NSG430 Exam 4 V3 | NSG 430 Adult Health
Nursing II | Grand Canyon University
This comprehensive exam-style preparation material is designed to support students preparing
for advanced adult health nursing assessments involving critical care, complex multisystem
disorders, and specialized nursing interventions. The content focuses on integrating adult
nursing knowledge into high-level clinical decision-making scenarios.
The questions are structured to closely mirror actual course assessments while reinforcing
analytical reasoning, prioritization, and safe nursing interventions. Detailed expert explanations
are included to improve comprehension and academic performance.
════════════════════════════════════
The Exam Covers:
• Advanced adult assessment
• Disaster preparedness nursing
• Pharmacological management in critical care
• Specialized adult nursing procedures
• Leadership in nursing practice
• Cultural considerations in adult care
• Complex patient prioritization
• Comprehensive adult health nursing review
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1. During a mass casualty incident, a nurse is using the START triage system. Which patient
should be assigned a RED tag?
A. A patient with a broken arm and minor abrasions who is walking.
B. A patient with no respirations after the airway is opened.
C. A patient with a large laceration on the leg who follows commands.
D. A patient with a respiratory rate of 32/min and a delayed capillary refill.
Correct Answer: D
,Expert Explanation: In the START triage system, RED tags are for immediate priority. A
respiratory rate over 30 per minute or delayed capillary refill indicates shock or
respiratory distress. This patient requires urgent life-saving intervention to survive.
2. A patient in the ICU has a Central Venous Pressure (CVP) of 1 mmHg. What is the nurse’s
priority action?
A. Continue to monitor the patient every 4 hours.
B. Administer a PRN dose of Furosemide.
C. Administer a prescribed 500 mL bolus of normal saline.
D. Assess the patient for signs of pulmonary edema.
Correct Answer: C
Expert Explanation: Normal CVP ranges from 2 to 8 mmHg. A value of 1 mmHg indicates
hypovolemia or fluid volume deficit. The nurse should anticipate fluid resuscitation to
improve preload and cardiac output.
3. Which of the following describes the ‘Warm’ phase of Septic Shock?
A. Hypotension, cool clammy skin, and bradycardia.
B. Profound metabolic acidosis and decreased urine output.
C. Hyperthermia, flushed skin, and high cardiac output.
D. Generalized edema and pulmonary congestion.
Correct Answer: C
, Expert Explanation: Septic shock typically begins with a hyperdynamic phase
characterized by vasodilation, warm flushed skin, and high cardiac output. This occurs as
the body attempts to compensate for systemic inflammation. Recognizing this early phase
is critical for timely antibiotic and fluid intervention.
4. A nurse is caring for a patient on a mechanical ventilator. The ‘High Pressure’ alarm begins
to sound. Which action should the nurse take first?
A. Disconnect the patient and use a manual resuscitation bag.
B. Administer a sedative to the patient immediately.
C. Increase the oxygen concentration to 100%.
D. Check the tubing for kinks or the patient for biting the tube.
Correct Answer: D
Expert Explanation: High pressure alarms are usually caused by resistance in the circuit,
such as kinks, secretions, or the patient biting the ET tube. Troubleshooting should begin
with simple physical obstructions. If the cause isn’t found and the patient is distressed,
manual ventilation would then be necessary.
5. Which task is most appropriate for the RN to delegate to an unlicensed assistive personnel
(UAP)?
A. Perform an admission assessment on a stable patient.
B. Obtain vital signs for a patient receiving a blood transfusion.
C. Monitor a patient’s neurological status post-stroke.
Nursing II | Grand Canyon University
This comprehensive exam-style preparation material is designed to support students preparing
for advanced adult health nursing assessments involving critical care, complex multisystem
disorders, and specialized nursing interventions. The content focuses on integrating adult
nursing knowledge into high-level clinical decision-making scenarios.
The questions are structured to closely mirror actual course assessments while reinforcing
analytical reasoning, prioritization, and safe nursing interventions. Detailed expert explanations
are included to improve comprehension and academic performance.
════════════════════════════════════
The Exam Covers:
• Advanced adult assessment
• Disaster preparedness nursing
• Pharmacological management in critical care
• Specialized adult nursing procedures
• Leadership in nursing practice
• Cultural considerations in adult care
• Complex patient prioritization
• Comprehensive adult health nursing review
════════════════════════════════════
1. During a mass casualty incident, a nurse is using the START triage system. Which patient
should be assigned a RED tag?
A. A patient with a broken arm and minor abrasions who is walking.
B. A patient with no respirations after the airway is opened.
C. A patient with a large laceration on the leg who follows commands.
D. A patient with a respiratory rate of 32/min and a delayed capillary refill.
Correct Answer: D
,Expert Explanation: In the START triage system, RED tags are for immediate priority. A
respiratory rate over 30 per minute or delayed capillary refill indicates shock or
respiratory distress. This patient requires urgent life-saving intervention to survive.
2. A patient in the ICU has a Central Venous Pressure (CVP) of 1 mmHg. What is the nurse’s
priority action?
A. Continue to monitor the patient every 4 hours.
B. Administer a PRN dose of Furosemide.
C. Administer a prescribed 500 mL bolus of normal saline.
D. Assess the patient for signs of pulmonary edema.
Correct Answer: C
Expert Explanation: Normal CVP ranges from 2 to 8 mmHg. A value of 1 mmHg indicates
hypovolemia or fluid volume deficit. The nurse should anticipate fluid resuscitation to
improve preload and cardiac output.
3. Which of the following describes the ‘Warm’ phase of Septic Shock?
A. Hypotension, cool clammy skin, and bradycardia.
B. Profound metabolic acidosis and decreased urine output.
C. Hyperthermia, flushed skin, and high cardiac output.
D. Generalized edema and pulmonary congestion.
Correct Answer: C
, Expert Explanation: Septic shock typically begins with a hyperdynamic phase
characterized by vasodilation, warm flushed skin, and high cardiac output. This occurs as
the body attempts to compensate for systemic inflammation. Recognizing this early phase
is critical for timely antibiotic and fluid intervention.
4. A nurse is caring for a patient on a mechanical ventilator. The ‘High Pressure’ alarm begins
to sound. Which action should the nurse take first?
A. Disconnect the patient and use a manual resuscitation bag.
B. Administer a sedative to the patient immediately.
C. Increase the oxygen concentration to 100%.
D. Check the tubing for kinks or the patient for biting the tube.
Correct Answer: D
Expert Explanation: High pressure alarms are usually caused by resistance in the circuit,
such as kinks, secretions, or the patient biting the ET tube. Troubleshooting should begin
with simple physical obstructions. If the cause isn’t found and the patient is distressed,
manual ventilation would then be necessary.
5. Which task is most appropriate for the RN to delegate to an unlicensed assistive personnel
(UAP)?
A. Perform an admission assessment on a stable patient.
B. Obtain vital signs for a patient receiving a blood transfusion.
C. Monitor a patient’s neurological status post-stroke.
