NURS 431: Complex Care Nursing With Answer Key
Course Examination
Total Points: 200
Time Allowed: 3 Hours
Format: 100 Questions (75 Multiple Choice & 25 Select-All-That-Apply)
Exam Instructions:
• Read each question carefully. Select the best possible answer for multiple-choice questions.
• For Select-All-That-Apply (SATA) questions, select all options that are correct. Partial credit may
be awarded at the instructor's discretion.
• Choose only one answer for standard multiple-choice questions unless specified otherwise.
• Use a No. 2 pencil to fill in the corresponding circle on your Scantron answer sheet.
• Do not write on the exam booklet.
• You may use the blank pages at the end of the booklet for scratch paper.
SECTION I: MULTIPLE CHOICE (75 Questions, 2 points each)
*Directions: For questions 1-75, select the single best answer and mark the corresponding letter on your
answer sheet.*
1. A nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle
accident. Which change in vital signs would the nurse interpret as a manifestation of increased
intracranial pressure (ICP)?
a. Hypotension and bradycardia
b. Hypertension and bradycardia
c. Hypotension and tachycardia
d. Hypertension and tachycardia
2. Which nursing intervention should be implemented as a priority in the care of a patient
experiencing increased ICP?
a. Cluster nursing care to allow for uninterrupted rest periods
b. Maintain the head of the bed in a flat position
c. Suction the airway every hour to prevent pneumonia
d. Administer 0.9% normal saline as a bolus for fluid resuscitation
,3. A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin
hydrochloride. The nurse notes that the I.V. site is warm, edematous, and taut. The nurse also
observes pinkish blood return and fluid leaking from the insertion site. Based on this
information, which condition should the nurse suspect?
a. Occlusion
b. Septicemia
c. Extravasation
d. Thrombophlebitis
4. A nurse is caring for a critically ill client in the surgical-trauma intensive care unit. Which nursing
action(s) will reduce the long-term negative effect of critical care experience for the client and
family?
a. Cluster nursing care to allow for uninterrupted rest periods
b. Maintain the head of the bed in a flat position
c. Suction the airway every hour to prevent pneumonia
d. Administer 0.9% normal saline as a bolus for fluid resuscitation
5. A client with a history of chronic obstructive pulmonary disease (COPD) presents with acute
respiratory distress. The nurse notes jugular venous distention and peripheral edema. Which
acid-base imbalance is most likely occurring?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
6. The nurse is caring for a patient with diabetic ketoacidosis (DKA). Which laboratory finding is
consistent with this condition?
a. Serum pH of 7.45
b. PaCO2 of 48 mm Hg
c. Serum bicarbonate of 18 mEq/L
d. Anion gap of 8 mEq/L
7. A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse
measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood
pressure of 162/90 mm Hg, and a temperature of 98.6°F (37°C). To help correct respiratory
alkalosis, the nurse should:
a. Encourage the client to breathe into a paper bag
b. Administer a prescribed sedative
c. Increase the flow rate of oxygen via nasal cannula
d. Have the client breathe 100% oxygen via non-rebreather mask
8. A client is admitted with a serum sodium level of 118 mEq/L. The nurse should anticipate which
of the following interventions as a priority?
a. Administer 3% normal saline
b. Restrict oral fluid intake to 1000 mL/day
c. Administer a loop diuretic as prescribed
d. Encourage increased dietary intake of sodium-rich foods
9. A patient with heart failure is receiving furosemide (Lasix) 40 mg IV push. The nurse should
monitor the patient for which electrolyte imbalance?
