NSG 3250 Exam and answers. Fina
1. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with a tidal volume of 6 mL/kg ideal body weight and positive end-expiratory pressure (PEEP) of
10 cm H2O. The plateau pressure is 28 cm H2O, and the partial pressure of arterial oxygen (PaO2)
is 65 mm Hg on an FiO2 of 0.6. Which intervention should the nurse anticipate to improve
oxygenation while minimizing ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg
B. Decrease PEEP to 5 cm H2O
C. Increase PEEP to 14 cm H2O and monitor plateau pressure
D. Switch to pressure-controlled ventilation with a peak pressure of 35 cm H2O
Answer: C
Rationale: In ARDS, lung-protective ventilation uses low tidal volumes (6 mL/kg) and moderate to high
PEEP to recruit alveoli and improve oxygenation. Increasing PEEP to 14 cm H2O can enhance
oxygenation by increasing mean airway pressure and recruiting collapsed alveoli, provided plateau
pressure remains 30 cm H2O. Option A would increase volutrauma. Option B would worsen
derecruitment. Option D could increase risk of barotrauma if peak pressures are high.
2. A patient with chronic kidney disease stage 4 (eGFR 25 mL/min/1.73m²) is prescribed lisinopril
10 mg daily for hypertension. Which laboratory value most warrants immediate nursing action?
A. Serum potassium 5.8 mEq/L
B. Serum creatinine 2.5 mg/dL (baseline 2.2)
C. Blood urea nitrogen 45 mg/dL
D. Hemoglobin 10.5 g/dL
Answer: A
Rationale: ACE inhibitors like lisinopril can cause hyperkalemia, especially in advanced CKD. A
potassium of 5.8 mEq/L is critically elevated and increases risk of cardiac arrhythmias. While a rise in
creatinine (option B) is important, it is typically monitored and may be acceptable if <30% from
baseline. BUN and hemoglobin levels are not immediately life-threatening. The nurse should hold the
medication and notify the provider.
3. A patient with a subarachnoid hemorrhage from a ruptured aneurysm develops hyponatremia
(serum sodium 125 mEq/L), polyuria (urine output 250 mL/hour), and elevated urine sodium (150
mEq/L). Which condition is most likely, and what is the priority intervention?
A. Syndrome of inappropriate antidiuretic hormone (SIADH); fluid restriction
B. Cerebral salt wasting (CSW); isotonic saline replacement
C. Diabetes insipidus; desmopressin administration
D. Acute kidney injury; hemodialysis
Answer: B
Page 1
,Rationale: After subarachnoid hemorrhage, cerebral salt wasting (CSW) is characterized by hyponatremia, high urine
output, and high urine sodium due to natriuretic peptide release. Unlike SIADH, CSW involves volume depletion, so
treatment is isotonic saline replacement to maintain euvolemia. Fluid restriction (option A) would worsen hypovolemia and
increase risk of vasospasm. Diabetes insipidus (option C) would have low urine sodium. Acute kidney injury (option D) would
not present with high urine sodium and polyuria.
4. A patient with heart failure with reduced ejection fraction (HFrEF, LVEF 30%) is admitted with
acute decompensation. The nurse administers furosemide 80 mg IV. One hour later, the patient's
urine output is 50 mL. The patient's blood pressure is 90/58 mm Hg, heart rate 110 bpm, and
respiratory rate 24/min. Which action should the nurse take first?
A. Administer a second dose of furosemide 80 mg IV
B. Start a dopamine infusion at 5 mcg/kg/min
C. Assess for signs of hypoperfusion and notify the provider
D. Increase the intravenous fluids to 250 mL/hr
Answer: C
Rationale: The patient's poor urine output after furosemide, combined with hypotension and tachycardia,
suggests low cardiac output and possible cardiogenic shock. The priority is to assess for end-organ
hypoperfusion (altered mental status, cool extremities, decreased capillary refill) and notify the provider
for further orders (e.g., inotropes, vasopressors). Administering more furosemide (option A) could
worsen hypotension. Dopamine (option B) may be considered but only after assessment. IV fluids (option
D) are generally avoided in acute decompensated HF with pulmonary congestion.
5. A patient with type 2 diabetes mellitus is admitted for management of a diabetic foot ulcer. The
provider orders sliding scale insulin lispro before meals and a continuous insulin infusion of 2
units/hour. The patient's blood glucose at 0700 is 180 mg/dL. At 0730, the patient is taken to the
operating room for wound debridement. Which action should the nurse prioritize?
