RNSG 1517 Final Exam Questions and Correct
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client who has developed acute left-sided
heart failure. Which assessment finding is most concerning?
A. Dependent ankle edema
B. Weight gain of 1 kg in 24 hours
C. Crackles throughout both lung fields
D. Jugular venous distention
Answer: C. Crackles throughout both lung fields
Rationale: Crackles indicate pulmonary congestion caused by fluid
accumulation in the alveoli, which is a significant manifestation of left-
sided heart failure and can progress to pulmonary edema. Dependent
edema and jugular venous distention are more commonly associated
with right-sided heart failure. Rapid weight gain indicates fluid
retention but is not as immediately threatening as respiratory
compromise.
, 2. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which oxygen-delivery approach is
generally most appropriate?
A. High-flow oxygen at 15 L/min
B. Controlled low-flow oxygen as prescribed
C. Oxygen by nonrebreather mask at all times
D. No oxygen because oxygen suppresses respiratory drive
Answer: B. Controlled low-flow oxygen as prescribed
Rationale: Clients with COPD may require carefully titrated oxygen
therapy to improve oxygenation while avoiding excessive oxygen
administration. Oxygen should never be withheld when clinically
indicated. A prescribed target oxygen saturation and the client's overall
clinical condition should guide therapy.
3. A client with asthma suddenly develops severe dyspnea and has
very diminished breath sounds. What should the nurse recognize?
A. The client is improving
B. The bronchodilator is working effectively
C. The client may be experiencing severe airway obstruction
D. The client has developed pulmonary edema
Answer: C. The client may be experiencing severe airway obstruction
,Rationale: Markedly diminished or absent breath sounds in a client with
severe asthma can indicate critically reduced airflow. This finding can be
more concerning than audible wheezing because little air may be
moving through the airways. Immediate assessment and treatment are
required.
4. A nurse is caring for a client with pneumonia. Which finding
requires the most immediate intervention?
A. Temperature of 38.1°C (100.6°F)
B. Productive cough
C. Respiratory rate of 32/min with oxygen saturation of 86%
D. Fatigue with activity
Answer: C. Respiratory rate of 32/min with oxygen saturation of 86%
Rationale: Significant tachypnea accompanied by hypoxemia indicates
impaired oxygenation and possible respiratory deterioration. Airway
and breathing take priority according to the ABC framework. Fever,
cough, and fatigue are expected manifestations of pneumonia but are
less immediately threatening.
5. A client with pulmonary embolism suddenly reports sharp chest
pain and difficulty breathing. Which action should the nurse take
first?
, A. Encourage ambulation
B. Place the client in an appropriate position and administer prescribed
oxygen
C. Offer oral fluids
D. Obtain a routine dietary history
Answer: B. Place the client in an appropriate position and administer
prescribed oxygen
Rationale: Pulmonary embolism can cause acute impairment of
oxygenation. The nurse should immediately support airway and
breathing, including positioning and prescribed oxygen, while activating
appropriate emergency interventions and notifying the healthcare
team.
6. A nurse is assessing a client with diabetes mellitus. Which finding
is most consistent with hypoglycemia?
A. Warm, dry skin
B. Fruity breath odor
C. Tremors and diaphoresis
D. Deep, rapid respirations
Answer: C. Tremors and diaphoresis
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client who has developed acute left-sided
heart failure. Which assessment finding is most concerning?
A. Dependent ankle edema
B. Weight gain of 1 kg in 24 hours
C. Crackles throughout both lung fields
D. Jugular venous distention
Answer: C. Crackles throughout both lung fields
Rationale: Crackles indicate pulmonary congestion caused by fluid
accumulation in the alveoli, which is a significant manifestation of left-
sided heart failure and can progress to pulmonary edema. Dependent
edema and jugular venous distention are more commonly associated
with right-sided heart failure. Rapid weight gain indicates fluid
retention but is not as immediately threatening as respiratory
compromise.
, 2. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which oxygen-delivery approach is
generally most appropriate?
A. High-flow oxygen at 15 L/min
B. Controlled low-flow oxygen as prescribed
C. Oxygen by nonrebreather mask at all times
D. No oxygen because oxygen suppresses respiratory drive
Answer: B. Controlled low-flow oxygen as prescribed
Rationale: Clients with COPD may require carefully titrated oxygen
therapy to improve oxygenation while avoiding excessive oxygen
administration. Oxygen should never be withheld when clinically
indicated. A prescribed target oxygen saturation and the client's overall
clinical condition should guide therapy.
3. A client with asthma suddenly develops severe dyspnea and has
very diminished breath sounds. What should the nurse recognize?
A. The client is improving
B. The bronchodilator is working effectively
C. The client may be experiencing severe airway obstruction
D. The client has developed pulmonary edema
Answer: C. The client may be experiencing severe airway obstruction
,Rationale: Markedly diminished or absent breath sounds in a client with
severe asthma can indicate critically reduced airflow. This finding can be
more concerning than audible wheezing because little air may be
moving through the airways. Immediate assessment and treatment are
required.
4. A nurse is caring for a client with pneumonia. Which finding
requires the most immediate intervention?
A. Temperature of 38.1°C (100.6°F)
B. Productive cough
C. Respiratory rate of 32/min with oxygen saturation of 86%
D. Fatigue with activity
Answer: C. Respiratory rate of 32/min with oxygen saturation of 86%
Rationale: Significant tachypnea accompanied by hypoxemia indicates
impaired oxygenation and possible respiratory deterioration. Airway
and breathing take priority according to the ABC framework. Fever,
cough, and fatigue are expected manifestations of pneumonia but are
less immediately threatening.
5. A client with pulmonary embolism suddenly reports sharp chest
pain and difficulty breathing. Which action should the nurse take
first?
, A. Encourage ambulation
B. Place the client in an appropriate position and administer prescribed
oxygen
C. Offer oral fluids
D. Obtain a routine dietary history
Answer: B. Place the client in an appropriate position and administer
prescribed oxygen
Rationale: Pulmonary embolism can cause acute impairment of
oxygenation. The nurse should immediately support airway and
breathing, including positioning and prescribed oxygen, while activating
appropriate emergency interventions and notifying the healthcare
team.
6. A nurse is assessing a client with diabetes mellitus. Which finding
is most consistent with hypoglycemia?
A. Warm, dry skin
B. Fruity breath odor
C. Tremors and diaphoresis
D. Deep, rapid respirations
Answer: C. Tremors and diaphoresis
