NSG 4100 Adult Health III Assessment 6 with
Complete Solutions
1. Heart Failure Management
A patient with chronic heart failure presents with worsening dyspnea and 2+ pitting
edema in the lower extremities. Which nursing intervention is the priority?
• A. Encourage increased oral fluids
• B. Assess lung sounds and oxygen saturation
• C. Elevate legs above the heart
• D. Restrict dietary sodium
Rationale: The priority is to assess for impaired gas exchange and worsening
pulmonary edema. Safety and airway always come first before other supportive
measures.
2. Postoperative Complications
A patient is 12 hours post-abdominal surgery and reports sudden severe abdominal
pain with rigid distention. What is the nurse’s first action?
• A. Administer prescribed opioid analgesics
• B. Notify the surgeon immediately
• C. Encourage ambulation
• D. Apply warm compresses
Rationale: Rigid abdomen and severe pain may indicate perforation or hemorrhage.
Immediate provider notification is critical to prevent life-threatening complications.
3. Diabetes Mellitus
A patient with type 1 diabetes is found confused, diaphoretic, and trembling. What is the
nurse’s best initial intervention?
• A. Administer insulin subcutaneously
• B. Provide 15 g of fast-acting carbohydrate
• C. Start IV fluids with normal saline
• D. Call the rapid response team
4. Respiratory Disorders
,A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. The patient
becomes increasingly drowsy. What should the nurse do?
• A. Increase oxygen flow to 6 L/min
• B. Lower oxygen flow and monitor closely
• C. Place patient in supine position
• D. Encourage pursed-lip breathing only
Rationale: High oxygen flow can suppress the hypoxic drive in COPD patients, leading
to CO₂ retention. Reducing oxygen and monitoring is the safest action.
5. Renal Disorders
A patient with chronic kidney disease has serum potassium of 6.2 mEq/L. Which
intervention is most urgent?
• A. Restrict dietary potassium
• B. Place patient on cardiac monitor
• C. Teach patient about dialysis
• D. Encourage oral fluids
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Continuous cardiac
monitoring is the immediate priority before dietary or long-term interventions.
7. Stroke Care
A patient with acute ischemic stroke suddenly develops difficulty speaking and right-
sided weakness. What is the priority nursing action?
• A. Reassure the patient
• B. Call the rapid response team
• C. Elevate the head of bed
• D. Administer aspirin
Rationale: Sudden neurological changes may indicate stroke progression or
hemorrhage. Immediate activation of emergency response ensures rapid intervention.
8. GI Bleeding
A patient with suspected upper GI bleed has coffee-ground emesis. Which lab value is
most important to monitor?
• A. Sodium
• B. Potassium
, • C. Hemoglobin and hematocrit
• D. Calcium
Rationale: GI bleeding can cause acute blood loss anemia. Monitoring H&H guides
transfusion and fluid resuscitation needs.
9. Pneumonia
A patient with pneumonia has a respiratory rate of 32/min, SpO₂ 86% on room air, and
use of accessory muscles. What is the priority intervention?
• A. Encourage coughing and deep breathing
• B. Apply oxygen therapy
• C. Administer IV antibiotics
• D. Provide oral fluids
Rationale: Hypoxemia requires immediate oxygen support before antibiotics or fluids.
10. Hypertension Crisis
A patient presents with BP 220/120 mmHg and severe headache. What complication is
the nurse most concerned about?
• A. Renal stones
• B. Stroke
• C. Pneumonia
• D. Hypoglycemia
Rationale: Hypertensive crisis can cause cerebral hemorrhage or ischemic stroke due
to extreme pressure.
11. Post-Thyroidectomy
A patient is 2 hours post-thyroidectomy and develops stridor. What is the nurse’s first
action?
• A. Reassure the patient
• B. Call for emergency airway equipment
• C. Administer pain medication
• D. Encourage coughing
Rationale: Stridor indicates airway obstruction, often from swelling or hematoma.
Airway management is the priority.