A. Hold the insulin infusion and administer the sliding scale dose
B. Continue the insulin infusion and hold the sliding scale dose
C. Administer both the infusion and sliding scale dose
D. Discontinue the infusion and start a different insulin regimen
Answer: B
Rationale: Continuous insulin infusion provides basal coverage and is essential during surgery to prevent
hyperglycemia and diabetic ketoacidosis. The sliding scale insulin lispro is for prandial coverage and
should be held because the patient is NPO for surgery. Administering both (option C) would risk
hypoglycemia. Holding the infusion (option A) would lead to inadequate insulin during surgery. The
infusion should be continued, and blood glucose monitored closely.
6. A patient with cirrhosis and ascites develops acute onset of confusion, asterixis, and a serum
ammonia level of 120 mcg/dL. The nurse administers lactulose 30 mL orally. Which finding
indicates a therapeutic response to lactulose?
A. Serum ammonia level decreases to 80 mcg/dL
B. Patient has two to three loose stools per day
C. Asterixis resolves and mental status improves
Page 2
,D. Abdominal girth decreases by 2 cm
Answer: C
Rationale: The goal of lactulose therapy in hepatic encephalopathy is to reduce ammonia absorption by
acidifying the colon, leading to ammonia trapping in stool. Clinical improvement (resolution of
asterixis, improved mental status) is the most direct indicator of therapeutic response. While a decrease
in ammonia (option A) is expected, it correlates imperfectly with clinical status. Lactulose should
produce 2-3 soft stools per day (option B), but that is a means to an end, not the goal itself. Decreased
abdominal girth (option D) reflects ascites management, not encephalopathy.
7. A patient is receiving a transfusion of packed red blood cells. Fifteen minutes after initiation, the
patient develops chills, rigors, and a temperature of 38.9°C (102°F). The nurse notes the patient's
blood pressure is 100/60 mm Hg (baseline 130/80) and heart rate is 110 bpm. What is the nurse's
priority action?
A. Slow the transfusion rate and administer acetaminophen
B. Stop the transfusion and maintain IV access with normal saline
C. Continue the transfusion and notify the provider
D. Administer diphenhydramine and continue the transfusion
Answer: B
Rationale: These signs (fever, chills, hypotension, tachycardia) suggest an acute hemolytic or febrile
non-hemolytic transfusion reaction. The priority is to stop the transfusion immediately to prevent further
infusion of incompatible blood products. Maintaining IV access with normal saline is crucial for
potential resuscitation. Slowing the transfusion (option A) or continuing (option C) could worsen the
reaction. Antipyretics (option A) or antihistamines (option D) may be used after stopping, but are not the
first action.
8. A patient with acute pancreatitis has a nasogastric tube to low intermittent suction. The nurse
assesses the patient and notes absent bowel sounds, abdominal distention, and a serum calcium
level of 7.2 mg/dL. Which complication should the nurse suspect?
A. Hypocalcemia due to saponification
B. Paralytic ileus due to peritonitis
C. Acute respiratory distress syndrome
D. Pancreatic pseudocyst formation
Answer: A
Rationale: In acute pancreatitis, hypocalcemia can occur due to saponification (calcium binding with
free fatty acids in necrotic fat) and is a marker of severe disease. Absent bowel sounds and distention are
common in pancreatitis due to ileus, but the specific finding of hypocalcemia points to saponification.
Paralytic ileus (option B) is a general complication, but the calcium level is the key. ARDS (option C)
would present with respiratory symptoms. Pseudocyst (option D) typically develops weeks later.
9. A patient with a history of intravenous drug use presents with fever, chills, and a new onset of a
loud, holosystolic murmur heard best at the apex. Blood cultures are positive for Staphylococcus
aureus. Which valvular abnormality is most likely, and what is the priority nursing intervention?
Page 3
, A. Aortic stenosis; prepare for valve replacement
B. Mitral regurgitation due to infective endocarditis; administer IV antibiotics
C. Tricuspid regurgitation; administer diuretics
D. Mitral stenosis; administer anticoagulation
Answer: B
Rationale: In intravenous drug users, infective endocarditis commonly affects the tricuspid valve, but a
holosystolic murmur at the apex is characteristic of mitral regurgitation. The loud murmur suggests
acute severe regurgitation. The priority is to initiate IV antibiotics as soon as possible after blood
cultures are obtained. Valve replacement (option A) may be considered later if medical therapy fails.
