NSG430 Final Exam Questions and Correct Answers
Question 1
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the patient's noninvasive cuff blood
pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intra-arterial catheter in the same arm is
assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments
Correct Answer
d. Frequent neurological assessments
Page 1 of 36
,Question 2
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 40% of his body surface
area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation
formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of
fluid in the first 24 hours?
Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
d. 11200 ml
Correct Answer
a. 14000 ml
Question 3
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury
Correct Answer
c. After the emergent phase of the injury
Page 2 of 36
,Question 4
After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess
first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
Correct Answer
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
Question 5
The charge nurse assigns patients based on their acuity and the level of experience of the critical care nurses on duty. This
is an example of implementation of:
Select one:
a. Healthy work environment
b. National patient safety goals
c. SBAR communication
d. Synergy model
Correct Answer
d. Synergy model
Page 3 of 36
, Question 6
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is
the best nursing action?
Select one:
a. Insert bilateral cotton nasal packing.
b. Have the patient blow the nose until clear.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears.
Correct Answer
c. Place a nasal drip pad under the nose.
Question 7
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly
but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses
a GCS score of 3. What is the priority nursing action?
Select one:
a. stimulate the patient hourly.
b. Notify the provider immediately.
c. Elevate the head of the bed.
d. Continue to monitor the patient.
Correct Answer
b. Notify the provider immediately.
Page 4 of 36
Question 1
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the patient's noninvasive cuff blood
pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intra-arterial catheter in the same arm is
assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments
Correct Answer
d. Frequent neurological assessments
Page 1 of 36
,Question 2
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 40% of his body surface
area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation
formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of
fluid in the first 24 hours?
Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
d. 11200 ml
Correct Answer
a. 14000 ml
Question 3
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury
Correct Answer
c. After the emergent phase of the injury
Page 2 of 36
,Question 4
After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess
first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
Correct Answer
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
Question 5
The charge nurse assigns patients based on their acuity and the level of experience of the critical care nurses on duty. This
is an example of implementation of:
Select one:
a. Healthy work environment
b. National patient safety goals
c. SBAR communication
d. Synergy model
Correct Answer
d. Synergy model
Page 3 of 36
, Question 6
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is
the best nursing action?
Select one:
a. Insert bilateral cotton nasal packing.
b. Have the patient blow the nose until clear.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears.
Correct Answer
c. Place a nasal drip pad under the nose.
Question 7
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly
but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses
a GCS score of 3. What is the priority nursing action?
Select one:
a. stimulate the patient hourly.
b. Notify the provider immediately.
c. Elevate the head of the bed.
d. Continue to monitor the patient.
Correct Answer
b. Notify the provider immediately.
Page 4 of 36
