,West Coast NURS 480 Final Exam | Advanced Medical-Surgical
Nursing (2026) Q&A
1. A client in the intensive care unit has a central venous pressure (CVP) of 2 mm Hg.
Blood pressure is 92/56 mm Hg, heart rate 118 bpm, and urine output has been 15
mL over the past 2 hours. Which intervention should the nurse anticipate first?
A) Administer norepinephrine (Levophed) infusion
B) Administer a 500 mL intravenous fluid bolus
C) Prepare for insertion of a pulmonary artery catheter
D) Administer furosemide (Lasix) 40 mg IV push
Correct Answer: B) Administer a 500 mL intravenous fluid bolus
Rationale: A low CVP (normal 2-8 mm Hg) indicates hypovolemia. The hypotension,
tachycardia, and oliguria further support decreased preload. Fluid resuscitation is the
priority intervention to increase intravascular volume and improve perfusion.
Vasopressors would be considered after fluid resuscitation if hypotension persists.
Diuretics would worsen hypovolemia and are contraindicated.
2. The nurse is assessing a client with suspected cardiogenic shock. Which
assessment finding requires immediate notification of the healthcare provider?
A) Heart rate 104 bpm
B) Urine output 30 mL/hour
C) Crackles auscultated in bilateral lung bases
D) Mean arterial pressure (MAP) 58 mm Hg
Correct Answer: D) Mean arterial pressure (MAP) 58 mm Hg
,Rationale: A MAP below 60 mm Hg indicates inadequate perfusion to vital organs
and requires immediate intervention to prevent irreversible organ damage.
Tachycardia is expected in shock. Urine output of 30 mL/hour is borderline but not
immediately critical. Crackles indicate pulmonary congestion but do not represent
the same urgency as inadequate perfusion pressure.
3. The nurse is caring for a client with pulmonary edema secondary to acute
decompensated heart failure. Which assessment finding indicates improvement in
the client's condition?
A) Jugular venous distention decreases from 4 cm to 2 cm above the sternal angle
B) B-type natriuretic peptide (BNP) increases from 600 to 850 pg/mL
C) Crackles advance from lung bases to apices
D) Client weight increases by 2 kg since admission
Correct Answer: A) Jugular venous distention decreases from 4 cm to 2 cm above
the sternal angle
Rationale: Decreasing JVD indicates reduced central venous pressure and improved
fluid status. A rising BNP, advancing crackles, and weight gain all indicate worsening
heart failure. Effective treatment of pulmonary edema should reduce JVD, clear lung
sounds, decrease BNP, and promote weight loss through diuresis.
4. A client with acute respiratory distress syndrome (ARDS) is receiving mechanical
ventilation with a PEEP of 15 cm H₂O. The nurse notes a sudden drop in blood
pressure and absent breath sounds on the right side. Which complication should the
nurse suspect?
A) Pulmonary embolism
B) Tension pneumothorax
C) Atelectasis
D) Pulmonary edema
, Correct Answer: B) Tension pneumothorax
Rationale: High PEEP levels increase the risk of barotrauma, which can lead to a
tension pneumothorax. Sudden hypotension and unilateral absent breath sounds are
classic signs requiring immediate intervention. Needle decompression is the priority
intervention before chest tube placement.
5. A client is admitted with septic shock. Which assessment finding requires the most
immediate intervention?
A) Heart rate of 118 beats/min
B) Mean arterial pressure (MAP) of 58 mm Hg
C) Temperature of 101.2°F
D) Respiratory rate of 24 breaths/min
Correct Answer: B) Mean arterial pressure (MAP) of 58 mm Hg
Rationale: A MAP below 65 mm Hg in septic shock indicates inadequate organ
perfusion and requires immediate intervention, often with vasopressors. Tachycardia
and fever are expected compensatory responses. Respiratory rate of 24 is elevated
but not the most critical finding.
6. A client with severe sepsis has a lactate level of 4.2 mmol/L. What does this finding
indicate?
