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BSN NSG 4513 Adult Health III – Cumulative Final Questions And Correct Answers (Verified A, Exams of Nursing

South CollegeNursing

BSN NSG 4513 Adult Health III – Cumulative Final Questions And Correct Answers (Verified Answers) Plus Rationales 2025 Q&A | Instant Download PDF

Typology: Exams

2024/2025

Available from 07/11/2025

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BSN NSG 4513 Adult Health III – Cumulative Final
Questions And Correct Answers (Verified Answers) Plus
Rationales 2025 Q&A | Instant Download PDF
1. A client with cirrhosis is scheduled for a paracentesis. Which assessment
finding requires immediate intervention?
• Skin turgor is poor
• Respiratory rate is 32/min
• Urine output is 40 mL/hour
• Abdomen is distended
A high respiratory rate may indicate respiratory distress due to pressure from
ascites; this is a priority.
2. A client with a spinal cord injury at T4 experiences sudden hypertension
and a pounding headache. What should the nurse do first?
• Notify the physician
• Raise the head of the bed
• Administer antihypertensives
• Check blood glucose level
Raising the head of the bed helps reduce intracranial pressure in autonomic
dysreflexia, a medical emergency.
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Download BSN NSG 4513 Adult Health III – Cumulative Final Questions And Correct Answers (Verified A and more Exams Nursing in PDF only on Docsity!