, a. Hyperkalemia
b. Hypokalemia
c. Hypercalcemia
d. Hypermagnesemia
10. The nurse is administering an analgesic to an older adult patient. Why is it important for the
nurse to assess the patient carefully before administration?
a. Older adults are more likely to become addicted to analgesics
b. Older adults metabolize medications more quickly, requiring higher doses
c. Older adults may have decreased renal and hepatic function, affecting drug metabolism
d. Older adults are less likely to experience pain, so analgesics are rarely needed
11. A client receives hydromorphone (Dilaudid) 2 mg intravenously for report of postoperative pain.
Fifteen minutes later, the nurse notes respirations are 6 breaths/minute and the client is
nonresponsive. The nurse administers prescribed naloxone (Narcan). The next time the client
reports pain, the best nursing action is:
a. Administer another dose of hydromorphone at the same dose
b. Administer half the previous dose of hydromorphone
c. Administer a non-opioid analgesic such as acetaminophen
d. Notify the provider and request a different opioid
12. A nurse is caring for a client with a new tracheostomy. Which action is essential to maintain
airway patency?
a. Deflate the cuff before suctioning
b. Suction the tracheostomy tube every hour
c. Use sterile technique when performing tracheostomy care
d. Apply oxygen via tracheostomy collar at 15 L/min
13. A patient is receiving mechanical ventilation in the pressure support mode. The nurse
understands that this mode:
a. Delivers a preset tidal volume with each breath
b. Allows the patient to initiate breaths and the ventilator provides support
c. Provides full ventilatory support and does not allow spontaneous breathing
d. Delivers a preset number of breaths per minute regardless of patient effort
14. The nurse is caring for a patient with a chest tube in place following a thoracotomy. The chest
tube becomes disconnected from the drainage system. What is the nurse's priority action?
a. Clamp the chest tube immediately
b. Place the end of the chest tube in sterile water
c. Notify the provider stat
d. Reconnect the chest tube to the drainage system
15. A patient with a history of seizures is admitted with status epilepticus. Which medication should
the nurse anticipate administering first?
a. Phenytoin (Dilantin) IV push
b. Levetiracetam (Keppra) IV infusion
c. Lorazepam (Ativan) IV push
d. Valproic acid (Depakote) IV infusion
16. The nurse is assessing a patient who sustained a traumatic brain injury. The patient is able to
open eyes only in response to painful stimuli, makes incomprehensible sounds, and withdraws
Course Examination
Total Points: 200
Time Allowed: 3 Hours
Format: 100 Questions (75 Multiple Choice & 25 Select-All-That-Apply)
Exam Instructions:
• Read each question carefully. Select the best possible answer for multiple-choice questions.
• For Select-All-That-Apply (SATA) questions, select all options that are correct. Partial credit may
be awarded at the instructor's discretion.
• Choose only one answer for standard multiple-choice questions unless specified otherwise.
• Use a No. 2 pencil to fill in the corresponding circle on your Scantron answer sheet.
• Do not write on the exam booklet.
• You may use the blank pages at the end of the booklet for scratch paper.
SECTION I: MULTIPLE CHOICE (75 Questions, 2 points each)
*Directions: For questions 1-75, select the single best answer and mark the corresponding letter on your
answer sheet.*
1. A nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle
accident. Which change in vital signs would the nurse interpret as a manifestation of increased
intracranial pressure (ICP)?
a. Hypotension and bradycardia
b. Hypertension and bradycardia
c. Hypotension and tachycardia
d. Hypertension and tachycardia
2. Which nursing intervention should be implemented as a priority in the care of a patient
experiencing increased ICP?
a. Cluster nursing care to allow for uninterrupted rest periods
b. Maintain the head of the bed in a flat position
c. Suction the airway every hour to prevent pneumonia
d. Administer 0.9% normal saline as a bolus for fluid resuscitation
,3. A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin
hydrochloride. The nurse notes that the I.V. site is warm, edematous, and taut. The nurse also
observes pinkish blood return and fluid leaking from the insertion site. Based on this
information, which condition should the nurse suspect?
a. Occlusion
b. Septicemia
c. Extravasation
d. Thrombophlebitis
4. A nurse is caring for a critically ill client in the surgical-trauma intensive care unit. Which nursing
action(s) will reduce the long-term negative effect of critical care experience for the client and
family?
