NSG 430 Exam 1
NSG 430 Exam 1 – UPDATED Questions with 100% Verified
Answers
Grand Canyon University
NSG 430
NSG 430 Exam 1
Q1 Patient stability
A -mild signs of deterioration: mild confusion, tachypnea -6-8 hours before cardiac or
respiratory arrest
Q2 PCU vs ICU
A -ICU nursing is delivering ICU care to patients wherever they may be -PCU is progressive
care units (intermediate or step down) that provide transition between ICU and general care
unit >at risk for serious complications
Q3 Complexity of unstable clients
A #1: physiologically unstable -critical analysis and decision making #2: risk of complications
-frequent assess and treatments, high risk of delirium #3: IV polypharmacy-titration
-vasoactive, thrombolytics, sedation, insulin, nutrition #4: advanced tachnology/devices
-vents, ICP, svO2, CCRT #5 psychosocial, ethical and safety concerns
Q4 Needs of caregivers
A -information -reassurance -access They need these bc without them they feel powerless and
will show signs of this
Q5 Unstable client S/S
A - Level of consciousness, Anxiety, Confusion, Weakness, Restlessness Feeling of
impending doom -Cool, clammy skin, Pallor, Cyanosis -Dysrhythmias, Tachycardia
-Hypotension, Narrowed pulse pressure -Rapid, weak, thready pulses -Tachypnea, dyspnea,
or shallow, irregular respirations - O2 saturation -Temperature dysregulation Chills
-Obvious hemorrhage or injury, Nausea and vomiting
Q6 Rapid response
Page 1
,NSG 430 Exam 1
A FUNCTIONS -identification and activation on client deterioration -initiate response for
assessment, intervention, triage -bedside nurse gives SBAR! FAILURE TO RECOGNIZE -failure
to recognize changes, diagnostics, clinical deviations from normal, lack of nurse intuition
TEAM -respiratory ventilates -nursing supervisor is general support -provider is hospitalist
-ICU nurse and assigned client nruse PROTOCOLS -begin tx before provider arrives -O2
airway management -12 EKG -labs, meds -critical thinking in action, contact the provider
fast
Q7 Palliative care vs hospice
A PALLIATIVE -*begins during RESTORATIVE or curative health care -indication: diagnosis of a
life-limiting illness HOSPICE -life expectancy is 6 months or less -requires physician
certification END OF LIFE CARE GOALS -when death is imminent -provide comfort, improve
quality of remaining life, ensure dignified death
Q8 End of life
A MANIFESTATIONS -decreased metabolism, body function -respiration ceases first, heart
stops beating after a few mins -slow, irregular breathing, cheyne-stokes respirations
-inability to cough or clear secretions (death rattle= grunting, gurgling, congested
breathing) -*hearing is the last sense to disappear -decreased sensation, perception of pain
and touch -blurred vision, absent blink reflex, patient appears to stare, eyelids half open
-decreased taste and smell -mottling on hands, feet, arms, legs -cold and clammy skin
-cyanosis of nose, nail beds, knees -*waxlike skin when very near death -gradual urinary
output decrease, incontinent of urine, unable to urinate -slowing of GI, accumulation of gas,
distention and nausea -loss of sphincter control -bowel movement may occur at death
-trouble holding bosy posture and alignment -loss of facial muscle time: sagging jaw,
difficulty speaking, loss of gag reflex, swallowing is difficult -increased heart rate, then later
slowing and weakend pulse -irregular rhythm of heart, decreased BP, delayed absorption of
IM or SQ drugs PSYCHOSOCIAL MANIFESTATIONS -altered decision making -anxiety, fear-
spirituality associated with decreased dispair -life review -peacefulness, saying goodbyes,
withdrawal
Q9 End of life cont.