BSN NSG 4513 Adult Health III – Cumulative Final

Questions And Correct Answers (Verified Answers) Plus

Rationales 2025 Q&A | Instant Download PDF

  1. A client with cirrhosis is scheduled for a paracentesis. Which assessment finding requires immediate intervention?
  • Skin turgor is poor
  • Respiratory rate is 32/min
  • Urine output is 40 mL/hour
  • Abdomen is distended A high respiratory rate may indicate respiratory distress due to pressure from ascites; this is a priority.
  1. A client with a spinal cord injury at T4 experiences sudden hypertension and a pounding headache. What should the nurse do first?
  • Notify the physician
  • Raise the head of the bed
  • Administer antihypertensives
  • Check blood glucose level Raising the head of the bed helps reduce intracranial pressure in autonomic dysreflexia, a medical emergency.
  1. A client is admitted with suspected meningitis. Which action should the nurse take first?
  • Administer IV fluids
  • Start antibiotics
  • Initiate droplet precautions
  • Perform neurological checks Precautions prevent the spread of infection before diagnosis confirmation.
  1. The nurse prepares to administer digoxin to a client with heart failure. Which finding is most concerning?
  • Potassium level 2.9 mEq/L
  • BP 140/88 mmHg
  • Heart rate 62 bpm
  • Oxygen saturation 94% Hypokalemia increases the risk of digoxin toxicity and must be corrected first.
  1. A client with COPD is receiving oxygen at 4 L/min via nasal cannula. The client becomes drowsy and confused. What should the nurse do?
  • Increase the oxygen flow rate
  • Lower the oxygen to 2 L/min
  • Notify the physician
  • Place the client in Trendelenburg position
  • A client post-appendectomy
  • A client with a femur fracture Long bone fractures increase the risk for fat embolism, a form of PE.
  1. A client with type 2 diabetes has a glucose level of 45 mg/dL. What is the nurse’s first action?
  • Recheck glucose in 15 minutes
  • Call the provider
  • Give 15 g of fast-acting carbohydrate
  • Administer glucagon IM Immediate treatment is required for hypoglycemia to prevent seizures or coma. 10.A client with heart failure reports a 5-lb weight gain in 2 days. What is the best nursing action?
  • Assess for edema and lung sounds
  • Restrict potassium
  • Encourage fluid intake
  • Notify dietary Rapid weight gain may indicate fluid overload and worsening heart failure. 11.What is the nurse’s best response to a client with cancer who asks about hospice care?
  • “It focuses on curing your disease.”
  • “You can’t receive treatment while in hospice.”
  • “Hospice provides comfort and support at end of life.”
  • “You must be in the hospital to receive hospice.” Hospice emphasizes quality of life and symptom management at the end of life. 12.What is a priority goal for a client with a spinal cord injury at C6?
  • Maintain patent airway
  • Provide emotional support
  • Assist with ambulation
  • Prevent skin breakdown Airway management is always the top priority, especially with high spinal cord injuries. 13.The nurse suspects hypovolemic shock in a trauma patient. Which finding confirms this suspicion?
  • Bounding pulses
  • Cool, clammy skin
  • Bradycardia
  • Hypertension Cool, clammy skin is a classic sign due to vasoconstriction and poor perfusion. 14.A client post-thyroidectomy reports tingling around the lips. What does this indicate?
  • Hypocalcemia
  • Hypernatremia
  • pH 7.
  • Potassium 2.8 mEq/L Correcting hypokalemia is essential before giving insulin to avoid life- threatening arrhythmias. 18.A client with a bowel obstruction reports sudden abdominal pain and stops passing gas. What should the nurse do?
  • Notify the physician immediately
  • Administer an antacid
  • Give a laxative
  • Increase IV fluids This may signal bowel perforation or strangulation, requiring emergency surgery. 19.Which ECG change indicates hyperkalemia?
  • ST depression
  • Tall peaked T waves
  • U waves
  • Prolonged QT interval Tall T waves are a hallmark sign of elevated serum potassium. 20.A client with cirrhosis is vomiting blood. What is the nurse’s first priority?
  • Insert an NG tube
  • Assess airway and vital signs
  • Prepare for surgery
  • Give IV vitamin K Bleeding varices can compromise airway and cause hypovolemic shock. 21.A client with advanced liver disease has a serum ammonia level of 110 mcg/dL. Which nursing intervention is priority?
  • Assess level of consciousness
  • Encourage high-protein diet
  • Administer IV potassium
  • Place in Trendelenburg position Elevated ammonia affects brain function, leading to hepatic encephalopathy; neurological checks are priority. 22.A client with chronic kidney disease is prescribed erythropoietin. Which finding indicates effectiveness?
  • Increased hemoglobin levels
  • Decreased creatinine
  • Increased urine output
  • Decreased serum potassium Erythropoietin stimulates red blood cell production to treat anemia in CKD. 23.Which nursing intervention is essential when caring for a client with a cervical spine injury?
  • Encourage fluid intake
  • Assess for signs of bleeding
  • Provide a low-fat diet Bleeding is the major complication following thrombolytic therapy. 27.A client develops chest pain during hemodialysis. What should the nurse do first?
  • Increase dialysate flow
  • Administer antihypertensives
  • Stop dialysis and assess the client
  • Give sodium bicarbonate Chest pain could indicate dialysis-related complications or cardiac events. Stop and assess. 28.What is the most important teaching point for a client newly diagnosed with Addison’s disease?
  • Increase potassium intake
  • Take corticosteroids daily as prescribed
  • Avoid sodium
  • Take insulin before meals Lifelong corticosteroid replacement is essential for survival in Addison’s disease. 29.Which finding is expected in a client with peritonitis?
  • Hyperactive bowel sounds
  • Soft, non-tender abdomen
  • Board-like abdominal rigidity
  • Bradycardia Board-like rigidity and pain are hallmark signs of peritoneal inflammation. 30.A client develops a high-pressure alarm on the ventilator. What should the nurse assess first?
  • Check for kinks or obstructions in tubing
  • Increase the oxygen concentration
  • Silence the alarm
  • Call respiratory therapy High-pressure alarms often indicate resistance or obstruction in the ventilator circuit. 31.What indicates that treatment for status epilepticus is effective?
  • Seizure activity stops
  • Oxygen saturation increases to 96%
  • Pupils are reactive to light
  • Blood pressure normalizes The goal of status epilepticus treatment is to stop continuous seizure activity. 32.A client is diagnosed with Guillain-Barré Syndrome. What is the priority assessment?
  • Muscle spasms

35.Which client behavior indicates a need for further teaching about warfarin (Coumadin)?