Diuretics (option C) and anticoagulation (option D) are not first-line treatments for acute infective
endocarditis.
10. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) monitor in
place. The ICP is 22 mm Hg, and the mean arterial pressure (MAP) is 70 mm Hg. The nurse
calculates the cerebral perfusion pressure (CPP). Which nursing action is most appropriate?
A. Administer mannitol 0.5 g/kg IV
B. Increase the head of bed to 45 degrees
C. Administer a bolus of isotonic saline
D. Sedate the patient with propofol
Answer: C
Rationale: CPP = MAP - ICP. Here CPP = 70 - 22 = 48 mm Hg, which is below the target of 60-70 mm
Hg. To improve CPP, the nurse should first increase MAP by administering a fluid bolus (isotonic saline)
to support blood pressure. Mannitol (option A) lowers ICP but could cause hypotension if volume
depleted. Elevating the head (option B) may help reduce ICP but does not address low MAP. Sedation
(option D) may lower ICP but also can lower MAP. The immediate priority is to improve cerebral
perfusion.
11. In a patient with acute decompensated heart failure, which combination of hemodynamic
parameters would most reliably indicate the need for inotropic support rather than vasodilator
therapy alone?
A. Cardiac index 2.8 L/min/m², pulmonary capillary wedge pressure 22 mm Hg, systemic vascular resistance
1400 dyn-s/cm
B. Cardiac index 1.8 L/min/m², pulmonary capillary wedge pressure 28 mm Hg, systemic vascular resistance
1200 dyn-s/cm
C. Cardiac index 2.2 L/min/m², pulmonary capillary wedge pressure 18 mm Hg, systemic vascular resistance
900 dyn-s/cm
D. Cardiac index 3.0 L/min/m², pulmonary capillary wedge pressure 16 mm Hg, systemic vascular resistance
1100 dyn-s/cm
Answer: B
Rationale: Inotropic support is indicated for low cardiac output (CI < 2.2) with elevated filling pressures
(PCWP > 18) and normal or high SVR. Option B shows low CI and high PCWP, consistent with
cardiogenic shock requiring inotropes. Option A has adequate CI, and options C and D have
near-normal parameters.
Page 4
1. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with a tidal volume of 6 mL/kg ideal body weight and positive end-expiratory pressure (PEEP) of
10 cm H2O. The plateau pressure is 28 cm H2O, and the partial pressure of arterial oxygen (PaO2)
is 65 mm Hg on an FiO2 of 0.6. Which intervention should the nurse anticipate to improve
oxygenation while minimizing ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg
B. Decrease PEEP to 5 cm H2O
C. Increase PEEP to 14 cm H2O and monitor plateau pressure
D. Switch to pressure-controlled ventilation with a peak pressure of 35 cm H2O
Answer: C
Rationale: In ARDS, lung-protective ventilation uses low tidal volumes (6 mL/kg) and moderate to high
PEEP to recruit alveoli and improve oxygenation. Increasing PEEP to 14 cm H2O can enhance
oxygenation by increasing mean airway pressure and recruiting collapsed alveoli, provided plateau
pressure remains 30 cm H2O. Option A would increase volutrauma. Option B would worsen
derecruitment. Option D could increase risk of barotrauma if peak pressures are high.
2. A patient with chronic kidney disease stage 4 (eGFR 25 mL/min/1.73m²) is prescribed lisinopril
10 mg daily for hypertension. Which laboratory value most warrants immediate nursing action?
A. Serum potassium 5.8 mEq/L
B. Serum creatinine 2.5 mg/dL (baseline 2.2)
C. Blood urea nitrogen 45 mg/dL
D. Hemoglobin 10.5 g/dL
Answer: A
Rationale: ACE inhibitors like lisinopril can cause hyperkalemia, especially in advanced CKD. A
potassium of 5.8 mEq/L is critically elevated and increases risk of cardiac arrhythmias. While a rise in
creatinine (option B) is important, it is typically monitored and may be acceptable if <30% from
baseline. BUN and hemoglobin levels are not immediately life-threatening. The nurse should hold the
medication and notify the provider.
3. A patient with a subarachnoid hemorrhage from a ruptured aneurysm develops hyponatremia
(serum sodium 125 mEq/L), polyuria (urine output 250 mL/hour), and elevated urine sodium (150
mEq/L). Which condition is most likely, and what is the priority intervention?