a. Cluster nursing care to allow for uninterrupted rest periods
b. Maintain the head of the bed in a flat position
c. Suction the airway every hour to prevent pneumonia
d. Administer 0.9% normal saline as a bolus for fluid resuscitation
5. A client with a history of chronic obstructive pulmonary disease (COPD) presents with acute
respiratory distress. The nurse notes jugular venous distention and peripheral edema. Which
acid-base imbalance is most likely occurring?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
6. The nurse is caring for a patient with diabetic ketoacidosis (DKA). Which laboratory finding is
consistent with this condition?
a. Serum pH of 7.45
b. PaCO2 of 48 mm Hg
c. Serum bicarbonate of 18 mEq/L
d. Anion gap of 8 mEq/L
7. A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse
measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood
pressure of 162/90 mm Hg, and a temperature of 98.6°F (37°C). To help correct respiratory
alkalosis, the nurse should:
a. Encourage the client to breathe into a paper bag
b. Administer a prescribed sedative
c. Increase the flow rate of oxygen via nasal cannula
d. Have the client breathe 100% oxygen via non-rebreather mask
8. A client is admitted with a serum sodium level of 118 mEq/L. The nurse should anticipate which
of the following interventions as a priority?
a. Administer 3% normal saline
b. Restrict oral fluid intake to 1000 mL/day
c. Administer a loop diuretic as prescribed
d. Encourage increased dietary intake of sodium-rich foods
9. A patient with heart failure is receiving furosemide (Lasix) 40 mg IV push. The nurse should
monitor the patient for which electrolyte imbalance?
, a. Hyperkalemia
b. Hypokalemia
c. Hypercalcemia
d. Hypermagnesemia
10. The nurse is administering an analgesic to an older adult patient. Why is it important for the
nurse to assess the patient carefully before administration?
a. Older adults are more likely to become addicted to analgesics
b. Older adults metabolize medications more quickly, requiring higher doses
c. Older adults may have decreased renal and hepatic function, affecting drug metabolism
d. Older adults are less likely to experience pain, so analgesics are rarely needed
11. A client receives hydromorphone (Dilaudid) 2 mg intravenously for report of postoperative pain.
Fifteen minutes later, the nurse notes respirations are 6 breaths/minute and the client is
nonresponsive. The nurse administers prescribed naloxone (Narcan). The next time the client
reports pain, the best nursing action is:
a. Administer another dose of hydromorphone at the same dose
b. Administer half the previous dose of hydromorphone
c. Administer a non-opioid analgesic such as acetaminophen
d. Notify the provider and request a different opioid
12. A nurse is caring for a client with a new tracheostomy. Which action is essential to maintain
airway patency?
a. Deflate the cuff before suctioning
b. Suction the tracheostomy tube every hour
c. Use sterile technique when performing tracheostomy care
d. Apply oxygen via tracheostomy collar at 15 L/min
13. A patient is receiving mechanical ventilation in the pressure support mode. The nurse
understands that this mode:
a. Delivers a preset tidal volume with each breath
b. Allows the patient to initiate breaths and the ventilator provides support
c. Provides full ventilatory support and does not allow spontaneous breathing
d. Delivers a preset number of breaths per minute regardless of patient effort
14. The nurse is caring for a patient with a chest tube in place following a thoracotomy. The chest
tube becomes disconnected from the drainage system. What is the nurse's priority action?
a. Clamp the chest tube immediately
b. Place the end of the chest tube in sterile water
c. Notify the provider stat
d. Reconnect the chest tube to the drainage system
15. A patient with a history of seizures is admitted with status epilepticus. Which medication should
the nurse anticipate administering first?
a. Phenytoin (Dilantin) IV push
b. Levetiracetam (Keppra) IV infusion
c. Lorazepam (Ativan) IV push
d. Valproic acid (Depakote) IV infusion
16. The nurse is assessing a patient who sustained a traumatic brain injury. The patient is able to
open eyes only in response to painful stimuli, makes incomprehensible sounds, and withdraws
