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NSG 2600/2610 – Adult Health Nursing Clinical Practicum
Questions And Correct Answers (Verified Answers) Plus
Rationales 2025 Q&A | Instant Download PDF
covering clinical judgment, prioritization, skills, pathophysiology, and safety
- A nurse is caring for a client post-abdominal surgery. Which assessment finding requires immediate action? a. Hypoactive bowel sounds b. Pain level of 5/ c. Firm, distended abdomen d. Serosanguinous drainage on dressing A firm, distended abdomen may indicate internal bleeding or paralytic ileus, requiring immediate intervention.
- A patient is receiving IV morphine. Which nursing action has the highest priority? a. Monitor for nausea b. Assess for itching c. Check respiratory rate d. Evaluate pain relief Opioids like morphine can cause respiratory depression, making respiratory assessment a priority.
- A nurse notes that a patient’s surgical wound has eviscerated. What is the priority nursing intervention?
a. Call the provider b. Apply a dry sterile dressing c. Cover the wound with sterile saline-soaked gauze d. Reinsert the organs gently Evisceration is a medical emergency; moist gauze helps prevent tissue drying and infection until surgery.
- A diabetic client with a foot ulcer should be instructed to: a. Soak feet daily b. Use heating pads c. Inspect feet daily d. Walk barefoot indoors Daily inspection helps detect early signs of infection or injury, preventing complications.
- A client with COPD is on 2L nasal cannula. Which assessment would prompt immediate action? a. O2 saturation of 91% b. Barrel chest c. Respiratory rate of 8/min d. Clubbed fingers A RR of 8/min indicates respiratory depression, which is life-threatening in a COPD patient.
- Which action should the nurse prioritize after a new central line is placed? a. Begin IV fluids b. Obtain chest x-ray
10.The nurse receives a lab result for a client on warfarin: INR 5.2. What action is most appropriate? a. Hold the next dose and notify provider b. Give vitamin K immediately c. Document the result d. Repeat the test INR above therapeutic range increases bleeding risk; notify provider for dose adjustment. 11.The nurse is assisting with thoracentesis. What is the proper patient position? a. Supine with head flat b. Left side-lying c. Sitting upright leaning over a bedside table d. High Fowler's with legs elevated This position allows better access to the pleural space and helps with fluid drainage. 12.Which finding requires urgent follow-up in a post-op client? a. Hemoglobin 12 g/dL b. 30 mL/hr urine output c. Sudden onset of chest pain and shortness of breath d. Pain 4/1 0 This may indicate a pulmonary embolism, a life-threatening complication.
13.Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)? a. Assessing IV site b. Assisting with ambulation c. Administering oral meds d. Teaching deep breathing exercises UAPs can assist with mobility under supervision, not assessment or medication. 14.Which nursing action helps prevent catheter-associated urinary tract infections (CAUTIs)? a. Maintain closed drainage system b. Flush the catheter daily c. Irrigate every shift d. Use antiseptic ointment at insertion site A closed system prevents contamination and lowers CAUTI risk. 15.A nurse caring for a stroke patient notes difficulty swallowing. What is the priority intervention? a. Elevate HOB 30° b. Keep patient NPO and notify provider c. Suction secretions d. Offer thickened liquids Keeping the client NPO prevents aspiration until a swallowing evaluation is done.
d. Bradycardia A positive Chvostek’s sign (facial twitching when cheek is tapped) indicates low calcium. 20.A nurse is changing a dressing on a client with MRSA. What PPE is necessary? a. Gown and gloves b. Gloves only c. Gown and mask d. Gloves and face shield Contact precautions for MRSA require gown and gloves. 21.A client with heart failure has gained 5 lbs in 2 days. What should the nurse do? a. Reassess in 24 hours b. Notify provider c. Encourage fluid intake d. Measure abdominal girth Rapid weight gain suggests fluid overload, needing prompt evaluation. 22.A nurse notes that a client has developed wheezing after antibiotic administration. What is the first action? a. Stop the infusion b. Notify pharmacy c. Check temperature
d. Reassure the client Wheezing may indicate anaphylaxis; stop the drug immediately. 23.A client newly diagnosed with diabetes asks how to avoid long-term complications. The best advice is: a. Reduce sugar completely b. Avoid all carbohydrates c. Maintain tight glucose control d. Take insulin only when symptomatic Tight glucose control slows the progression of complications. 24.A nurse preparing to administer a subcutaneous injection should: a. Use a 22-gauge, 1.5-inch needle b. Inject at a 90° angle in all clients c. Pinch the skin and inject at 45–90° d. Use Z-track method Subcutaneous injections are best delivered into pinched skin at 45–90°. 25.A post-op client complains of gas pain. What intervention is most effective? a. Encourage ambulation b. Provide ice chips c. Give laxative d. Offer heating pad Ambulation stimulates peristalsis and helps relieve gas pain. 26.A nurse is reinforcing teaching to a client with a new colostomy. Which statement indicates understanding?
