NSG 320 EXAM 2
NSG Adult Health Nursing 320 Exam
Questions and Correct Answers Already
Graded A+ Brand New Version 2025
A client's arterial blood gas report indicates that pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20
mEq/L. Which client should the nurse consider is most likely to exhibit these results?
1. 54-year-old with vomiting
2. 17-year-old with panic attacks
3. 24-year-old with diabetic ketoacidosis
4. 65-year-old with advanced emphysema
- Correct Answer :3
The low pH and bicarbonate levels are consistent with metabolic acidosis, which can be caused
by excess ketones, a result of diabetic ketoacidosis. A 54-year-old with vomiting most likely will
experience metabolic alkalosis from loss of gastric hydrochloric acid. A 17-year-old with panic
attacks most likely will experience metabolic alkalosis from hyperventilation. A 65-year-old with
advanced emphysema most likely will experience respiratory acidosis.
How should the nurse monitor for the complication of subcutaneous emphysema after the
insertion of chest tubes?
1. Palpate around the tube insertion sites for crepitus.
2. Auscultate the breath sounds for crackles and rhonchi.
3. Observe the client for the presence of a barrel-shaped chest.
4. Compare the length of inspiration with the length of expiration.
A+ TEST BANK 1
, NSG 320 EXAM 2
- Correct Answer :1
Subcutaneous emphysema occurs when air leaks from the intrapleural space through the
thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard
when tissues containing gas are palpated. Crackles and rhonchi are unrelated to crepitus. They
occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client
for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli
associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of
inspiration with the length of expiration is unrelated to subcutaneous emphysema, which
involves gas in the soft tissues from a pleural leak.
After surgery a client's fever does not respond to antipyretics. The health care provider
prescribes that the client be placed on a hypothermia blanket. A response to hypothermia
therapy that the nurse should prevent is:
1. Shivering
2. Vomiting
3. Dehydration
4. Hypotension
- Correct Answer :1
Shivering should be prevented; peripheral vasoconstriction increases the temperature, the
circulatory rate, and oxygen consumption. Vomiting is not a response to hypothermia therapy.
Dehydration is not a response to hypothermia therapy; presence of a fever can cause
dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance.
Hypotension is not a response to hypothermia therapy; hypotension can occur with dehydration
if oral or parenteral fluid intake is inadequate to maintain fluid balance.
A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action
should the nurse take next?
1. Count the pulse at another site.
2. Notify the health care provider.
3. Lower the legs to increase blood flow.
4. Verify the pulse by using a Doppler.
A+ TEST BANK 2
, NSG 320 EXAM 2
- Correct Answer :4
Clients with venous insufficiency often have edema, which may make palpation of an arterial
pulse difficult. A Doppler uses sound waves so that the pulse can be heard. The quality of the
pedal pulse, not the rate, is assessed to determine the adequacy of peripheral arterial
circulation; the most distal site is preferred. The nurse must make other assessments of
circulation before notifying the health care provider. Lowering the legs will increase edema and
make palpation of pulses more difficult.
A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include
when responding to a family member's questions about the condition?
1. An irreversible phenomenon
2. A failure of the circulatory pump
3. Usually a fleeting reaction to tissue injury
4. Generally caused by decreased blood volume
- Correct Answer :2
Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but
always involves a drop in blood pressure and failure of the peripheral circulation because of
sympathetic nervous system involvement. In cardiogenic shock, the failure of peripheral
circulation is caused by the ineffective pumping action of the heart. Shock can be reversed by
the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to
tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is
not fleeting. Hypovolemia is only one cause.
For which expected response should the nurse monitor a client after a cardiac catheterization?
1. Marked increase in the volume of urine output
2. Decrease in blood pressure of 25% from the precatheterization blood pressure
3. Complaints of heart pounding with mild chest discomfort
4. Respiratory distress with an increase in respiratory rate more than 24 respirations per minute
- Correct Answer :1
A+ TEST BANK 3
, NSG 320 EXAM 2
There is increased urinary output as a result of the diuretic effect of the contrast medium. A
decrease of 10% to 20% is expected because of the diuretic effect of the contrast medium; a
decrease greater than 20% may be pathologic. Although heart pounding with mild chest
discomfort may occur during the procedure because of trauma to the conduction system, it
usually does not continue after the procedure. Respiratory distress may be an indication of a
pulmonary embolus from a venous clot and should be reported immediately.
Two portable drainage catheters with hemovacs attached were placed during a client's
hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the
nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. The
priority nursing intervention is to:
1. Turn the client onto the right side
2. Notify the health care provider immediately
3. Document the output as an expected finding
4. Irrigate the drainage catheter to ensure patency –
Correct Answer :2
Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this
amount of drainage should be reported. Placing the client in the side-lying position will have no
effect on the portable wound drainage system; it functions via negative pressure, not gravity.
Drainage of 180 mL in six hours is excessive and should be reported. It is unusual for drainage
catheters to need irrigation to remain patent. It is evident that the catheter is not obstructed.
A client has left ventricular heart failure. For which clinical indicators should the nurse assess the
client? Select all that apply.
