Exam 4: NSG 430/ NSG430 (New 2025/ 2026
Update) Adult Health Nursing II | Questions
with Verified Answers| 100% Correct| Grade A
GCU.
What is an important nursing intervention for a client with neurogenic shock?>>
ANS >>keep their room warm to avoid hypothermia (they cannot regulate their
temperature)
What is the treatment, for septic shock?>> ANS >>cultures, IV
antibiotics (within 1 hour broad to specific), and intravenous fluid resus
What is important to report in septic shock?>> ANS >>cool and clammy skin
(indicates shock is progressing)
What is the treatment, for all distributive shocks (neurogenic,
septic, and anaphylactic)>> ANS >>Fluid bolus 30mL/kg (3 times) if
doesn't work then give vasopressors
What can cause a sickle cell anemia crisis?>> ANS >>High altitudes, cold,
dehydration, and infection
What can prevent sickle cell anemia?>> ANS >>avoid causes, fluids, treat infection
quickly, immunizations (pneumococcal, Hib, flu, hep)
Shock, is a deficit of oxygen at a cellular level so with any shock it
is important for the nurse to administer . >> ANS >>oxygen
What is the definitive lab for shock? Why?>> ANS >>-Lactate
-Shock is caused by a decreased level of oxygen to the organs. Lactate is produced
when there is tissue hypoperfusion.
What are the causes of hypovolemic shock?>> ANS >>Hemorrhage, N/V from
dehydration, and burns
,What are the signs and symptoms of hypovolemic shock?>> ANS >>- cool and
clammy skin
-hypotension
-tachycardia
What is cardiogenic shock?>> ANS >>A pumping failure of the heart
What are the signs and symptoms of cardiogenic shock?>> ANS >>crackles, SOB
(MONITOR RESPIRATORY), decreased UOP, LOC, and BP
What medications are given for cardiogenic shock?>> ANS >>-Increase
contractility (dopamine, dobutamine, digoxin)
-Decrease afterload (diuretics to reduce preload/improve CO and dobutamine)
-Improve perfusion (vasodilators such as nitroprusside: effective if skin is warm
and pink)
What are the signs and symptoms of neurogenic shock?>> ANS >>hypotension,
bradycardia, and poikilothermia
What are important nursing interventions for sickle cell anemia crisis?>> ANS
>>O2, fluids/electrolytes, pain management (morphine), and hydroxyurea
What can cause DIC?>> ANS >>bacterial septicemia
What are nursing interventions for DIC?>> ANS >>-STABILIZE ABCs (O2, fluids,
etc)
-Treat cause
-Give fresh frozen plasma
Patient with septicemia develops bleeding at venipuncture site and blood in
stools. What is the nurse’s priority?>> ANS >>NOTIFY HCP (suggests DIC)
What is the S/S of a febrile, nonhemolytic blood transfusion reaction?>> ANS
, >>fever, chills, and headache
What is a prevention measure of a febrile blood transfusion reaction?>> ANS
>>acetaminophen or antihistamine 30 minutes prior to infusion
What are the signs and symptoms of an acute hemolytic blood transfusion
reaction?>> ANS >>fever, chills, Lower, BACK PAIN, HYPOTENSION, and
hematuria
What is the treatment, for an acute hemolytic blood transfusion reaction?>> ANS
>>stop infusion, draw labs, UA, increase BP, and urinary Cath
What is TACO?>> ANS >>transfusion associated circulatory overload (HF)
What is the BNP level in TACO?>> ANS >>>1,000
What is the treatment for TACO?>> ANS >>O2, intubation, and diuresis
What is TRALI?>> ANS >>transfusion related acute lung injury (caused by a
reaction from donors WBC)
What are the s/s of TRALI?>> ANS >>hypotension, occurs 6 hours after infusion,
and dyspnea
NO DIURETICS (given in TACO)
What is the BNP in TRALI?>> ANS >><250
Update) Adult Health Nursing II | Questions
with Verified Answers| 100% Correct| Grade A
GCU.
What is an important nursing intervention for a client with neurogenic shock?>>
ANS >>keep their room warm to avoid hypothermia (they cannot regulate their
temperature)
What is the treatment, for septic shock?>> ANS >>cultures, IV
antibiotics (within 1 hour broad to specific), and intravenous fluid resus
What is important to report in septic shock?>> ANS >>cool and clammy skin
(indicates shock is progressing)
What is the treatment, for all distributive shocks (neurogenic,
septic, and anaphylactic)>> ANS >>Fluid bolus 30mL/kg (3 times) if
doesn't work then give vasopressors
What can cause a sickle cell anemia crisis?>> ANS >>High altitudes, cold,
dehydration, and infection
What can prevent sickle cell anemia?>> ANS >>avoid causes, fluids, treat infection
quickly, immunizations (pneumococcal, Hib, flu, hep)
Shock, is a deficit of oxygen at a cellular level so with any shock it
is important for the nurse to administer . >> ANS >>oxygen
What is the definitive lab for shock? Why?>> ANS >>-Lactate
-Shock is caused by a decreased level of oxygen to the organs. Lactate is produced
when there is tissue hypoperfusion.
What are the causes of hypovolemic shock?>> ANS >>Hemorrhage, N/V from
dehydration, and burns
,What are the signs and symptoms of hypovolemic shock?>> ANS >>- cool and
clammy skin
-hypotension
-tachycardia
What is cardiogenic shock?>> ANS >>A pumping failure of the heart
What are the signs and symptoms of cardiogenic shock?>> ANS >>crackles, SOB
(MONITOR RESPIRATORY), decreased UOP, LOC, and BP
What medications are given for cardiogenic shock?>> ANS >>-Increase
contractility (dopamine, dobutamine, digoxin)
-Decrease afterload (diuretics to reduce preload/improve CO and dobutamine)
-Improve perfusion (vasodilators such as nitroprusside: effective if skin is warm
and pink)
What are the signs and symptoms of neurogenic shock?>> ANS >>hypotension,
bradycardia, and poikilothermia
What are important nursing interventions for sickle cell anemia crisis?>> ANS
>>O2, fluids/electrolytes, pain management (morphine), and hydroxyurea
What can cause DIC?>> ANS >>bacterial septicemia
What are nursing interventions for DIC?>> ANS >>-STABILIZE ABCs (O2, fluids,
etc)
-Treat cause
-Give fresh frozen plasma
Patient with septicemia develops bleeding at venipuncture site and blood in
stools. What is the nurse’s priority?>> ANS >>NOTIFY HCP (suggests DIC)
What is the S/S of a febrile, nonhemolytic blood transfusion reaction?>> ANS
, >>fever, chills, and headache
What is a prevention measure of a febrile blood transfusion reaction?>> ANS
>>acetaminophen or antihistamine 30 minutes prior to infusion
What are the signs and symptoms of an acute hemolytic blood transfusion
reaction?>> ANS >>fever, chills, Lower, BACK PAIN, HYPOTENSION, and
hematuria
What is the treatment, for an acute hemolytic blood transfusion reaction?>> ANS
>>stop infusion, draw labs, UA, increase BP, and urinary Cath
What is TACO?>> ANS >>transfusion associated circulatory overload (HF)
What is the BNP level in TACO?>> ANS >>>1,000
What is the treatment for TACO?>> ANS >>O2, intubation, and diuresis
What is TRALI?>> ANS >>transfusion related acute lung injury (caused by a
reaction from donors WBC)
What are the s/s of TRALI?>> ANS >>hypotension, occurs 6 hours after infusion,
and dyspnea
NO DIURETICS (given in TACO)
What is the BNP in TRALI?>> ANS >><250