A. Syndrome of inappropriate antidiuretic hormone (SIADH); fluid restriction
B. Cerebral salt wasting (CSW); isotonic saline replacement
C. Diabetes insipidus; desmopressin administration
D. Acute kidney injury; hemodialysis
Answer: B
Page 1
,Rationale: After subarachnoid hemorrhage, cerebral salt wasting (CSW) is characterized by hyponatremia, high urine
output, and high urine sodium due to natriuretic peptide release. Unlike SIADH, CSW involves volume depletion, so
treatment is isotonic saline replacement to maintain euvolemia. Fluid restriction (option A) would worsen hypovolemia and
increase risk of vasospasm. Diabetes insipidus (option C) would have low urine sodium. Acute kidney injury (option D) would
not present with high urine sodium and polyuria.
4. A patient with heart failure with reduced ejection fraction (HFrEF, LVEF 30%) is admitted with
acute decompensation. The nurse administers furosemide 80 mg IV. One hour later, the patient's
urine output is 50 mL. The patient's blood pressure is 90/58 mm Hg, heart rate 110 bpm, and
respiratory rate 24/min. Which action should the nurse take first?
A. Administer a second dose of furosemide 80 mg IV
B. Start a dopamine infusion at 5 mcg/kg/min
C. Assess for signs of hypoperfusion and notify the provider
D. Increase the intravenous fluids to 250 mL/hr
Answer: C
Rationale: The patient's poor urine output after furosemide, combined with hypotension and tachycardia,
suggests low cardiac output and possible cardiogenic shock. The priority is to assess for end-organ
hypoperfusion (altered mental status, cool extremities, decreased capillary refill) and notify the provider
for further orders (e.g., inotropes, vasopressors). Administering more furosemide (option A) could
worsen hypotension. Dopamine (option B) may be considered but only after assessment. IV fluids (option
D) are generally avoided in acute decompensated HF with pulmonary congestion.
5. A patient with type 2 diabetes mellitus is admitted for management of a diabetic foot ulcer. The
provider orders sliding scale insulin lispro before meals and a continuous insulin infusion of 2
units/hour. The patient's blood glucose at 0700 is 180 mg/dL. At 0730, the patient is taken to the
operating room for wound debridement. Which action should the nurse prioritize?
A. Hold the insulin infusion and administer the sliding scale dose
B. Continue the insulin infusion and hold the sliding scale dose
C. Administer both the infusion and sliding scale dose
D. Discontinue the infusion and start a different insulin regimen
Answer: B
Rationale: Continuous insulin infusion provides basal coverage and is essential during surgery to prevent
hyperglycemia and diabetic ketoacidosis. The sliding scale insulin lispro is for prandial coverage and
should be held because the patient is NPO for surgery. Administering both (option C) would risk
hypoglycemia. Holding the infusion (option A) would lead to inadequate insulin during surgery. The
infusion should be continued, and blood glucose monitored closely.
6. A patient with cirrhosis and ascites develops acute onset of confusion, asterixis, and a serum
ammonia level of 120 mcg/dL. The nurse administers lactulose 30 mL orally. Which finding
indicates a therapeutic response to lactulose?
A. Serum ammonia level decreases to 80 mcg/dL
B. Patient has two to three loose stools per day
C. Asterixis resolves and mental status improves
Page 2
,D. Abdominal girth decreases by 2 cm
Answer: C
Rationale: The goal of lactulose therapy in hepatic encephalopathy is to reduce ammonia absorption by
acidifying the colon, leading to ammonia trapping in stool. Clinical improvement (resolution of
asterixis, improved mental status) is the most direct indicator of therapeutic response. While a decrease
in ammonia (option A) is expected, it correlates imperfectly with clinical status. Lactulose should
produce 2-3 soft stools per day (option B), but that is a means to an end, not the goal itself. Decreased
abdominal girth (option D) reflects ascites management, not encephalopathy.
7. A patient is receiving a transfusion of packed red blood cells. Fifteen minutes after initiation, the
patient develops chills, rigors, and a temperature of 38.9°C (102°F). The nurse notes the patient's
blood pressure is 100/60 mm Hg (baseline 130/80) and heart rate is 110 bpm. What is the nurse's
priority action?