b. Droplet precautions c. Handwashing with soap and water d. Negative pressure room Soap and water physically remove C. diff spores from the hands. 30.Which nursing action demonstrates safe use of restraints? a. Tie restraints to the bed rails b. Use PRN restraint orders c. Use the least restrictive restraint possible d. Leave the client unattended if sedated Nurses must use the least restrictive option to preserve dignity and safety. 31.A nurse is caring for a client with a chest tube. Which finding requires immediate action? a. Continuous bubbling in the water seal chamber b. Fluctuation in water level with breathing c. Serosanguinous drainage in collection chamber d. Occlusive dressing at insertion site Continuous bubbling in the water seal chamber suggests an air leak. 32.Which instruction is most important for a client using a metered-dose inhaler for asthma? a. Hold your breath after inhaling the medication b. Blow out rapidly after inhaling c. Inhale through the nose
d. Take multiple puffs without spacing Holding the breath helps the medication deposit in the lungs effectively. 33.A nurse is caring for a post-op patient at risk for DVT. What is the most effective preventive action? a. Use ice packs b. Massage the calves c. Encourage early ambulation d. Place pillows under the knees Ambulation promotes venous return and prevents clot formation. 34.A client with a sodium level of 125 mEq/L is at risk for which condition? a. Hypotension b. Muscle cramps c. Seizures d. Flushed skin Hyponatremia can lead to cerebral edema and seizures. 35.A nurse is caring for a client with a stage III pressure injury. What dressing type is most appropriate? a. Dry gauze b. Transparent film c. Hydrocolloid or foam d. Tegaderm These dressings promote moist healing and protect the wound.
d. BUN 18 Hypokalemia can cause cardiac dysrhythmias and needs urgent correction. 40.A client with chest pain is prescribed nitroglycerin. What is a priority nursing assessment? a. Temperature b. Urine output c. Blood pressure d. Respiratory rate Nitroglycerin causes vasodilation, which may lower blood pressure. 41.The nurse is reviewing discharge teaching for a client with heart failure. Which statement indicates understanding? a. "I should weigh myself weekly." b. "I’ll take NSAIDs for swelling." c. "I’ll call the provider if I gain 3 pounds in 2 days." d. "I can skip my diuretic if I feel dizzy." Rapid weight gain indicates fluid retention and requires intervention. 42.A client with cirrhosis is at risk for bleeding. Which lab supports this? a. Elevated ALT b. Prolonged PT c. Low BUN d. High platelets Cirrhosis impairs clotting factor production, leading to prolonged PT.
43.A diabetic client is diaphoretic and anxious. What is the nurse’s first action? a. Check blood glucose b. Notify provider c. Administer insulin d. Offer reassurance Always assess glucose levels first when hypoglycemia is suspected. 44.Which finding requires priority intervention during enteral feeding? a. Gastric residual of 400 mL b. Bowel sounds present c. pH of aspirate is 4 d. Tube is marked and secured High residuals increase the risk of aspiration and feeding intolerance. 45.A client with a head injury has a urine output of 1000 mL in 2 hours. What condition is suspected? a. UTI b. SIADH c. Diabetes insipidus d. Dehydration DI causes excessive dilute urine due to lack of ADH. 46.A nurse inserts an indwelling urinary catheter. Which action prevents infection? a. Maintain sterile technique during insertion b. Collect a routine sample from the drainage bag
a. Restrain the arms b. Protect the head and clear the area c. Insert oral airway d. Hold the legs Protecting the client from injury is the first priority. 51.A client with TB is being discharged. Which teaching point is essential? a. Avoid spicy foods b. Continue medications for the full duration c. Use oxygen at home d. Take antibiotics only when symptomatic TB treatment requires long-term therapy to prevent resistance. 52.Which assessment indicates dehydration in an older adult? a. Warm skin b. Moist mucous membranes c. Poor skin turgor and dry mouth d. Edema in lower extremities Classic signs of dehydration include dry mouth and decreased skin elasticity. 53.A client reports severe right lower quadrant pain and nausea. What is the priority intervention? a. Provide warm compress b. Administer laxatives c. Notify the provider immediately
d. Encourage fluids This may be appendicitis, requiring prompt surgical evaluation. 54.A nurse notices a new heart murmur in a client receiving IV antibiotics. What condition is suspected? a. Infective endocarditis b. Pericarditis c. Hypertension d. Aortic stenosis Infective endocarditis often causes new murmurs due to valve infection. 55.The nurse prepares to administer insulin to a client. What should be done first? a. Inject into the thigh b. Shake the insulin c. Check blood glucose d. Ask the client how they feel Always check glucose before giving insulin to avoid hypoglycemia. 56.A client newly diagnosed with hypertension asks how to manage it. What is the best response? a. "Drink more fluids." b. "Use salt liberally." c. "Exercise regularly and reduce sodium intake." d. "Limit potassium intake." Lifestyle changes including exercise and reduced sodium help control BP.
Allergic reactions are a potential adverse effect of antibiotics and must be monitored closely. 61.A client is receiving oxygen via nasal cannula at 4 L/min. What complication should the nurse monitor for? a. Hypercapnia b. Dry nasal mucosa c. Oxygen toxicity d. Bronchospasm Flow rates over 2 L/min can dry mucous membranes; humidification may be required. 62.A nurse notes swelling and coolness at a peripheral IV site. What is the best action? a. Increase the flow rate b. Apply a heating pad c. Stop the infusion and remove the IV d. Reposition the catheter Swelling and coolness indicate infiltration; the IV should be discontinued. 63.A client with asthma is prescribed albuterol. What is a common side effect to monitor? a. Bradycardia b. Tachycardia c. Hypertension
d. Hypokalemia Albuterol stimulates beta-2 receptors, which can increase heart rate. 64.Which symptom is a red flag in a patient with deep vein thrombosis (DVT)? a. Pain in the calf b. Swelling in one leg c. Sudden shortness of breath d. Warmth over the area This may indicate a pulmonary embolism, which is a medical emergency. 65.A nurse is preparing to discharge a client post-MI. Which instruction is most important? a. Eat a high-protein diet b. Enroll in a cardiac rehabilitation program c. Avoid all physical activity d. Monitor temperature daily Cardiac rehab improves outcomes by promoting exercise and education. 66.A nurse receives an order for vancomycin IV. Which lab value is essential to review? a. Hemoglobin b. Potassium c. Creatinine d. Platelets Vancomycin is nephrotoxic; renal function must be assessed before administration.