12. Myocardial Infarction
Complete Solutions
1. Heart Failure Management
A patient with chronic heart failure presents with worsening dyspnea and 2+ pitting
edema in the lower extremities. Which nursing intervention is the priority?
• A. Encourage increased oral fluids
• B. Assess lung sounds and oxygen saturation
• C. Elevate legs above the heart
• D. Restrict dietary sodium
Rationale: The priority is to assess for impaired gas exchange and worsening
pulmonary edema. Safety and airway always come first before other supportive
measures.
2. Postoperative Complications
A patient is 12 hours post-abdominal surgery and reports sudden severe abdominal
pain with rigid distention. What is the nurse’s first action?
• A. Administer prescribed opioid analgesics
• B. Notify the surgeon immediately
• C. Encourage ambulation
• D. Apply warm compresses
Rationale: Rigid abdomen and severe pain may indicate perforation or hemorrhage.
Immediate provider notification is critical to prevent life-threatening complications.
3. Diabetes Mellitus
A patient with type 1 diabetes is found confused, diaphoretic, and trembling. What is the
nurse’s best initial intervention?
• A. Administer insulin subcutaneously
• B. Provide 15 g of fast-acting carbohydrate
• C. Start IV fluids with normal saline
• D. Call the rapid response team
4. Respiratory Disorders
,A patient with COPD is receiving oxygen at 4 L/min via nasal cannula. The patient
becomes increasingly drowsy. What should the nurse do?
• A. Increase oxygen flow to 6 L/min
• B. Lower oxygen flow and monitor closely
• C. Place patient in supine position
• D. Encourage pursed-lip breathing only
Rationale: High oxygen flow can suppress the hypoxic drive in COPD patients, leading
to CO₂ retention. Reducing oxygen and monitoring is the safest action.
5. Renal Disorders
A patient with chronic kidney disease has serum potassium of 6.2 mEq/L. Which
intervention is most urgent?
• A. Restrict dietary potassium
• B. Place patient on cardiac monitor
• C. Teach patient about dialysis
• D. Encourage oral fluids
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Continuous cardiac
monitoring is the immediate priority before dietary or long-term interventions.
7. Stroke Care
A patient with acute ischemic stroke suddenly develops difficulty speaking and right-
sided weakness. What is the priority nursing action?
• A. Reassure the patient
• B. Call the rapid response team
• C. Elevate the head of bed
• D. Administer aspirin
Rationale: Sudden neurological changes may indicate stroke progression or
hemorrhage. Immediate activation of emergency response ensures rapid intervention.
8. GI Bleeding
A patient with suspected upper GI bleed has coffee-ground emesis. Which lab value is
most important to monitor?
• A. Sodium
• B. Potassium
, • C. Hemoglobin and hematocrit
• D. Calcium
Rationale: GI bleeding can cause acute blood loss anemia. Monitoring H&H guides
transfusion and fluid resuscitation needs.
9. Pneumonia
A patient with pneumonia has a respiratory rate of 32/min, SpO₂ 86% on room air, and
use of accessory muscles. What is the priority intervention?
• A. Encourage coughing and deep breathing
• B. Apply oxygen therapy
• C. Administer IV antibiotics
• D. Provide oral fluids
Rationale: Hypoxemia requires immediate oxygen support before antibiotics or fluids.
10. Hypertension Crisis
A patient presents with BP 220/120 mmHg and severe headache. What complication is
the nurse most concerned about?
• A. Renal stones
• B. Stroke
• C. Pneumonia
• D. Hypoglycemia
Rationale: Hypertensive crisis can cause cerebral hemorrhage or ischemic stroke due
to extreme pressure.
11. Post-Thyroidectomy
A patient is 2 hours post-thyroidectomy and develops stridor. What is the nurse’s first
action?
• A. Reassure the patient
• B. Call for emergency airway equipment
• C. Administer pain medication
• D. Encourage coughing
Rationale: Stridor indicates airway obstruction, often from swelling or hematoma.
Airway management is the priority.
12. Myocardial Infarction
