NSG 4100 Adult Health III Assessment 8 with
Complete Solutions
Q1: A patient with COPD presents with worsening dyspnea. Which nursing intervention
is most appropriate?
• A. Encourage fluid intake of 3L/day
• B. Position in high Fowler’s
• C. Administer sedatives for anxiety
• D. Restrict oxygen to 1 L/min
Answer: B. Position in high Fowler’s
Rationale: Upright positioning maximizes lung expansion and improves ventilation.
Sedatives may depress respiration, and fluid overload can worsen pulmonary
congestion.
Q2: A patient with heart failure reports sudden weight gain of 3 pounds in 24 hours.
What should the nurse do first?
• A. Document and continue monitoring
• B. Notify the provider immediately
• C. Restrict dietary protein
• D. Encourage ambulation
Answer: B. Notify the provider immediately
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure,
requiring prompt medical intervention.
Q3: A patient with type 2 diabetes has a fasting blood glucose of 60 mg/dL. Which
action is most appropriate?
• A. Administer scheduled insulin
• B. Provide orange juice
• C. Encourage exercise
• D. Document and reassess in 1 hour
Answer: B. Provide orange juice
Rationale: Hypoglycemia requires immediate treatment with fast-acting carbohydrates
to prevent complications.
Q4: A patient with pneumonia is receiving IV antibiotics. Which finding indicates
improvement?
, • A. Increased sputum production
• B. Decreased breath sounds
• C. SpO₂ rising from 88% to 95%
• D. Persistent fever of 101°F
Answer: C. SpO₂ rising from 88% to 95%
Rationale: Improved oxygenation is a key indicator of recovery. Persistent fever or
decreased breath sounds suggest ongoing infection.
Q5: A patient with chronic kidney disease has serum potassium of 6.2 mEq/L. Which
intervention is priority?
• A. Place on cardiac monitor
• B. Encourage potassium-rich foods
• C. Administer loop diuretic
• D. Restrict fluids
Answer: A. Place on cardiac monitor
Rationale: Hyperkalemia can cause life-threatening arrhythmias; continuous
monitoring is essential before further interventions.
Q6: A patient with cirrhosis develops ascites. Which nursing action is most appropriate?
• A. Encourage high-sodium diet
• B. Measure abdominal girth daily
• C. Restrict protein intake completely
• D. Position supine for comfort
Answer: B. Measure abdominal girth daily
Rationale: Monitoring abdominal girth helps track fluid accumulation and guides
treatment effectiveness.
Q7: A patient with a new tracheostomy becomes anxious and tachypneic. The nurse
notes gurgling sounds. What is the best action?
• A. Reassure the patient
• B. Suction the tracheostomy
• C. Increase oxygen flow
• D. Call respiratory therapy
Answer: B. Suction the tracheostomy
, Rationale: Gurgling indicates secretion obstruction; suctioning restores airway patency
immediately.
Q8: A patient with myocardial infarction reports chest pain unrelieved by nitroglycerin.
What is the nurse’s priority?
• A. Administer morphine as ordered
• B. Encourage deep breathing
• C. Document pain characteristics
• D. Provide reassurance
Answer: A. Administer morphine as ordered
Rationale: Morphine relieves pain, decreases preload, and reduces myocardial oxygen
demand, making it the priority intervention.
Q9: A patient with acute pancreatitis reports severe epigastric pain radiating to the
back. Which intervention is priority?
• A. Administer opioid analgesics
• B. Encourage ambulation
• C. Provide high-fat diet
• D. Position supine
Answer: A. Administer opioid analgesics
Rationale: Pain control is the priority in acute pancreatitis; opioids are most effective.
Q10: A patient with stroke has right-sided weakness. Which nursing intervention
promotes independence?
• A. Place items on the left side
• B. Assist with all ADLs
• C. Encourage use of unaffected side only
• D. Restrict mobility until therapy begins
Answer: A. Place items on the left side
Rationale: Positioning items on the unaffected side maximizes independence and
safety.
Q11: A patient with DVT is prescribed anticoagulants. Which teaching is most
important?
