NR341 Complex Adult
Health – Exam 1 Study
Guide
1. Question:
A patient with COPD is admitted with increased shortness of breath and a respiratory
rate of 30. Which nursing intervention is most appropriate?
A. Place the patient in supine position
B. Administer high-flow oxygen via non-rebreather mask
C. Position the patient in high Fowler’s and apply oxygen as ordered
D. Encourage the patient to increase fluid intake to 4 liters per day
Answer:
C. Position the patient in high Fowler’s and apply oxygen as ordered
Rationale: Upright positioning improves lung expansion and oxygen delivery. High-
flow O2 should be used cautiously in COPD to avoid suppressing the hypoxic drive.
2. Question:
Which arterial blood gas (ABG) result is consistent with respiratory acidosis?
A. pH 7.48, PaCO₂ 30, HCO₃ 24
B. pH 7.30, PaCO₂ 55, HCO₃ 25
C. pH 7.35, PaCO₂ 40, HCO₃ 24
D. pH 7.50, PaCO₂ 25, HCO₃ 20
Answer:
,B. pH 7.30, PaCO₂ 55, HCO₃ 25
Rationale: Respiratory acidosis occurs when CO₂ is retained, leading to a low pH and
elevated PaCO₂.
3. Question:
The nurse is caring for a patient with a tracheostomy. Which action should be done
first if the patient suddenly cannot breathe and is cyanotic?
A. Call the rapid response team
B. Remove the inner cannula and suction
C. Administer oxygen via nasal cannula
D. Check the tracheostomy tube for obstruction
Answer:
D. Check the tracheostomy tube for obstruction
Rationale: The priority is to assess and clear the airway. If blocked, suctioning or tube
replacement may be needed immediately.
4. Question:
A nurse is educating a patient about the proper use of an incentive spirometer after
surgery. Which statement indicates correct understanding?
A. “I should blow forcefully into the mouthpiece.”
B. “I will inhale slowly and deeply through the mouthpiece.”
C. “I should use it only when I feel short of breath.”
D. “I will use the device once a day before bedtime.”
Answer:
B. “I will inhale slowly and deeply through the mouthpiece.”
Rationale: The incentive spirometer encourages deep inhalation to prevent
atelectasis and promote lung expansion.
,5. Question:
Which of the following are signs of tension pneumothorax? Select all that apply.
A. Tracheal deviation to the unaffected side
B. Hypotension
C. Bradycardia
D. Absent breath sounds on affected side
E. Distended neck veins
Answer:
A, B, D, E
Rationale: Classic signs of tension pneumothorax include tracheal deviation,
hypotension, absent breath sounds, and jugular vein distention. Tachycardia, not
bradycardia, is common.
Section 2: Cardiac & Perfusion
6. Question:
A patient with heart failure reports sudden weight gain of 5 pounds in two days.
Which action should the nurse take?
A. Reassure the patient this is normal
B. Assess for edema and lung crackles
C. Increase the patient’s fluid intake
D. Hold all medications until the provider is notified
Answer:
B. Assess for edema and lung crackles
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
Assess before notifying the provider.
, 7. Question:
Which ECG rhythm requires immediate defibrillation?
A. Atrial fibrillation
B. Ventricular fibrillation
C. Sinus tachycardia
D. First-degree heart block
Answer:
B. Ventricular fibrillation
Rationale: V-fib is a life-threatening arrhythmia and requires rapid defibrillation.
8. Question:
A patient with a history of DVT suddenly develops shortness of breath and chest
pain. What is the priority action?
A. Place the patient in Trendelenburg position
B. Administer prescribed anticoagulants
C. Elevate the head of the bed and apply oxygen
D. Encourage the patient to cough and deep breathe
Answer:
C. Elevate the head of the bed and apply oxygen
Rationale: These are classic signs of pulmonary embolism. Support oxygenation first,
then notify the provider.
9. Question:
The nurse is caring for a patient with a central venous catheter. Which finding
indicates possible catheter-related infection?
