NSG 430 FINAL EXAM – COMPLETE STUDY GUIDE WITH
ANSWER CHOICES & RATIONALES
1. Risk Factors for Bacterial Infection (SATA)
Which of the following are risk factors for bacterial infection? Select
all that apply.
A. Diabetes Mellitus
B. Atopic dermatitis
C. Moisture
D. Obesity
E. Skin neoplasms
Answer: A, B, C, D, E (all are correct)
Rationale: Diabetes impairs immunity/wound healing. Atopic dermatitis
and skin neoplasms break the skin barrier. Moisture promotes bacterial
growth. Obesity impairs wound healing and immune function.
2. Treatment for Lower Extremity Cellulitis (SATA)
Which orders would the nurse expect for a patient with lower
extremity cellulitis? Select all that apply.
A. Apply cold packs to the extremity
B. Elevate the extremity
C. Administer IV Vancomycin
D. Apply heat packs
,Answer: B, C, D
Rationale: Elevation reduces edema. Vancomycin covers MRSA. Heat
promotes circulation; cold would vasoconstrict and impair healing.
3. Cardiogenic Shock – MODS Indicator
Which data collected by the nurse caring for a patient with cardiogenic
shock indicates the patient may be developing multiple organ
dysfunction syndrome (MODS)?
A. The patient's serum creatinine level is elevated.
B. The patient reports intermittent chest pressure.
C. The patient's extremities are cool and pulses are weak.
D. The patient has bilateral crackles throughout lung fields.
Answer: A
Rationale: Elevated creatinine signals acute kidney injury, a key MODS
component. The other findings are expected in cardiogenic shock.
4. INR/PT Levels Doubled – Treatment
A patient's INR/PT levels have doubled. What medication should the
nurse anticipate administering?
A. Vitamin K orally
B. Fresh frozen plasma
C. Protamine sulfate
D. Platelet transfusion
Answer: B
Rationale: FFP provides immediate clotting factors to reverse severe
coagulopathy. Vitamin K works slower.
,5. Pericarditis Pain Management
A patient recovering from heart surgery develops pericarditis and
complains of level 6 (0–10 scale) chest pain with deep breathing.
Which ordered PRN medication is most appropriate?
A. Fentanyl 1 mg IV
B. IV morphine sulfate 4 mg
C. Oral ibuprofen (Motrin) 600 mg
D. Oral acetaminophen (Tylenol) 650 mg
Answer: C
Rationale: Pericarditis pain is inflammatory; NSAIDs like ibuprofen are
first-line. Opioids are less effective for this type of pain.
6. Acute Myocardial Infarction (AMI) Assessment
Which assessment data collected by the nurse admitting a patient
with chest pain suggests the pain is caused by an acute myocardial
infarction?
A. The pain increases with deep breathing.
B. The pain has lasted longer than 30 minutes
C. The pain is relieved after taking nitroglycerin.
D. The pain is reproducible when the patient raises the arms.
Answer: B
Rationale: AMI pain is typically prolonged (>30 min), unrelieved by
rest/nitroglycerin, and not reproducible with movement.
, 7. Bleeding Esophageal Varices – Balloon Tamponade
Which nursing action will be included in the plan of care for a patient
being treated for bleeding esophageal varices with balloon
tamponade?
A. Instruct the patient to cough every hour.
B. Monitor the patient for shortness of breath.
C. Verify the position of the balloon every 4 hours.
D. Deflate the gastric balloon if the patient reports nausea.
Answer: B
Rationale: Balloon tamponade can cause airway obstruction/aspiration;
monitoring for respiratory distress is priority. Coughing is discouraged.
8. Brain Injury – Most Important Finding
When admitting a 42-year-old patient with a possible brain injury after
a car accident, which finding is most important to report to the HCP?
A. Blood pressure 140/90 mm Hg
B. Patient states they regularly take warfarin (Coumadin)
C. Glasgow Coma Scale 14
D. Pupils equal and reactive
Answer: B
Rationale: Warfarin increases bleeding risk; in a patient with possible
head injury, this poses a life-threatening hemorrhage risk.