• A. Avoid green leafy vegetables
• B. Report signs of bleeding
Complete Solutions
Q1: A patient with COPD presents with worsening dyspnea. Which nursing intervention
is most appropriate?
• A. Encourage fluid intake of 3L/day
• B. Position in high Fowler’s
• C. Administer sedatives for anxiety
• D. Restrict oxygen to 1 L/min
Answer: B. Position in high Fowler’s
Rationale: Upright positioning maximizes lung expansion and improves ventilation.
Sedatives may depress respiration, and fluid overload can worsen pulmonary
congestion.
Q2: A patient with heart failure reports sudden weight gain of 3 pounds in 24 hours.
What should the nurse do first?
• A. Document and continue monitoring
• B. Notify the provider immediately
• C. Restrict dietary protein
• D. Encourage ambulation
Answer: B. Notify the provider immediately
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure,
requiring prompt medical intervention.
Q3: A patient with type 2 diabetes has a fasting blood glucose of 60 mg/dL. Which
action is most appropriate?
• A. Administer scheduled insulin
• B. Provide orange juice
• C. Encourage exercise
• D. Document and reassess in 1 hour
Answer: B. Provide orange juice
Rationale: Hypoglycemia requires immediate treatment with fast-acting carbohydrates
to prevent complications.
Q4: A patient with pneumonia is receiving IV antibiotics. Which finding indicates
improvement?
, • A. Increased sputum production
• B. Decreased breath sounds
• C. SpO₂ rising from 88% to 95%
• D. Persistent fever of 101°F
Answer: C. SpO₂ rising from 88% to 95%
Rationale: Improved oxygenation is a key indicator of recovery. Persistent fever or
decreased breath sounds suggest ongoing infection.
Q5: A patient with chronic kidney disease has serum potassium of 6.2 mEq/L. Which
intervention is priority?
• A. Place on cardiac monitor
• B. Encourage potassium-rich foods
• C. Administer loop diuretic
• D. Restrict fluids
Answer: A. Place on cardiac monitor
Rationale: Hyperkalemia can cause life-threatening arrhythmias; continuous
monitoring is essential before further interventions.
Q6: A patient with cirrhosis develops ascites. Which nursing action is most appropriate?
• A. Encourage high-sodium diet
• B. Measure abdominal girth daily
• C. Restrict protein intake completely
• D. Position supine for comfort
Answer: B. Measure abdominal girth daily
Rationale: Monitoring abdominal girth helps track fluid accumulation and guides
treatment effectiveness.
Q7: A patient with a new tracheostomy becomes anxious and tachypneic. The nurse
notes gurgling sounds. What is the best action?
• A. Reassure the patient
• B. Suction the tracheostomy
• C. Increase oxygen flow
• D. Call respiratory therapy
Answer: B. Suction the tracheostomy
, Rationale: Gurgling indicates secretion obstruction; suctioning restores airway patency
immediately.
Q8: A patient with myocardial infarction reports chest pain unrelieved by nitroglycerin.
What is the nurse’s priority?
• A. Administer morphine as ordered
• B. Encourage deep breathing
• C. Document pain characteristics
• D. Provide reassurance
Answer: A. Administer morphine as ordered
Rationale: Morphine relieves pain, decreases preload, and reduces myocardial oxygen
demand, making it the priority intervention.
Q9: A patient with acute pancreatitis reports severe epigastric pain radiating to the
back. Which intervention is priority?
• A. Administer opioid analgesics
• B. Encourage ambulation
• C. Provide high-fat diet
• D. Position supine
Answer: A. Administer opioid analgesics
Rationale: Pain control is the priority in acute pancreatitis; opioids are most effective.
Q10: A patient with stroke has right-sided weakness. Which nursing intervention
promotes independence?
• A. Place items on the left side
• B. Assist with all ADLs
• C. Encourage use of unaffected side only
• D. Restrict mobility until therapy begins
Answer: A. Place items on the left side
Rationale: Positioning items on the unaffected side maximizes independence and
safety.
Q11: A patient with DVT is prescribed anticoagulants. Which teaching is most
important?
• A. Avoid green leafy vegetables
• B. Report signs of bleeding
