NSG 300 Exam 4 V2 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 4) | Grand Canyon University
1. A nurse is assessing a client who is exhibiting early signs of hypoxia. Which of the following
clinical manifestations should the nurse expect?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Bradypnea
Correct Answer: B
Explanation: Restlessness is a primary early indicator of hypoxia because the central
nervous system is highly sensitive to declining oxygen levels. During this initial stage, the
body attempts to compensate by increasing heart rate and respiratory effort. Failure to
recognize these subtle changes can lead to rapid physiological deterioration.
2. A nurse is caring for a client at risk for developing pressure injuries. Which of the following
factors should the nurse identify as increasing the risk for skin breakdown? (Select all that
apply)
A. Incontinence
B. Protein deficiency
,C. Immobility
D. Adequate hydration
E. Reduced sensory perception
F. Frequent repositioning
Correct Answer: ABCE
Explanation: Moisture from incontinence softens the skin, making it more susceptible to
friction and shearing forces. Nutritional status, specifically protein intake, is vital for
maintaining tissue integrity and promoting repair. Reduced sensory perception prevents
the patient from feeling the discomfort that normally prompts movement, leading to
prolonged pressure.
3. A client’s arterial blood gas (ABG) results are as follows: pH 7.30, PaCO2 52 mmHg, and
HCO3 26 mEq/L. The nurse should interpret these findings as which of the following?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: A
Explanation: The pH level is below the normal range of 7.35 to 7.45, indicating acidosis.
The PaCO2 is elevated above the normal limit of 45 mmHg, suggesting that the acidosis is
, respiratory in origin. Because the bicarbonate is within normal limits, this represents
uncompensated respiratory acidosis.
4. A nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which
of the following sites is the preferred location for this injection due to the absence of large
nerves and blood vessels?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Correct Answer: D
Explanation: The ventrogluteal site is considered the safest for IM injections because it is
situated away from major nerves and blood vessels. It provides a thick muscle mass that
can accommodate larger volumes of medication. Current nursing standards recommend
this site for adults over the dorsogluteal site to avoid sciatic nerve injury.
5. During the inflammatory phase of wound healing, which of the following processes occurs?
A. Collagen synthesis provides strength to the wound.
B. The wound contracts to reduce the surface area.
C. Hemostasis occurs and phagocytosis begins.
D. Epithelial cells migrate across the wound bed.
Nursing | Actual Q&A with Rationale (NSG300
Exam 4) | Grand Canyon University
1. A nurse is assessing a client who is exhibiting early signs of hypoxia. Which of the following
clinical manifestations should the nurse expect?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Bradypnea
Correct Answer: B
Explanation: Restlessness is a primary early indicator of hypoxia because the central
nervous system is highly sensitive to declining oxygen levels. During this initial stage, the
body attempts to compensate by increasing heart rate and respiratory effort. Failure to
recognize these subtle changes can lead to rapid physiological deterioration.
2. A nurse is caring for a client at risk for developing pressure injuries. Which of the following
factors should the nurse identify as increasing the risk for skin breakdown? (Select all that
apply)
A. Incontinence
B. Protein deficiency
,C. Immobility
D. Adequate hydration
E. Reduced sensory perception
F. Frequent repositioning
Correct Answer: ABCE
Explanation: Moisture from incontinence softens the skin, making it more susceptible to
friction and shearing forces. Nutritional status, specifically protein intake, is vital for
maintaining tissue integrity and promoting repair. Reduced sensory perception prevents
the patient from feeling the discomfort that normally prompts movement, leading to
prolonged pressure.
3. A client’s arterial blood gas (ABG) results are as follows: pH 7.30, PaCO2 52 mmHg, and
HCO3 26 mEq/L. The nurse should interpret these findings as which of the following?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: A
Explanation: The pH level is below the normal range of 7.35 to 7.45, indicating acidosis.
The PaCO2 is elevated above the normal limit of 45 mmHg, suggesting that the acidosis is
, respiratory in origin. Because the bicarbonate is within normal limits, this represents
uncompensated respiratory acidosis.
4. A nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which
of the following sites is the preferred location for this injection due to the absence of large
nerves and blood vessels?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Correct Answer: D
Explanation: The ventrogluteal site is considered the safest for IM injections because it is
situated away from major nerves and blood vessels. It provides a thick muscle mass that
can accommodate larger volumes of medication. Current nursing standards recommend
this site for adults over the dorsogluteal site to avoid sciatic nerve injury.
5. During the inflammatory phase of wound healing, which of the following processes occurs?
A. Collagen synthesis provides strength to the wound.
B. The wound contracts to reduce the surface area.
C. Hemostasis occurs and phagocytosis begins.
D. Epithelial cells migrate across the wound bed.