A. Slow the transfusion rate and administer acetaminophen
B. Stop the transfusion and maintain IV access with normal saline
C. Continue the transfusion and notify the provider
D. Administer diphenhydramine and continue the transfusion
Answer: B
Rationale: These signs (fever, chills, hypotension, tachycardia) suggest an acute hemolytic or febrile
non-hemolytic transfusion reaction. The priority is to stop the transfusion immediately to prevent further
infusion of incompatible blood products. Maintaining IV access with normal saline is crucial for
potential resuscitation. Slowing the transfusion (option A) or continuing (option C) could worsen the
reaction. Antipyretics (option A) or antihistamines (option D) may be used after stopping, but are not the
first action.
8. A patient with acute pancreatitis has a nasogastric tube to low intermittent suction. The nurse
assesses the patient and notes absent bowel sounds, abdominal distention, and a serum calcium
level of 7.2 mg/dL. Which complication should the nurse suspect?
A. Hypocalcemia due to saponification
B. Paralytic ileus due to peritonitis
C. Acute respiratory distress syndrome
D. Pancreatic pseudocyst formation
Answer: A
Rationale: In acute pancreatitis, hypocalcemia can occur due to saponification (calcium binding with
free fatty acids in necrotic fat) and is a marker of severe disease. Absent bowel sounds and distention are
common in pancreatitis due to ileus, but the specific finding of hypocalcemia points to saponification.
Paralytic ileus (option B) is a general complication, but the calcium level is the key. ARDS (option C)
would present with respiratory symptoms. Pseudocyst (option D) typically develops weeks later.
9. A patient with a history of intravenous drug use presents with fever, chills, and a new onset of a
loud, holosystolic murmur heard best at the apex. Blood cultures are positive for Staphylococcus
aureus. Which valvular abnormality is most likely, and what is the priority nursing intervention?
Page 3
, A. Aortic stenosis; prepare for valve replacement
B. Mitral regurgitation due to infective endocarditis; administer IV antibiotics
C. Tricuspid regurgitation; administer diuretics
D. Mitral stenosis; administer anticoagulation
Answer: B
Rationale: In intravenous drug users, infective endocarditis commonly affects the tricuspid valve, but a
holosystolic murmur at the apex is characteristic of mitral regurgitation. The loud murmur suggests
acute severe regurgitation. The priority is to initiate IV antibiotics as soon as possible after blood
cultures are obtained. Valve replacement (option A) may be considered later if medical therapy fails.
Diuretics (option C) and anticoagulation (option D) are not first-line treatments for acute infective
endocarditis.
10. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) monitor in
place. The ICP is 22 mm Hg, and the mean arterial pressure (MAP) is 70 mm Hg. The nurse
calculates the cerebral perfusion pressure (CPP). Which nursing action is most appropriate?
A. Administer mannitol 0.5 g/kg IV
B. Increase the head of bed to 45 degrees
C. Administer a bolus of isotonic saline
D. Sedate the patient with propofol
Answer: C
Rationale: CPP = MAP - ICP. Here CPP = 70 - 22 = 48 mm Hg, which is below the target of 60-70 mm
Hg. To improve CPP, the nurse should first increase MAP by administering a fluid bolus (isotonic saline)
to support blood pressure. Mannitol (option A) lowers ICP but could cause hypotension if volume
depleted. Elevating the head (option B) may help reduce ICP but does not address low MAP. Sedation
(option D) may lower ICP but also can lower MAP. The immediate priority is to improve cerebral
perfusion.
11. In a patient with acute decompensated heart failure, which combination of hemodynamic
parameters would most reliably indicate the need for inotropic support rather than vasodilator
therapy alone?
A. Cardiac index 2.8 L/min/m², pulmonary capillary wedge pressure 22 mm Hg, systemic vascular resistance
1400 dyn-s/cm
B. Cardiac index 1.8 L/min/m², pulmonary capillary wedge pressure 28 mm Hg, systemic vascular resistance
1200 dyn-s/cm
C. Cardiac index 2.2 L/min/m², pulmonary capillary wedge pressure 18 mm Hg, systemic vascular resistance
900 dyn-s/cm
D. Cardiac index 3.0 L/min/m², pulmonary capillary wedge pressure 16 mm Hg, systemic vascular resistance
1100 dyn-s/cm
Answer: B
Rationale: Inotropic support is indicated for low cardiac output (CI < 2.2) with elevated filling pressures
(PCWP > 18) and normal or high SVR. Option B shows low CI and high PCWP, consistent with
cardiogenic shock requiring inotropes. Option A has adequate CI, and options C and D have
near-normal parameters.
Page 4
