NSG 401 — Advanced Adult Health Nursing
Exam Questions and Correct Answers (Verified
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1. A client with septic shock has a blood pressure of 82/48 mmHg,
heart rate of 124/min, and cool, clammy skin despite receiving an
initial isotonic fluid bolus. Which intervention should the nurse
anticipate next?
A. Administer a loop diuretic
B. Restrict all intravenous fluids
C. Initiate vasopressor therapy
D. Administer an oral antihypertensive
Answer: C. Initiate vasopressor therapy
Rationale: In septic shock, persistent hypotension after adequate fluid
resuscitation indicates the need for vasopressor support.
Norepinephrine is commonly used to increase vascular tone and
,maintain adequate mean arterial pressure. Diuretics, fluid restriction,
and antihypertensives would worsen tissue perfusion in this setting.
2. A client with acute pulmonary edema is severely dyspneic and
coughing up pink, frothy sputum. Which position should the nurse
place the client in initially?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Left lateral
Answer: B. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and
reduces venous return to the heart, which can decrease pulmonary
congestion. A supine or Trendelenburg position can worsen
respiratory distress by increasing venous return and reducing
diaphragmatic expansion.
3. A client with chronic heart failure reports a 2.5-kg weight gain
over three days. Which interpretation is most appropriate?
A. The weight gain is expected with aging
B. The client has likely gained muscle mass
,C. The client may be retaining excess fluid
D. The client should increase sodium intake
Answer: C. The client may be retaining excess fluid
Rationale: Rapid weight gain in a client with heart failure is usually an
indicator of fluid retention rather than an increase in muscle or
adipose tissue. Daily weight monitoring is an important method of
detecting worsening heart failure early.
4. A client taking digoxin has an apical pulse of 52/min and reports
nausea and seeing yellow halos around lights. What should the
nurse do first?
A. Administer the scheduled dose
B. Hold the medication and notify the provider
C. Encourage increased sodium intake
D. Administer an additional dose
Answer: B. Hold the medication and notify the provider
Rationale: Bradycardia, nausea, and visual disturbances such as
yellow or green halos are classic manifestations of digoxin toxicity.
The nurse should withhold the medication and promptly notify the
healthcare provider. Serum digoxin and electrolyte levels may also
need evaluation.
, 5. A client with acute myocardial infarction suddenly develops
severe dyspnea, hypotension, and a new loud systolic murmur.
Which complication should the nurse suspect?
A. Pericarditis
B. Ventricular aneurysm
C. Papillary muscle rupture
D. Stable angina
Answer: C. Papillary muscle rupture
Rationale: Papillary muscle rupture is a serious mechanical
complication that can occur after myocardial infarction. It can cause
acute mitral regurgitation, producing pulmonary edema, hypotension,
and a new systolic murmur.
6. A client with atrial fibrillation is prescribed warfarin. Which
laboratory test is most important for monitoring therapeutic
effect?
A. Troponin
B. INR
C. Serum sodium
D. Creatine kinase
Answer: B. INR
Exam Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A| Instant
Download Pdf
1. A client with septic shock has a blood pressure of 82/48 mmHg,
heart rate of 124/min, and cool, clammy skin despite receiving an
initial isotonic fluid bolus. Which intervention should the nurse
anticipate next?
A. Administer a loop diuretic
B. Restrict all intravenous fluids
C. Initiate vasopressor therapy
D. Administer an oral antihypertensive
Answer: C. Initiate vasopressor therapy
Rationale: In septic shock, persistent hypotension after adequate fluid
resuscitation indicates the need for vasopressor support.
Norepinephrine is commonly used to increase vascular tone and
,maintain adequate mean arterial pressure. Diuretics, fluid restriction,
and antihypertensives would worsen tissue perfusion in this setting.
2. A client with acute pulmonary edema is severely dyspneic and
coughing up pink, frothy sputum. Which position should the nurse
place the client in initially?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Left lateral
Answer: B. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and
reduces venous return to the heart, which can decrease pulmonary
congestion. A supine or Trendelenburg position can worsen
respiratory distress by increasing venous return and reducing
diaphragmatic expansion.
3. A client with chronic heart failure reports a 2.5-kg weight gain
over three days. Which interpretation is most appropriate?
A. The weight gain is expected with aging
B. The client has likely gained muscle mass
,C. The client may be retaining excess fluid
D. The client should increase sodium intake
Answer: C. The client may be retaining excess fluid
Rationale: Rapid weight gain in a client with heart failure is usually an
indicator of fluid retention rather than an increase in muscle or
adipose tissue. Daily weight monitoring is an important method of
detecting worsening heart failure early.
4. A client taking digoxin has an apical pulse of 52/min and reports
nausea and seeing yellow halos around lights. What should the
nurse do first?
A. Administer the scheduled dose
B. Hold the medication and notify the provider
C. Encourage increased sodium intake
D. Administer an additional dose
Answer: B. Hold the medication and notify the provider
Rationale: Bradycardia, nausea, and visual disturbances such as
yellow or green halos are classic manifestations of digoxin toxicity.
The nurse should withhold the medication and promptly notify the
healthcare provider. Serum digoxin and electrolyte levels may also
need evaluation.
, 5. A client with acute myocardial infarction suddenly develops
severe dyspnea, hypotension, and a new loud systolic murmur.
Which complication should the nurse suspect?
A. Pericarditis
B. Ventricular aneurysm
C. Papillary muscle rupture
D. Stable angina
Answer: C. Papillary muscle rupture
Rationale: Papillary muscle rupture is a serious mechanical
complication that can occur after myocardial infarction. It can cause
acute mitral regurgitation, producing pulmonary edema, hypotension,
and a new systolic murmur.
6. A client with atrial fibrillation is prescribed warfarin. Which
laboratory test is most important for monitoring therapeutic
effect?
A. Troponin
B. INR
C. Serum sodium
D. Creatine kinase
Answer: B. INR