A. Pain at insertion site and fever
B. Clear drainage at insertion site
C. Flushed skin near insertion site
Health – Exam 1 Study
Guide
1. Question:
A patient with COPD is admitted with increased shortness of breath and a respiratory
rate of 30. Which nursing intervention is most appropriate?
A. Place the patient in supine position
B. Administer high-flow oxygen via non-rebreather mask
C. Position the patient in high Fowler’s and apply oxygen as ordered
D. Encourage the patient to increase fluid intake to 4 liters per day
Answer:
C. Position the patient in high Fowler’s and apply oxygen as ordered
Rationale: Upright positioning improves lung expansion and oxygen delivery. High-
flow O2 should be used cautiously in COPD to avoid suppressing the hypoxic drive.
2. Question:
Which arterial blood gas (ABG) result is consistent with respiratory acidosis?
A. pH 7.48, PaCO₂ 30, HCO₃ 24
B. pH 7.30, PaCO₂ 55, HCO₃ 25
C. pH 7.35, PaCO₂ 40, HCO₃ 24
D. pH 7.50, PaCO₂ 25, HCO₃ 20
Answer:
,B. pH 7.30, PaCO₂ 55, HCO₃ 25
Rationale: Respiratory acidosis occurs when CO₂ is retained, leading to a low pH and
elevated PaCO₂.
3. Question:
The nurse is caring for a patient with a tracheostomy. Which action should be done
first if the patient suddenly cannot breathe and is cyanotic?
A. Call the rapid response team
B. Remove the inner cannula and suction
C. Administer oxygen via nasal cannula
D. Check the tracheostomy tube for obstruction
Answer:
D. Check the tracheostomy tube for obstruction
Rationale: The priority is to assess and clear the airway. If blocked, suctioning or tube
replacement may be needed immediately.
4. Question:
A nurse is educating a patient about the proper use of an incentive spirometer after
surgery. Which statement indicates correct understanding?
A. “I should blow forcefully into the mouthpiece.”
B. “I will inhale slowly and deeply through the mouthpiece.”
C. “I should use it only when I feel short of breath.”
D. “I will use the device once a day before bedtime.”
Answer:
B. “I will inhale slowly and deeply through the mouthpiece.”
Rationale: The incentive spirometer encourages deep inhalation to prevent
atelectasis and promote lung expansion.
,5. Question:
Which of the following are signs of tension pneumothorax? Select all that apply.
A. Tracheal deviation to the unaffected side
B. Hypotension
C. Bradycardia
D. Absent breath sounds on affected side
E. Distended neck veins
Answer:
A, B, D, E
Rationale: Classic signs of tension pneumothorax include tracheal deviation,
hypotension, absent breath sounds, and jugular vein distention. Tachycardia, not
bradycardia, is common.
Section 2: Cardiac & Perfusion
6. Question:
A patient with heart failure reports sudden weight gain of 5 pounds in two days.
Which action should the nurse take?
A. Reassure the patient this is normal
B. Assess for edema and lung crackles
C. Increase the patient’s fluid intake
D. Hold all medications until the provider is notified
Answer:
B. Assess for edema and lung crackles
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
Assess before notifying the provider.
, 7. Question:
Which ECG rhythm requires immediate defibrillation?
A. Atrial fibrillation
B. Ventricular fibrillation
C. Sinus tachycardia
D. First-degree heart block
Answer:
B. Ventricular fibrillation
Rationale: V-fib is a life-threatening arrhythmia and requires rapid defibrillation.
8. Question:
A patient with a history of DVT suddenly develops shortness of breath and chest
pain. What is the priority action?
A. Place the patient in Trendelenburg position
B. Administer prescribed anticoagulants
C. Elevate the head of the bed and apply oxygen
D. Encourage the patient to cough and deep breathe
Answer:
C. Elevate the head of the bed and apply oxygen
Rationale: These are classic signs of pulmonary embolism. Support oxygenation first,
then notify the provider.
9. Question:
The nurse is caring for a patient with a central venous catheter. Which finding
indicates possible catheter-related infection?
A. Pain at insertion site and fever
B. Clear drainage at insertion site
C. Flushed skin near insertion site