1. Ascites
2. Crackles
3. Peripheral edema
4. Dyspnea on exertion
5. Jugular vein distention
- Correct Answer :2, 4
A+ TEST BANK 4
NSG Adult Health Nursing 320 Exam
Questions and Correct Answers Already
Graded A+ Brand New Version 2025
A client's arterial blood gas report indicates that pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20
mEq/L. Which client should the nurse consider is most likely to exhibit these results?
1. 54-year-old with vomiting
2. 17-year-old with panic attacks
3. 24-year-old with diabetic ketoacidosis
4. 65-year-old with advanced emphysema
- Correct Answer :3
The low pH and bicarbonate levels are consistent with metabolic acidosis, which can be caused
by excess ketones, a result of diabetic ketoacidosis. A 54-year-old with vomiting most likely will
experience metabolic alkalosis from loss of gastric hydrochloric acid. A 17-year-old with panic
attacks most likely will experience metabolic alkalosis from hyperventilation. A 65-year-old with
advanced emphysema most likely will experience respiratory acidosis.
How should the nurse monitor for the complication of subcutaneous emphysema after the
insertion of chest tubes?
1. Palpate around the tube insertion sites for crepitus.
2. Auscultate the breath sounds for crackles and rhonchi.
3. Observe the client for the presence of a barrel-shaped chest.
4. Compare the length of inspiration with the length of expiration.
A+ TEST BANK 1
, NSG 320 EXAM 2
- Correct Answer :1
Subcutaneous emphysema occurs when air leaks from the intrapleural space through the
thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard
when tissues containing gas are palpated. Crackles and rhonchi are unrelated to crepitus. They
occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client
for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli
associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of
inspiration with the length of expiration is unrelated to subcutaneous emphysema, which
involves gas in the soft tissues from a pleural leak.
After surgery a client's fever does not respond to antipyretics. The health care provider
prescribes that the client be placed on a hypothermia blanket. A response to hypothermia
therapy that the nurse should prevent is:
1. Shivering
2. Vomiting
3. Dehydration
4. Hypotension
- Correct Answer :1
Shivering should be prevented; peripheral vasoconstriction increases the temperature, the
circulatory rate, and oxygen consumption. Vomiting is not a response to hypothermia therapy.
Dehydration is not a response to hypothermia therapy; presence of a fever can cause
dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance.
Hypotension is not a response to hypothermia therapy; hypotension can occur with dehydration
if oral or parenteral fluid intake is inadequate to maintain fluid balance.
A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action
should the nurse take next?
1. Count the pulse at another site.
2. Notify the health care provider.
3. Lower the legs to increase blood flow.
4. Verify the pulse by using a Doppler.
A+ TEST BANK 2
, NSG 320 EXAM 2
- Correct Answer :4
Clients with venous insufficiency often have edema, which may make palpation of an arterial
pulse difficult. A Doppler uses sound waves so that the pulse can be heard. The quality of the
pedal pulse, not the rate, is assessed to determine the adequacy of peripheral arterial
circulation; the most distal site is preferred. The nurse must make other assessments of
circulation before notifying the health care provider. Lowering the legs will increase edema and
make palpation of pulses more difficult.
A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include
when responding to a family member's questions about the condition?
1. An irreversible phenomenon
2. A failure of the circulatory pump
3. Usually a fleeting reaction to tissue injury
4. Generally caused by decreased blood volume
- Correct Answer :2
Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but
always involves a drop in blood pressure and failure of the peripheral circulation because of
sympathetic nervous system involvement. In cardiogenic shock, the failure of peripheral
circulation is caused by the ineffective pumping action of the heart. Shock can be reversed by
the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to
tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is
not fleeting. Hypovolemia is only one cause.
For which expected response should the nurse monitor a client after a cardiac catheterization?
1. Marked increase in the volume of urine output
2. Decrease in blood pressure of 25% from the precatheterization blood pressure
3. Complaints of heart pounding with mild chest discomfort
4. Respiratory distress with an increase in respiratory rate more than 24 respirations per minute
- Correct Answer :1
A+ TEST BANK 3
, NSG 320 EXAM 2
There is increased urinary output as a result of the diuretic effect of the contrast medium. A
decrease of 10% to 20% is expected because of the diuretic effect of the contrast medium; a
decrease greater than 20% may be pathologic. Although heart pounding with mild chest
discomfort may occur during the procedure because of trauma to the conduction system, it
usually does not continue after the procedure. Respiratory distress may be an indication of a
pulmonary embolus from a venous clot and should be reported immediately.
Two portable drainage catheters with hemovacs attached were placed during a client's
hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the
nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. The
priority nursing intervention is to:
1. Turn the client onto the right side
2. Notify the health care provider immediately
3. Document the output as an expected finding
4. Irrigate the drainage catheter to ensure patency –
Correct Answer :2
Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this
amount of drainage should be reported. Placing the client in the side-lying position will have no
effect on the portable wound drainage system; it functions via negative pressure, not gravity.
Drainage of 180 mL in six hours is excessive and should be reported. It is unusual for drainage
catheters to need irrigation to remain patent. It is evident that the catheter is not obstructed.
A client has left ventricular heart failure. For which clinical indicators should the nurse assess the
client? Select all that apply.
1. Ascites
2. Crackles
3. Peripheral edema
4. Dyspnea on exertion
5. Jugular vein distention
- Correct Answer :2, 4
A+ TEST BANK 4
