NSG430 Final Exam V1 | NSG 430 Adult
Health Nursing II | Grand Canyon
University
1. A patient is experiencing supraventricular tachycardia (SVT) and remains symptomatic
despite vagal maneuvers. Which medication should the nurse prepare to administer as a
rapid IV push?
A. Epinephrine
B. Amiodarone
C. Atropine
D. Adenosine
Answer: D
Rationale: Adenosine is the primary drug used to convert SVT to a normal sinus rhythm. It
works by slowing the electrical conduction through the AV node of the heart. The nurse
must administer it quickly and follow with a rapid saline flush due to its extremely short
half-life.
2. A nurse is monitoring a patient with a head injury and notes a blood pressure of 180/60
mmHg, a heart rate of 48 bpm, and irregular respirations. What does this clinical triad
indicate?
A. Cushing’s Triad
,B. Beck’s Triad
C. Virchow’s Triad
D. Wernicke’s Encephalopathy
Answer: A
Rationale: Cushing’s triad consists of widened pulse pressure, bradycardia, and irregular
respirations. These are late signs of significantly increased intracranial pressure (ICP). The
nurse must treat this as a medical emergency to prevent brain herniation.
3. A patient with Acute Respiratory Distress Syndrome (ARDS) is not responding to increasing
levels of supplemental oxygen. What is this phenomenon called?
A. Refractory Hypoxemia
B. Respiratory Alkalosis
C. Hypoventilation
D. Diffusion Limitation
Answer: A
Rationale: Refractory hypoxemia is a hallmark sign of ARDS where oxygen levels remain
low regardless of the oxygen concentration delivered. It occurs because the alveoli are
filled with fluid or have collapsed, preventing gas exchange. Management often requires
high levels of Positive End-Expiratory Pressure (PEEP).
, 4. Which medication should the nurse anticipate administering to a patient with hepatic
encephalopathy to reduce serum ammonia levels?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Rifaximin
Answer: B
Rationale: Lactulose works by drawing ammonia into the colon where it is excreted
through the stool. The goal is to achieve 2 to 3 soft bowel movements per day. Effective
treatment is measured by an improvement in the patient’s neurological status.
5. A patient with a T6 spinal cord injury reports a sudden, severe headache and is found to
have a blood pressure of 210/110 mmHg. What is the priority nursing action?
A. Administer an anti-hypertensive medication
B. Place the patient in a flat, supine position
C. Assess the patient for bladder distension
D. Check the patient’s pupils for reactivity
Answer: C
Health Nursing II | Grand Canyon
University
1. A patient is experiencing supraventricular tachycardia (SVT) and remains symptomatic
despite vagal maneuvers. Which medication should the nurse prepare to administer as a
rapid IV push?
A. Epinephrine
B. Amiodarone
C. Atropine
D. Adenosine
Answer: D
Rationale: Adenosine is the primary drug used to convert SVT to a normal sinus rhythm. It
works by slowing the electrical conduction through the AV node of the heart. The nurse
must administer it quickly and follow with a rapid saline flush due to its extremely short
half-life.
2. A nurse is monitoring a patient with a head injury and notes a blood pressure of 180/60
mmHg, a heart rate of 48 bpm, and irregular respirations. What does this clinical triad
indicate?
A. Cushing’s Triad
,B. Beck’s Triad
C. Virchow’s Triad
D. Wernicke’s Encephalopathy
Answer: A
Rationale: Cushing’s triad consists of widened pulse pressure, bradycardia, and irregular
respirations. These are late signs of significantly increased intracranial pressure (ICP). The
nurse must treat this as a medical emergency to prevent brain herniation.
3. A patient with Acute Respiratory Distress Syndrome (ARDS) is not responding to increasing
levels of supplemental oxygen. What is this phenomenon called?
A. Refractory Hypoxemia
B. Respiratory Alkalosis
C. Hypoventilation
D. Diffusion Limitation
Answer: A
Rationale: Refractory hypoxemia is a hallmark sign of ARDS where oxygen levels remain
low regardless of the oxygen concentration delivered. It occurs because the alveoli are
filled with fluid or have collapsed, preventing gas exchange. Management often requires
high levels of Positive End-Expiratory Pressure (PEEP).
, 4. Which medication should the nurse anticipate administering to a patient with hepatic
encephalopathy to reduce serum ammonia levels?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Rifaximin
Answer: B
Rationale: Lactulose works by drawing ammonia into the colon where it is excreted
through the stool. The goal is to achieve 2 to 3 soft bowel movements per day. Effective
treatment is measured by an improvement in the patient’s neurological status.
5. A patient with a T6 spinal cord injury reports a sudden, severe headache and is found to
have a blood pressure of 210/110 mmHg. What is the priority nursing action?
A. Administer an anti-hypertensive medication
B. Place the patient in a flat, supine position
C. Assess the patient for bladder distension
D. Check the patient’s pupils for reactivity
Answer: C