ANSWER CHOICES & RATIONALES
1. Risk Factors for Bacterial Infection (SATA)
Which of the following are risk factors for bacterial infection? Select
all that apply.
A. Diabetes Mellitus
B. Atopic dermatitis
C. Moisture
D. Obesity
E. Skin neoplasms
Answer: A, B, C, D, E (all are correct)
Rationale: Diabetes impairs immunity/wound healing. Atopic dermatitis
and skin neoplasms break the skin barrier. Moisture promotes bacterial
growth. Obesity impairs wound healing and immune function.
2. Treatment for Lower Extremity Cellulitis (SATA)
Which orders would the nurse expect for a patient with lower
extremity cellulitis? Select all that apply.
A. Apply cold packs to the extremity
B. Elevate the extremity
C. Administer IV Vancomycin
D. Apply heat packs
,Answer: B, C, D
Rationale: Elevation reduces edema. Vancomycin covers MRSA. Heat
promotes circulation; cold would vasoconstrict and impair healing.
3. Cardiogenic Shock – MODS Indicator
Which data collected by the nurse caring for a patient with cardiogenic
shock indicates the patient may be developing multiple organ
dysfunction syndrome (MODS)?
A. The patient's serum creatinine level is elevated.
B. The patient reports intermittent chest pressure.
C. The patient's extremities are cool and pulses are weak.
D. The patient has bilateral crackles throughout lung fields.
Answer: A
Rationale: Elevated creatinine signals acute kidney injury, a key MODS
component. The other findings are expected in cardiogenic shock.
4. INR/PT Levels Doubled – Treatment
A patient's INR/PT levels have doubled. What medication should the
nurse anticipate administering?
A. Vitamin K orally
B. Fresh frozen plasma
C. Protamine sulfate
D. Platelet transfusion
Answer: B
Rationale: FFP provides immediate clotting factors to reverse severe
coagulopathy. Vitamin K works slower.
,5. Pericarditis Pain Management
A patient recovering from heart surgery develops pericarditis and
complains of level 6 (0–10 scale) chest pain with deep breathing.
Which ordered PRN medication is most appropriate?
A. Fentanyl 1 mg IV
B. IV morphine sulfate 4 mg
C. Oral ibuprofen (Motrin) 600 mg
D. Oral acetaminophen (Tylenol) 650 mg
Answer: C
Rationale: Pericarditis pain is inflammatory; NSAIDs like ibuprofen are
first-line. Opioids are less effective for this type of pain.
6. Acute Myocardial Infarction (AMI) Assessment
Which assessment data collected by the nurse admitting a patient
with chest pain suggests the pain is caused by an acute myocardial
infarction?
A. The pain increases with deep breathing.
B. The pain has lasted longer than 30 minutes
C. The pain is relieved after taking nitroglycerin.
D. The pain is reproducible when the patient raises the arms.
Answer: B
Rationale: AMI pain is typically prolonged (>30 min), unrelieved by
rest/nitroglycerin, and not reproducible with movement.
, 7. Bleeding Esophageal Varices – Balloon Tamponade
Which nursing action will be included in the plan of care for a patient
being treated for bleeding esophageal varices with balloon
tamponade?
A. Instruct the patient to cough every hour.
B. Monitor the patient for shortness of breath.
C. Verify the position of the balloon every 4 hours.
D. Deflate the gastric balloon if the patient reports nausea.
Answer: B
Rationale: Balloon tamponade can cause airway obstruction/aspiration;
monitoring for respiratory distress is priority. Coughing is discouraged.
8. Brain Injury – Most Important Finding
When admitting a 42-year-old patient with a possible brain injury after
a car accident, which finding is most important to report to the HCP?
A. Blood pressure 140/90 mm Hg
B. Patient states they regularly take warfarin (Coumadin)
C. Glasgow Coma Scale 14
D. Pupils equal and reactive
Answer: B
Rationale: Warfarin increases bleeding risk; in a patient with possible
head injury, this poses a life-threatening hemorrhage risk.