  • Uses a soft toothbrush
  • Eats large amounts of spinach
  • Wears a medic alert bracelet
  • Gets INR checked regularly Vitamin K (in spinach) counteracts warfarin’s effects and should be limited. 36.What is the primary concern for a client with newly diagnosed multiple sclerosis (MS)?
  • Constipation
  • Risk for injury from weakness or spasticity
  • Hyperactivity
  • Excess energy Weakness, muscle spasms, and poor coordination put MS clients at risk for falls. 37.A client with a history of seizures is postictal and confused. What should the nurse do first?
  • Administer lorazepam
  • Reorient and provide a safe environment
  • Call the provider
  • Document seizure type During the postictal phase, ensuring safety and reorientation is the priority.

38.Which symptom suggests a client with a mechanical mitral valve is experiencing a complication?

  • Heart rate of 82 bpm
  • Fatigue
  • Sudden shortness of breath and hemoptysis
  • Occasional palpitations These symptoms may indicate valve thrombosis or embolism, which is life- threatening. 39.The nurse is caring for a client who received radiation to the neck. Which assessment is most important?
  • Nutritional intake
  • Airway patency
  • Skin breakdown
  • Daily weights Radiation to the neck can cause edema or scarring, compromising the airway. 40.What is the best action if a client receiving blood transfusion reports chills and back pain?
  • Slow the infusion
  • Stop the transfusion immediately
  • Check the blood pressure
  • Apply warm compresses
  • Give insulin stat
  • Encourage a low-sugar diet Hyperglycemia is an expected finding in Cushing’s due to cortisol excess. 44.The nurse is caring for a client after thyroid surgery. Which is the most concerning assessment?
  • Hoarseness
  • Nausea
  • Stridor and difficulty breathing
  • Incisional pain Stridor signals airway obstruction and requires emergency intervention. 45.What is the best action for a nurse caring for a client with end-stage renal disease and a potassium level of 6.8 mEq/L?
  • Notify provider immediately
  • Restrict sodium
  • Monitor for fatigue
  • Encourage fluid intake Severely elevated potassium is life-threatening and must be addressed quickly. 46.A client with advanced cancer is in hospice. They become nonresponsive, with noisy respirations. What should the nurse do?
  • Provide comfort care and reposition
  • Administer naloxone
  • Increase IV fluids
  • Call the provider Noisy respirations are common in dying clients; comfort care is appropriate. 47.Which assessment finding in a client with diabetes insipidus requires urgent action?
  • Polyuria
  • Polydipsia
  • Serum sodium of 156 mEq/L
  • Urine specific gravity of 1. Hypernatremia can lead to neurological complications; it must be corrected promptly. 48.A client reports vision changes after starting ethambutol for TB. What should the nurse do?
  • Encourage hydration
  • Hold the medication and notify the provider
  • Document the finding
  • Administer eye drops Ethambutol can cause optic neuritis; early detection prevents permanent damage. 49.A client with a brain tumor develops bradycardia, widened pulse pressure, and irregular respirations. What is this?

52.A client receiving IV vancomycin develops flushing and hypotension. What is the likely cause?

  • Anaphylaxis
  • Red man syndrome
  • Sepsis
  • Vasovagal reaction Red man syndrome is a reaction to rapid vancomycin infusion; slow the rate and monitor. 53.What is the priority action for a client with a suspected ischemic stroke?
  • Administer aspirin
  • Obtain a non-contrast CT scan
  • Start IV fluids
  • Give supplemental oxygen A CT scan rules out hemorrhagic stroke before thrombolytic therapy can be started. 54.A client on a telemetry unit suddenly shows asystole. What is the nurse’s first response?
  • Administer epinephrine
  • Check the code cart
  • Assess the client
  • Begin compressions

Always verify asystole with client assessment before initiating emergency measures. 55.Which lab value should the nurse monitor in a client receiving heparin?

  • INR
  • Platelets
  • aPTT
  • Hemoglobin aPTT is used to monitor therapeutic response to heparin. 56.A client with severe burns is admitted. What is the nurse’s priority during the first 24 hours?
  • Wound care
  • Nutritional support
  • Fluid resuscitation
  • Pain management Fluid shifts cause hypovolemia in burn clients; early resuscitation is critical. 57.Which is the most serious complication of atrial fibrillation?
  • Dehydration
  • Embolic stroke
  • Dizziness
  • Bradycardia Irregular atrial activity increases the risk for clot formation and stroke.