NSG 3160 EXAM 4 COMPREHENSIVE
STUDY GUIDE QUESTIONS & VERIFIED
ANSWERS 2026/2027 UPDATE
1. A patient’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 55 mmHg, and HCO3 26
mEq/L. Which condition does the nurse suspect?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Conceptual Explanation: The pH is low (<7.35), indicating acidosis. The PaCO2 is high
(>45), indicating a respiratory cause. The HCO3 is normal, meaning there is no
compensation yet.
2. In the Resuscitative Phase of burn injury, what is the primary nursing priority?
A. Fluid resuscitation
B. Nutritional support
C. Wound debridement
D. Physical therapy
,Answer: A
Conceptual Explanation: Fluid resuscitation is critical during the first 24-48 hours to
prevent hypovolemic shock due to massive capillary leak.
3. A nurse is caring for a patient with Acute Kidney Injury (AKI). The patient’s potassium is 6.8
mEq/L. Which medication should the nurse expect to administer first to protect the heart?
A. Sodium Polystyrene Sulfonate
B. Insulin and Dextrose
C. Furosemide
D. Calcium Gluconate
Answer: D
Conceptual Explanation: Calcium gluconate does not lower potassium, but it stabilizes the
myocardial cell membrane to prevent lethal arrhythmias.
4. Which assessment finding is most indicative of Cardiac Tamponade?
A. Muffled heart sounds and jugular venous distention
B. Hypertension and bradycardia
C. Crackles in the lungs and pedal edema
D. Flattened neck veins and tachycardia
Answer: A
, Conceptual Explanation: Beck’s Triad (hypotension, muffled heart sounds, and JVD) is the
classic sign of cardiac tamponade.
5. A patient with a spinal cord injury at T6 reports a severe headache and nasal congestion.
The BP is 190/100. What is the nurse’s first action?
A. Check for a full bladder or fecal impaction
B. Administer PRN antihypertensives
C. Place the patient in a supine position
D. Notify the provider immediately
Answer: A
Conceptual Explanation: These are signs of Autonomic Dysreflexia. The first action is to
identify and remove the noxious stimulus, most commonly a full bladder.
6. A patient on a mechanical ventilator has a high-pressure alarm sounding. Which condition
could be the cause?
A. Disconnected tubing
B. Cuff leak
C. Self-extubation
D. Patient biting the ETT
Answer: D
STUDY GUIDE QUESTIONS & VERIFIED
ANSWERS 2026/2027 UPDATE
1. A patient’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 55 mmHg, and HCO3 26
mEq/L. Which condition does the nurse suspect?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Conceptual Explanation: The pH is low (<7.35), indicating acidosis. The PaCO2 is high
(>45), indicating a respiratory cause. The HCO3 is normal, meaning there is no
compensation yet.
2. In the Resuscitative Phase of burn injury, what is the primary nursing priority?
A. Fluid resuscitation
B. Nutritional support
C. Wound debridement
D. Physical therapy
,Answer: A
Conceptual Explanation: Fluid resuscitation is critical during the first 24-48 hours to
prevent hypovolemic shock due to massive capillary leak.
3. A nurse is caring for a patient with Acute Kidney Injury (AKI). The patient’s potassium is 6.8
mEq/L. Which medication should the nurse expect to administer first to protect the heart?
A. Sodium Polystyrene Sulfonate
B. Insulin and Dextrose
C. Furosemide
D. Calcium Gluconate
Answer: D
Conceptual Explanation: Calcium gluconate does not lower potassium, but it stabilizes the
myocardial cell membrane to prevent lethal arrhythmias.
4. Which assessment finding is most indicative of Cardiac Tamponade?
A. Muffled heart sounds and jugular venous distention
B. Hypertension and bradycardia
C. Crackles in the lungs and pedal edema
D. Flattened neck veins and tachycardia
Answer: A
, Conceptual Explanation: Beck’s Triad (hypotension, muffled heart sounds, and JVD) is the
classic sign of cardiac tamponade.
5. A patient with a spinal cord injury at T6 reports a severe headache and nasal congestion.
The BP is 190/100. What is the nurse’s first action?
A. Check for a full bladder or fecal impaction
B. Administer PRN antihypertensives
C. Place the patient in a supine position
D. Notify the provider immediately
Answer: A
Conceptual Explanation: These are signs of Autonomic Dysreflexia. The first action is to
identify and remove the noxious stimulus, most commonly a full bladder.
6. A patient on a mechanical ventilator has a high-pressure alarm sounding. Which condition
could be the cause?
A. Disconnected tubing
B. Cuff leak
C. Self-extubation
D. Patient biting the ETT
Answer: D
