Exam 3 NUR 445 UPDATED ACTUAL
Questions and CORRECT Answers
1) The nurse is educating the client and their family about the client new diagnosis of ALS. Which
statement my client/family need future education? - CORRECT ANSWER - Answer: Any
statement implying ALS is reversible, cognition is always affected, or that rest slows progression. ALS
affects motor neurons—not cognitive function—and has no cure; focus on symptom management.
2) A female client is admitted to the ICU with cardiogenic shock following a MI. What treatment option
should the nurse anticipate may be ordered? - CORRECT ANSWER - Answer: Inotropic agents
(e.g., dobutamine), nitrates if blood pressure allows, oxygen, possible intra‑aortic balloon pump (IABP).
3) The nurse has administered a dose of IM penicillin to a client. Five minute later the client report SOB
and itching. The nurse note strider and raised red rash. What path change is happening to the client? -
CORRECT ANSWER - Answer: Anaphylaxis—type I hypersensitivity; mast cell degranulation →
histamine → bronchoconstriction and urticaria.
4) A client is being admitted with septic shock. Which lavatory test is the priority for the nurse to obtain
before imitating antibiotic therapy? - CORRECT ANSWER - Answer: Serum lactate (and blood
cultures)—elevated lactic acid helps guide resuscitation and identifies organ hypoperfusion.
5) The nurse assesses a client with brain tumor. Which finding would be consistent with this diagnosis? -
CORRECT ANSWER - Answer: Headache (usually worse in AM), vomiting, visual changes,
seizures, personality changes, focal deficits.
6) The nurse is caring for a client in the emergency department who was brough in with signs of a stroke.
The health care team is determining if the client should be prescribing tissue plasminogen activator
(TPA). Which finding in the client health history should the nurse understand would exclude them from
being eligible for TPA administration? - CORRECT ANSWER - answer: Recent major surgery or
head trauma, hemorrhagic stroke, current anticoagulation with high INR (>1.7), uncontrolled
hypertension, recent GI bleed.
7) The nurse assesses a client with ICP. What priority action should the nurse complete? - CORRECT
ANSWER - Answer: Head elevation to 30°, maintain neck midline, avoid suctioning or Valsalva
maneuvers, monitor pupil/neurological changes.
, 8) Which of the following medication classification would most likely help prevent stress ulcer for a
client in the ICU. (SATA) - CORRECT ANSWER - Answer: Proton pump inhibitors (e.g.,
pantoprazole); H₂ receptor blockers (e.g., ranitidine); sucralfate.
9) Which classifications listed below are used as treatment to support cardiac output in client diagnosed
with shock? - CORRECT ANSWER - Answer: Inotropic agents (dobutamine, dobutrex);
vasopressors (norepinephrine, dopamine); vasodilators in cardiogenic shock (nitroprusside).
10) The nurse is caring for a client diagnosed with obstructive shock. Which of the following assessment
finding indicates decrease cardiac output? - CORRECT ANSWER - Answer: JVD, muffled heart
sounds, hypotension (e.g., in tamponade) or pulsus paradoxus; ↓ peripheral pulses.
11) The nurse recognizes which disorder increase the client risk for obstructive shock? - CORRECT
ANSWER - Answer: Pericardial tamponade, tension pneumothorax, massive pulmonary embolism,
cardiac tamponade.
What is the name of the main type of shock which is characterized by widespread vasodilation and
increase capillary permeability? - CORRECT ANSWER - Answer: Distributive shock (specifically,
septic shock).
13) The nurse cares for the client with sepsis after a crushing injury to the left leg. Based on the nurses
note. What is the nurse's priority intervention to prevent the development of multiple organ dysfunction
(MOD)? - CORRECT ANSWER - Answer: Early fluid resuscitation, broad‑spectrum antibiotics,
oxygenation, hemodynamic monitoring—these are all priorities.
While a nurse is evaluating the sepsis bundle of care policy. What labatory test should the nurse identify
as the most important to monitor? - CORRECT ANSWER - Answer: Lactate level (rising indicates
poor perfusion) along with cultures and renal function.
The nurse cares for a client with septic shock. Which assessment findings should indicate that the
treatment was effective? (SATA) - CORRECT ANSWER - Answer: Improved blood pressure;
decreased lactate; increased urine output; decreased heart rate.
The nurse is caring for a client 4 hr after a evacuation of the subdural hematoma. Which assessment is the
nurse's priority? - CORRECT ANSWER - Answer: Level of consciousness & pupil symmetry—
detects rebleeding or rising ICP.
