal to prevent air
entry. Clamping can cause tension pneumothorax, and oxygen does not address the problem
directly.
Question 9
A patient with Parkinson’s disease is at risk for falls. Which intervention is most appropriate?
A. Encourage rapid movements to maintain strength B. Provide a cane and teach proper use C.
Restrict ambulation to prevent injury D. Place bed in high position for easy exit
Answer: B. Provide a cane and teach proper use