A -pay attention to nonverbal cues -provide culturally competent care -decisional capacity:
ability to consent and refuse care (organ tissue donate, advance directives, resuscitation,
etc) -organ donation: with persons consent before death and family permission after death
-physician assisted suicide: hastens death
Page 2
, NSG 430 Exam 1
Q10 Nursing management and role of nurse for end of life care
A -relieve suffering -clarify misunderstanding about use of pain meds. addiction is not a
concern when providing comfort for terminally ill. -double effect: morally permissible to give
a med that has potential for harm if given to relieve pain but *not intended to hasten death
GUIDES TO CARE -code of ethics for nurses- relieve suffering -principle of beneficence- care
is provided to benefit -standard of care- nursing acts required for safe and competent
nursing practices ASSESSMENT -detect s/s from review of body systems -assess for
discomfort and pain -legal guidlines for donation of organs and tissues -assess coping of pt
and fam -q8hr assess -monitor for system failure, vigilance -*address pain level and
respiratory status, emotions -communication: prepare fam for unusual pt communication
IMPLEMENTATIONS -coping strategies -care of emotional and physical needs -anger: normal
response to grief. grieving person cannot be forced to accept the loss -*elizabeth kubler ross
swiss american FEARS OF DEATH -pain -shortness of breath-air
hunger-opioids-bronchodilators-o2 -loneliness, abandonment -meaninglessness, life review
POSTMORTEM -close pts eyes, replace dentures, wash and position body -allow fam as much
time as they need -*as a nurse recognize your values, attitudes and feelings about death
Q11 Diabetic ketoacidosis (DKA)
A -profound deficiency of insulin -most likely occur in type 1 diabetes -characterized:
hyperglycemia, ketosis, acidosis, dehydration -ketones cause metabolic acidosis -can be
managed outpatient, but may need to hospitalize for severe fluid and electrolyte imbalance,
fever, N/V, diarrhea, altered mental state. NEED to be communicating with provider
PRECIPITATING FACTORS -illness, infection -inadequate insulin dosage -undiagnosed T1DM
-poor self management, neglect MANIFESTATIONS -dehydration, poor skin turgor, dry
mucous membranes, tachycardia, orthostatic hypotension -lethargy and weakness early
-skin dry and loose, eyes soft and sunken -renal failure which may occur from hypovolemia
shock can cause the retention of ketones and glucose which progresses acidosis IMPORTANT
-abdominal pain, anorexia, nausea,vomiting -*kussumal respirations (rapid, deep breathing
by exhalation of excess CO2), sweet fruity breath odor (acetone) -blood glucose > or =
250mg/dl -pH lower than 7.30 -serum bicarbonate <16meq/L -moderate to high ketones in
urine or serum
Q12 DKA treatment
Page 3
NSG 430 Exam 1 – UPDATED Questions with 100% Verified
Answers
Grand Canyon University
NSG 430
NSG 430 Exam 1
Q1 Patient stability
A -mild signs of deterioration: mild confusion, tachypnea -6-8 hours before cardiac or
respiratory arrest
Q2 PCU vs ICU
A -ICU nursing is delivering ICU care to patients wherever they may be -PCU is progressive
care units (intermediate or step down) that provide transition between ICU and general care
unit >at risk for serious complications
Q3 Complexity of unstable clients
A #1: physiologically unstable -critical analysis and decision making #2: risk of complications
-frequent assess and treatments, high risk of delirium #3: IV polypharmacy-titration
-vasoactive, thrombolytics, sedation, insulin, nutrition #4: advanced tachnology/devices
-vents, ICP, svO2, CCRT #5 psychosocial, ethical and safety concerns
Q4 Needs of caregivers
A -information -reassurance -access They need these bc without them they feel powerless and
will show signs of this
Q5 Unstable client S/S
A - Level of consciousness, Anxiety, Confusion, Weakness, Restlessness Feeling of
impending doom -Cool, clammy skin, Pallor, Cyanosis -Dysrhythmias, Tachycardia
-Hypotension, Narrowed pulse pressure -Rapid, weak, thready pulses -Tachypnea, dyspnea,
or shallow, irregular respirations - O2 saturation -Temperature dysregulation Chills
-Obvious hemorrhage or injury, Nausea and vomiting
Q6 Rapid response
Page 1
,NSG 430 Exam 1
A FUNCTIONS -identification and activation on client deterioration -initiate response for
assessment, intervention, triage -bedside nurse gives SBAR! FAILURE TO RECOGNIZE -failure
to recognize changes, diagnostics, clinical deviations from normal, lack of nurse intuition
TEAM -respiratory ventilates -nursing supervisor is general support -provider is hospitalist