Questions and CORRECT Answers
1) The nurse is educating the client and their family about the client new diagnosis of ALS. Which
statement my client/family need future education? - CORRECT ANSWER - Answer: Any
statement implying ALS is reversible, cognition is always affected, or that rest slows progression. ALS
affects motor neurons—not cognitive function—and has no cure; focus on symptom management.
2) A female client is admitted to the ICU with cardiogenic shock following a MI. What treatment option
should the nurse anticipate may be ordered? - CORRECT ANSWER - Answer: Inotropic agents
(e.g., dobutamine), nitrates if blood pressure allows, oxygen, possible intra‑aortic balloon pump (IABP).
3) The nurse has administered a dose of IM penicillin to a client. Five minute later the client report SOB
and itching. The nurse note strider and raised red rash. What path change is happening to the client? -
CORRECT ANSWER - Answer: Anaphylaxis—type I hypersensitivity; mast cell degranulation →
histamine → bronchoconstriction and urticaria.
4) A client is being admitted with septic shock. Which lavatory test is the priority for the nurse to obtain
before imitating antibiotic therapy? - CORRECT ANSWER - Answer: Serum lactate (and blood
cultures)—elevated lactic acid helps guide resuscitation and identifies organ hypoperfusion.
5) The nurse assesses a client with brain tumor. Which finding would be consistent with this diagnosis? -
CORRECT ANSWER - Answer: Headache (usually worse in AM), vomiting, visual changes,
seizures, personality changes, focal deficits.
6) The nurse is caring for a client in the emergency department who was brough in with signs of a stroke.
The health care team is determining if the client should be prescribing tissue plasminogen activator
(TPA). Which finding in the client health history should the nurse understand would exclude them from
being eligible for TPA administration? - CORRECT ANSWER - answer: Recent major surgery or
head trauma, hemorrhagic stroke, current anticoagulation with high INR (>1.7), uncontrolled
hypertension, recent GI bleed.
7) The nurse assesses a client with ICP. What priority action should the nurse complete? - CORRECT
ANSWER - Answer: Head elevation to 30°, maintain neck midline, avoid suctioning or Valsalva
maneuvers, monitor pupil/neurological changes.
, 8) Which of the following medication classification would most likely help prevent stress ulcer for a
client in the ICU. (SATA) - CORRECT ANSWER - Answer: Proton pump inhibitors (e.g.,
pantoprazole); H₂ receptor blockers (e.g., ranitidine); sucralfate.
9) Which classifications listed below are used as treatment to support cardiac output in client diagnosed
with shock? - CORRECT ANSWER - Answer: Inotropic agents (dobutamine, dobutrex);
vasopressors (norepinephrine, dopamine); vasodilators in cardiogenic shock (nitroprusside).
10) The nurse is caring for a client diagnosed with obstructive shock. Which of the following assessment
finding indicates decrease cardiac output? - CORRECT ANSWER - Answer: JVD, muffled heart
sounds, hypotension (e.g., in tamponade) or pulsus paradoxus; ↓ peripheral pulses.
11) The nurse recognizes which disorder increase the client risk for obstructive shock? - CORRECT
ANSWER - Answer: Pericardial tamponade, tension pneumothorax, massive pulmonary embolism,
cardiac tamponade.
What is the name of the main type of shock which is characterized by widespread vasodilation and
increase capillary permeability? - CORRECT ANSWER - Answer: Distributive shock (specifically,
septic shock).
13) The nurse cares for the client with sepsis after a crushing injury to the left leg. Based on the nurses
note. What is the nurse's priority intervention to prevent the development of multiple organ dysfunction
(MOD)? - CORRECT ANSWER - Answer: Early fluid resuscitation, broad‑spectrum antibiotics,
oxygenation, hemodynamic monitoring—these are all priorities.
While a nurse is evaluating the sepsis bundle of care policy. What labatory test should the nurse identify
as the most important to monitor? - CORRECT ANSWER - Answer: Lactate level (rising indicates
poor perfusion) along with cultures and renal function.
The nurse cares for a client with septic shock. Which assessment findings should indicate that the
treatment was effective? (SATA) - CORRECT ANSWER - Answer: Improved blood pressure;
decreased lactate; increased urine output; decreased heart rate.
The nurse is caring for a client 4 hr after a evacuation of the subdural hematoma. Which assessment is the
nurse's priority? - CORRECT ANSWER - Answer: Level of consciousness & pupil symmetry—
detects rebleeding or rising ICP.
