NSG430 EXAM QUESTIONS AND
DETAILED ANSWERS. EXPERT
VERIFIED FOR GUARANTEED PASS.
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the
patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure
measurement via an intra-arterial catheter in the same arm is assessed by the nurse to be
108/70 mm Hg. What is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments - ANS d. Frequent neurological assessments
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury
covers 40% of his body surface area. The nurse calculates the fluid needs for the first 24 hours
after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of
intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid
in the first 24 hours?
Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
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,d. 11200 ml - ANS a. 14000 ml
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury - ANS c. After the emergent phase of the injury
After receiving the handoff report from the day shift charge nurse, which patient should the
evening charge nurse assess first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F -
ANS d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of
104°F
The charge nurse assigns patients based on their acuity and the level of experience of the
critical care nurses on duty. This is an example of implementation of:
Select one:
a. Healthy work environment
b. National patient safety goals
c. SBAR communication
d. Synergy model - ANS d. Synergy model
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from
the patient's left naris. What is the best nursing action?
Select one:
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, a. Insert bilateral cotton nasal packing.
b. Have the patient blow the nose until clear.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears. - ANS c. Place a nasal drip pad under the
nose.
The nurse is caring for a patient who was hit on the head with a hammer. The patient was
unconscious at the scene briefly but is now conscious upon arrival at the emergency
department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is
the priority nursing action?
Select one:
a. stimulate the patient hourly.
b. Notify the provider immediately.
c. Elevate the head of the bed.
d. Continue to monitor the patient. - ANS b. Notify the provider immediately.
The nurse is caring for a patient who has a diminished level of consciousness and who is
mechanically ventilated. While performing endotracheal suctioning, the patient's hands clench
and pull into the chest. What is the best interpretation by the nurse?
Select one:
a. The patient is exhibiting purposeful movement.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting extension posturing.
d. The patient is exhibiting decorticate posturing. - ANS d. The patient is exhibiting
decorticate posturing.
(9) Which of the following would be seen in a patient with myxedema coma?
Select one:
a. Decreased reflexes
b. Hyperthermia
c. Tachycardia
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DETAILED ANSWERS. EXPERT
VERIFIED FOR GUARANTEED PASS.
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the
patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure
measurement via an intra-arterial catheter in the same arm is assessed by the nurse to be
108/70 mm Hg. What is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments - ANS d. Frequent neurological assessments
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury
covers 40% of his body surface area. The nurse calculates the fluid needs for the first 24 hours
after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of
intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid
in the first 24 hours?
Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED
,d. 11200 ml - ANS a. 14000 ml
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury - ANS c. After the emergent phase of the injury
After receiving the handoff report from the day shift charge nurse, which patient should the
evening charge nurse assess first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F -
ANS d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of
104°F
The charge nurse assigns patients based on their acuity and the level of experience of the
critical care nurses on duty. This is an example of implementation of:
Select one:
a. Healthy work environment
b. National patient safety goals
c. SBAR communication
d. Synergy model - ANS d. Synergy model
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from
the patient's left naris. What is the best nursing action?
Select one:
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED
, a. Insert bilateral cotton nasal packing.
b. Have the patient blow the nose until clear.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears. - ANS c. Place a nasal drip pad under the
nose.
The nurse is caring for a patient who was hit on the head with a hammer. The patient was
unconscious at the scene briefly but is now conscious upon arrival at the emergency
department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is
the priority nursing action?
Select one:
a. stimulate the patient hourly.
b. Notify the provider immediately.
c. Elevate the head of the bed.
d. Continue to monitor the patient. - ANS b. Notify the provider immediately.
The nurse is caring for a patient who has a diminished level of consciousness and who is
mechanically ventilated. While performing endotracheal suctioning, the patient's hands clench
and pull into the chest. What is the best interpretation by the nurse?
Select one:
a. The patient is exhibiting purposeful movement.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting extension posturing.
d. The patient is exhibiting decorticate posturing. - ANS d. The patient is exhibiting
decorticate posturing.
(9) Which of the following would be seen in a patient with myxedema coma?
Select one:
a. Decreased reflexes
b. Hyperthermia
c. Tachycardia
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