-ICU nurse and assigned client nruse PROTOCOLS -begin tx before provider arrives -O2
airway management -12 EKG -labs, meds -critical thinking in action, contact the provider
fast
Q7 Palliative care vs hospice
A PALLIATIVE -*begins during RESTORATIVE or curative health care -indication: diagnosis of a
life-limiting illness HOSPICE -life expectancy is 6 months or less -requires physician
certification END OF LIFE CARE GOALS -when death is imminent -provide comfort, improve
quality of remaining life, ensure dignified death
Q8 End of life
A MANIFESTATIONS -decreased metabolism, body function -respiration ceases first, heart
stops beating after a few mins -slow, irregular breathing, cheyne-stokes respirations
-inability to cough or clear secretions (death rattle= grunting, gurgling, congested
breathing) -*hearing is the last sense to disappear -decreased sensation, perception of pain
and touch -blurred vision, absent blink reflex, patient appears to stare, eyelids half open
-decreased taste and smell -mottling on hands, feet, arms, legs -cold and clammy skin
-cyanosis of nose, nail beds, knees -*waxlike skin when very near death -gradual urinary
output decrease, incontinent of urine, unable to urinate -slowing of GI, accumulation of gas,
distention and nausea -loss of sphincter control -bowel movement may occur at death
-trouble holding bosy posture and alignment -loss of facial muscle time: sagging jaw,
difficulty speaking, loss of gag reflex, swallowing is difficult -increased heart rate, then later
slowing and weakend pulse -irregular rhythm of heart, decreased BP, delayed absorption of
IM or SQ drugs PSYCHOSOCIAL MANIFESTATIONS -altered decision making -anxiety, fear-
spirituality associated with decreased dispair -life review -peacefulness, saying goodbyes,
withdrawal
Q9 End of life cont.
A -pay attention to nonverbal cues -provide culturally competent care -decisional capacity:
ability to consent and refuse care (organ tissue donate, advance directives, resuscitation,
etc) -organ donation: with persons consent before death and family permission after death
-physician assisted suicide: hastens death
Page 2
, NSG 430 Exam 1
Q10 Nursing management and role of nurse for end of life care
A -relieve suffering -clarify misunderstanding about use of pain meds. addiction is not a
concern when providing comfort for terminally ill. -double effect: morally permissible to give
a med that has potential for harm if given to relieve pain but *not intended to hasten death
GUIDES TO CARE -code of ethics for nurses- relieve suffering -principle of beneficence- care
is provided to benefit -standard of care- nursing acts required for safe and competent
nursing practices ASSESSMENT -detect s/s from review of body systems -assess for
discomfort and pain -legal guidlines for donation of organs and tissues -assess coping of pt
and fam -q8hr assess -monitor for system failure, vigilance -*address pain level and
respiratory status, emotions -communication: prepare fam for unusual pt communication
IMPLEMENTATIONS -coping strategies -care of emotional and physical needs -anger: normal
response to grief. grieving person cannot be forced to accept the loss -*elizabeth kubler ross
swiss american FEARS OF DEATH -pain -shortness of breath-air
hunger-opioids-bronchodilators-o2 -loneliness, abandonment -meaninglessness, life review
POSTMORTEM -close pts eyes, replace dentures, wash and position body -allow fam as much
time as they need -*as a nurse recognize your values, attitudes and feelings about death
Q11 Diabetic ketoacidosis (DKA)
A -profound deficiency of insulin -most likely occur in type 1 diabetes -characterized:
hyperglycemia, ketosis, acidosis, dehydration -ketones cause metabolic acidosis -can be
managed outpatient, but may need to hospitalize for severe fluid and electrolyte imbalance,
fever, N/V, diarrhea, altered mental state. NEED to be communicating with provider
PRECIPITATING FACTORS -illness, infection -inadequate insulin dosage -undiagnosed T1DM
-poor self management, neglect MANIFESTATIONS -dehydration, poor skin turgor, dry
mucous membranes, tachycardia, orthostatic hypotension -lethargy and weakness early
-skin dry and loose, eyes soft and sunken -renal failure which may occur from hypovolemia
shock can cause the retention of ketones and glucose which progresses acidosis IMPORTANT
-abdominal pain, anorexia, nausea,vomiting -*kussumal respirations (rapid, deep breathing
by exhalation of excess CO2), sweet fruity breath odor (acetone) -blood glucose > or =
250mg/dl -pH lower than 7.30 -serum bicarbonate <16meq/L -moderate to high ketones in
urine or serum
Q12 DKA treatment
Page 3
