NSG 320 Exam 4 V1 | NSG 320 Adult
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 4) | Grand
Canyon University
1. A patient who suffered an ischemic stroke 2 hours ago is being evaluated for tPA
administration. Which assessment finding would contraindicate the use of tissue
plasminogen activator (tPA)?
A. Blood pressure of 160/90 mmHg
B. Platelet count of 150,000/uL
C. Patient is 75 years old
D. Gastrointestinal bleed 2 weeks ago
Correct Answer: D
Explanation: tPA is a potent fibrinolytic that increases the risk of life-threatening
hemorrhage. A recent history of internal bleeding, such as a GI bleed within the last 21
days, is a major contraindication for its administration. Although hypertension must be
managed, only a blood pressure exceeding 185/110 mmHg is an immediate exclusion
criterion.
,2. A nurse is caring for a patient with a traumatic brain injury. Which of the following are
clinical manifestations of Cushing’s Triad, indicating increased intracranial pressure? (Select
all that apply)
A. Bradycardia
B. Tachycardia
C. Systolic hypertension with widened pulse pressure
D. Irregular respirations
E. Hypotension
F. Narrowed pulse pressure
Correct Answer: A, C, D
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure and
brainstem herniation. It is characterized by bradycardia, systolic hypertension with a
widened pulse pressure, and irregular respiratory patterns. Recognizing these symptoms is
vital for critical care nurses to prevent permanent neurological damage.
3. A patient with Acute Kidney Injury (AKI) is in the diuretic phase. What is the priority
nursing intervention for this patient?
A. Monitor for dehydration and electrolyte imbalances
B. Monitor for hyperkalemia and metabolic acidosis
C. Restrict fluid intake to 500 mL per day
,D. Administer phosphate binders with meals
Correct Answer: A
Explanation: The diuretic phase of AKI is characterized by a massive increase in urine
output, often reaching 5 liters or more per day. During this phase, the kidneys have
regained the ability to excrete waste but cannot yet concentrate urine, leading to a high risk
of hypovolemia. Nurses must prioritize monitoring for hypotension, dehydration, and low
levels of potassium and sodium.
4. A patient with a T4 spinal cord injury suddenly reports a severe, throbbing headache and
nasal congestion. The nurse notes the patient is flushed and sweating above the level of
injury. What is the nurse’s first action?
A. Administer an ordered antihypertensive medication
B. Assess for a distended bladder or fecal impaction
C. Elevate the head of the bed to 45 degrees or higher
D. Call the rapid response team immediately
Correct Answer: C
Explanation: The patient is exhibiting classic signs of autonomic dysreflexia, which is a
medical emergency. The first priority is to sit the patient up to utilize orthostatic pressure
to help lower the blood pressure. After positioning, the nurse should then investigate the
cause, such as bladder distention or a kinked catheter.
, 5. The nurse is assessing a patient with suspected Parkinson’s disease. Which clinical
manifestations are expected findings? (Select all that apply)
A. Resting tremor
B. Intentional tremor
C. Muscle rigidity
D. Bradykinesia
E. Postural instability
F. Scanning speech
Correct Answer: A, C, D, E
Explanation: Parkinson’s disease is a progressive neurodegenerative disorder
characterized by the classic triad of tremor, rigidity, and bradykinesia. The tremor
associated with this disease is typically a ‘pill-rolling’ tremor that occurs at rest. Postural
instability and a shuffling gait are also common features as the disease progresses.
6. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which of the following orders should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally
B. Give IV regular insulin and 50% dextrose
C. Schedule the patient for urgent hemodialysis
D. Obtain a stat 12-lead electrocardiogram (ECG)
Health Nursing I | Actual Q&A with
Rationale (NSG320 Exam 4) | Grand
Canyon University
1. A patient who suffered an ischemic stroke 2 hours ago is being evaluated for tPA
administration. Which assessment finding would contraindicate the use of tissue
plasminogen activator (tPA)?
A. Blood pressure of 160/90 mmHg
B. Platelet count of 150,000/uL
C. Patient is 75 years old
D. Gastrointestinal bleed 2 weeks ago
Correct Answer: D
Explanation: tPA is a potent fibrinolytic that increases the risk of life-threatening
hemorrhage. A recent history of internal bleeding, such as a GI bleed within the last 21
days, is a major contraindication for its administration. Although hypertension must be
managed, only a blood pressure exceeding 185/110 mmHg is an immediate exclusion
criterion.
,2. A nurse is caring for a patient with a traumatic brain injury. Which of the following are
clinical manifestations of Cushing’s Triad, indicating increased intracranial pressure? (Select
all that apply)
A. Bradycardia
B. Tachycardia
C. Systolic hypertension with widened pulse pressure
D. Irregular respirations
E. Hypotension
F. Narrowed pulse pressure
Correct Answer: A, C, D
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure and
brainstem herniation. It is characterized by bradycardia, systolic hypertension with a
widened pulse pressure, and irregular respiratory patterns. Recognizing these symptoms is
vital for critical care nurses to prevent permanent neurological damage.
3. A patient with Acute Kidney Injury (AKI) is in the diuretic phase. What is the priority
nursing intervention for this patient?
A. Monitor for dehydration and electrolyte imbalances
B. Monitor for hyperkalemia and metabolic acidosis
C. Restrict fluid intake to 500 mL per day
,D. Administer phosphate binders with meals
Correct Answer: A
Explanation: The diuretic phase of AKI is characterized by a massive increase in urine
output, often reaching 5 liters or more per day. During this phase, the kidneys have
regained the ability to excrete waste but cannot yet concentrate urine, leading to a high risk
of hypovolemia. Nurses must prioritize monitoring for hypotension, dehydration, and low
levels of potassium and sodium.
4. A patient with a T4 spinal cord injury suddenly reports a severe, throbbing headache and
nasal congestion. The nurse notes the patient is flushed and sweating above the level of
injury. What is the nurse’s first action?
A. Administer an ordered antihypertensive medication
B. Assess for a distended bladder or fecal impaction
C. Elevate the head of the bed to 45 degrees or higher
D. Call the rapid response team immediately
Correct Answer: C
Explanation: The patient is exhibiting classic signs of autonomic dysreflexia, which is a
medical emergency. The first priority is to sit the patient up to utilize orthostatic pressure
to help lower the blood pressure. After positioning, the nurse should then investigate the
cause, such as bladder distention or a kinked catheter.
, 5. The nurse is assessing a patient with suspected Parkinson’s disease. Which clinical
manifestations are expected findings? (Select all that apply)
A. Resting tremor
B. Intentional tremor
C. Muscle rigidity
D. Bradykinesia
E. Postural instability
F. Scanning speech
Correct Answer: A, C, D, E
Explanation: Parkinson’s disease is a progressive neurodegenerative disorder
characterized by the classic triad of tremor, rigidity, and bradykinesia. The tremor
associated with this disease is typically a ‘pill-rolling’ tremor that occurs at rest. Postural
instability and a shuffling gait are also common features as the disease progresses.
6. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which of the following orders should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally
B. Give IV regular insulin and 50% dextrose
C. Schedule the patient for urgent hemodialysis
D. Obtain a stat 12-lead electrocardiogram (ECG)