A) Adequate tissue perfusion
B) Anaerobic metabolism and tissue hypoperfusion
C) Normal metabolic function
D) Improved response to fluid resuscitation
Nursing (2026) Q&A
1. A client in the intensive care unit has a central venous pressure (CVP) of 2 mm Hg.
Blood pressure is 92/56 mm Hg, heart rate 118 bpm, and urine output has been 15
mL over the past 2 hours. Which intervention should the nurse anticipate first?
A) Administer norepinephrine (Levophed) infusion
B) Administer a 500 mL intravenous fluid bolus
C) Prepare for insertion of a pulmonary artery catheter
D) Administer furosemide (Lasix) 40 mg IV push
Correct Answer: B) Administer a 500 mL intravenous fluid bolus
Rationale: A low CVP (normal 2-8 mm Hg) indicates hypovolemia. The hypotension,
tachycardia, and oliguria further support decreased preload. Fluid resuscitation is the
priority intervention to increase intravascular volume and improve perfusion.
Vasopressors would be considered after fluid resuscitation if hypotension persists.
Diuretics would worsen hypovolemia and are contraindicated.
2. The nurse is assessing a client with suspected cardiogenic shock. Which
assessment finding requires immediate notification of the healthcare provider?
A) Heart rate 104 bpm
B) Urine output 30 mL/hour
C) Crackles auscultated in bilateral lung bases
D) Mean arterial pressure (MAP) 58 mm Hg
Correct Answer: D) Mean arterial pressure (MAP) 58 mm Hg
,Rationale: A MAP below 60 mm Hg indicates inadequate perfusion to vital organs
and requires immediate intervention to prevent irreversible organ damage.
Tachycardia is expected in shock. Urine output of 30 mL/hour is borderline but not
immediately critical. Crackles indicate pulmonary congestion but do not represent
the same urgency as inadequate perfusion pressure.
3. The nurse is caring for a client with pulmonary edema secondary to acute
decompensated heart failure. Which assessment finding indicates improvement in
the client's condition?
A) Jugular venous distention decreases from 4 cm to 2 cm above the sternal angle
B) B-type natriuretic peptide (BNP) increases from 600 to 850 pg/mL
C) Crackles advance from lung bases to apices
D) Client weight increases by 2 kg since admission
Correct Answer: A) Jugular venous distention decreases from 4 cm to 2 cm above
the sternal angle
Rationale: Decreasing JVD indicates reduced central venous pressure and improved
fluid status. A rising BNP, advancing crackles, and weight gain all indicate worsening
heart failure. Effective treatment of pulmonary edema should reduce JVD, clear lung
sounds, decrease BNP, and promote weight loss through diuresis.
4. A client with acute respiratory distress syndrome (ARDS) is receiving mechanical
ventilation with a PEEP of 15 cm H₂O. The nurse notes a sudden drop in blood
pressure and absent breath sounds on the right side. Which complication should the
nurse suspect?
A) Pulmonary embolism
B) Tension pneumothorax
C) Atelectasis
D) Pulmonary edema
, Correct Answer: B) Tension pneumothorax
Rationale: High PEEP levels increase the risk of barotrauma, which can lead to a
tension pneumothorax. Sudden hypotension and unilateral absent breath sounds are
classic signs requiring immediate intervention. Needle decompression is the priority
intervention before chest tube placement.
5. A client is admitted with septic shock. Which assessment finding requires the most
immediate intervention?
A) Heart rate of 118 beats/min
B) Mean arterial pressure (MAP) of 58 mm Hg
C) Temperature of 101.2°F
D) Respiratory rate of 24 breaths/min
Correct Answer: B) Mean arterial pressure (MAP) of 58 mm Hg
Rationale: A MAP below 65 mm Hg in septic shock indicates inadequate organ
perfusion and requires immediate intervention, often with vasopressors. Tachycardia
and fever are expected compensatory responses. Respiratory rate of 24 is elevated
but not the most critical finding.
6. A client with severe sepsis has a lactate level of 4.2 mmol/L. What does this finding
indicate?
A) Adequate tissue perfusion
B) Anaerobic metabolism and tissue hypoperfusion
C) Normal metabolic function
D) Improved response to fluid resuscitation
