NSG430 Exam 1 V3 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A patient with ARDS is placed in the prone position. What is the primary physiological
benefit of this intervention?
A. It increases the patient’s comfort level and reduces the need for sedation.
B. It decreases the risk of ventilator-associated pneumonia (VAP).
C. It recruits collapsed alveoli and improves ventilation-perfusion matching.
D. It reduces the workload of the right ventricle by decreasing pulmonary pressure.
Answer: C
Rationale: Prone positioning is utilized in ARDS to shift blood flow to better-ventilated
areas of the lungs. It helps in the recruitment of posterior alveoli that are often collapsed
when the patient is supine. This maneuver significantly improves oxygenation in patients
with refractory hypoxemia.
2. A nurse identifies ventricular fibrillation (VF) on the cardiac monitor. Which action should
the nurse take first?
A. Administer a bolus of Amiodarone 300 mg intravenously.
B. Initiate high-quality CPR and prepare for immediate defibrillation.
C. Perform immediate synchronized cardioversion at 100 joules.
,D. Check the patient’s carotid pulse for at least 10 seconds.
Answer: B
Rationale: Ventricular fibrillation is a lethal, pulseless rhythm that requires immediate
high-quality CPR and defibrillation. Delaying defibrillation decreases the chances of
successful resuscitation significantly. This rhythm results in no cardiac output and is an
absolute emergency.
3. When monitoring a patient with a pulmonary artery catheter, the nurse notes a PAWP of
18 mmHg. What is the most likely clinical interpretation?
A. The patient is experiencing hypovolemic shock.
B. The patient is severely dehydrated and needs a fluid bolus.
C. The patient has signs of left-sided heart failure or fluid overload.
D. The patient has normal hemodynamic pressures for an adult.
Answer: C
Rationale: The normal range for Pulmonary Artery Wedge Pressure (PAWP) is typically 4
to 12 mmHg. An elevation to 18 mmHg indicates increased pressure in the left atrium and
left ventricle. This often signifies left-sided heart failure, mitral valve issues, or significant
fluid volume excess.
4. Which assessment finding in a patient with a chest tube requires immediate intervention
by the nurse?
A. Continuous bubbling in the water seal chamber.
, B. Tidaling in the water seal chamber during inspiration and expiration.
C. Occasional bubbling in the suction control chamber.
D. Drainage of 50 mL of serosanguineous fluid in the first hour.
Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak in the
system or from the patient’s pleural space. This prevents the restoration of negative
pressure and can lead to a tension pneumothorax. The nurse should immediately locate the
source of the leak starting from the insertion site down to the drainage unit.
5. A patient is scheduled for a procedure and is extremely anxious. Which communication
technique best demonstrates patient-centered care?
A. Reassure the patient by saying, ‘Everything will be fine, we do this all the time.’
B. Acknowledge their anxiety and ask, ‘Can you tell me more about what concerns you?’
C. Provide a detailed medical pamphlet and leave the room for them to read it.
D. Tell the patient that anxiety can complicate the recovery process.
Answer: B
Rationale: Using open-ended questions allows the patient to express specific fears and
concerns. This builds a therapeutic relationship and helps the nurse provide targeted
education and support. It demonstrates empathy and respects the patient’s emotional state
during a stressful event.
Nursing II | Grand Canyon University
1. A patient with ARDS is placed in the prone position. What is the primary physiological
benefit of this intervention?
A. It increases the patient’s comfort level and reduces the need for sedation.
B. It decreases the risk of ventilator-associated pneumonia (VAP).
C. It recruits collapsed alveoli and improves ventilation-perfusion matching.
D. It reduces the workload of the right ventricle by decreasing pulmonary pressure.
Answer: C
Rationale: Prone positioning is utilized in ARDS to shift blood flow to better-ventilated
areas of the lungs. It helps in the recruitment of posterior alveoli that are often collapsed
when the patient is supine. This maneuver significantly improves oxygenation in patients
with refractory hypoxemia.
2. A nurse identifies ventricular fibrillation (VF) on the cardiac monitor. Which action should
the nurse take first?
A. Administer a bolus of Amiodarone 300 mg intravenously.
B. Initiate high-quality CPR and prepare for immediate defibrillation.
C. Perform immediate synchronized cardioversion at 100 joules.
,D. Check the patient’s carotid pulse for at least 10 seconds.
Answer: B
Rationale: Ventricular fibrillation is a lethal, pulseless rhythm that requires immediate
high-quality CPR and defibrillation. Delaying defibrillation decreases the chances of
successful resuscitation significantly. This rhythm results in no cardiac output and is an
absolute emergency.
3. When monitoring a patient with a pulmonary artery catheter, the nurse notes a PAWP of
18 mmHg. What is the most likely clinical interpretation?
A. The patient is experiencing hypovolemic shock.
B. The patient is severely dehydrated and needs a fluid bolus.
C. The patient has signs of left-sided heart failure or fluid overload.
D. The patient has normal hemodynamic pressures for an adult.
Answer: C
Rationale: The normal range for Pulmonary Artery Wedge Pressure (PAWP) is typically 4
to 12 mmHg. An elevation to 18 mmHg indicates increased pressure in the left atrium and
left ventricle. This often signifies left-sided heart failure, mitral valve issues, or significant
fluid volume excess.
4. Which assessment finding in a patient with a chest tube requires immediate intervention
by the nurse?
A. Continuous bubbling in the water seal chamber.
, B. Tidaling in the water seal chamber during inspiration and expiration.
C. Occasional bubbling in the suction control chamber.
D. Drainage of 50 mL of serosanguineous fluid in the first hour.
Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak in the
system or from the patient’s pleural space. This prevents the restoration of negative
pressure and can lead to a tension pneumothorax. The nurse should immediately locate the
source of the leak starting from the insertion site down to the drainage unit.
5. A patient is scheduled for a procedure and is extremely anxious. Which communication
technique best demonstrates patient-centered care?
A. Reassure the patient by saying, ‘Everything will be fine, we do this all the time.’
B. Acknowledge their anxiety and ask, ‘Can you tell me more about what concerns you?’
C. Provide a detailed medical pamphlet and leave the room for them to read it.
D. Tell the patient that anxiety can complicate the recovery process.
Answer: B
Rationale: Using open-ended questions allows the patient to express specific fears and
concerns. This builds a therapeutic relationship and helps the nurse provide targeted
education and support. It demonstrates empathy and respects the patient’s emotional state
during a stressful event.
