NSG430 Exam 4 V1 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A patient is in the compensatory stage of shock. Which clinical manifestation should the
nurse expect to find?
A. Narrowing pulse pressure
B. Absent bowel sounds
C. Lethargy and confusion
D. Anuria
Answer: A
Rationale: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. A narrowing pulse
pressure occurs as the diastolic pressure rises due to systemic vasoconstriction while
systolic pressure is maintained. This stage is characterized by clinical stability, though the
underlying pathophysiology is progressing.
2. Which intervention is a priority for a patient diagnosed with septic shock who has a low
mean arterial pressure (MAP)?
A. Administering broad-spectrum antibiotics
B. Initiating vasopressor therapy with norepinephrine
C. Rapid fluid resuscitation with isotonic crystalloids
,D. Obtaining blood cultures from two different sites
Answer: C
Rationale: Fluid resuscitation is the initial priority in septic shock to restore intravascular
volume and improve tissue perfusion. Isotonic crystalloids, such as Normal Saline or
Lactated Ringer’s, are typically administered at 30 mL/kg. This intervention must precede
or occur simultaneously with antibiotic administration to stabilize the patient’s
hemodynamics.
3. A patient on mechanical ventilation triggers the high-pressure alarm. What is the nurse’s
first action?
A. Assess the patient’s respiratory status
B. Suction the patient’s airway
C. Check for kinks in the ventilator tubing
D. Manually ventilate the patient with a bag-valve-mask
Answer: A
Rationale: The first step when an alarm sounds is always to assess the patient to ensure
they are ventilating and are not in immediate distress. High-pressure alarms can be caused
by coughing, biting the tube, or secretions, but a physical assessment determines the
severity of the issue. If the cause is not immediately found and the patient is distressed,
manual ventilation would be the next step.
, 4. Which hemodynamic parameter is most indicative of cardiogenic shock?
A. Increased Pulmonary Artery Wedge Pressure (PAWP)
B. Increased Cardiac Index
C. Decreased Central Venous Pressure (CVP)
D. Decreased Systemic Vascular Resistance (SVR)
Answer: A
Rationale: In cardiogenic shock, the heart’s pumping ability is compromised, leading to a
backup of blood into the pulmonary circulation. This results in an increased PAWP,
reflecting high left-ventricular end-diastolic pressure. Conversely, the cardiac index will be
low and the SVR will be high as the body tries to compensate.
5. What is the primary goal of applying Positive End-Expiratory Pressure (PEEP) in a patient
with ARDS?
A. To increase the fraction of inspired oxygen (FiO2)
B. To prevent ventilator-associated pneumonia
C. To keep alveoli open and improve gas exchange
D. To decrease the work of breathing by decreasing tidal volume
Answer: C
Rationale: PEEP provides pressure at the end of expiration to prevent alveolar collapse
and recruit previously collapsed alveoli. This increases the surface area available for gas
Nursing II | Grand Canyon University
1. A patient is in the compensatory stage of shock. Which clinical manifestation should the
nurse expect to find?
A. Narrowing pulse pressure
B. Absent bowel sounds
C. Lethargy and confusion
D. Anuria
Answer: A
Rationale: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. A narrowing pulse
pressure occurs as the diastolic pressure rises due to systemic vasoconstriction while
systolic pressure is maintained. This stage is characterized by clinical stability, though the
underlying pathophysiology is progressing.
2. Which intervention is a priority for a patient diagnosed with septic shock who has a low
mean arterial pressure (MAP)?
A. Administering broad-spectrum antibiotics
B. Initiating vasopressor therapy with norepinephrine
C. Rapid fluid resuscitation with isotonic crystalloids
,D. Obtaining blood cultures from two different sites
Answer: C
Rationale: Fluid resuscitation is the initial priority in septic shock to restore intravascular
volume and improve tissue perfusion. Isotonic crystalloids, such as Normal Saline or
Lactated Ringer’s, are typically administered at 30 mL/kg. This intervention must precede
or occur simultaneously with antibiotic administration to stabilize the patient’s
hemodynamics.
3. A patient on mechanical ventilation triggers the high-pressure alarm. What is the nurse’s
first action?
A. Assess the patient’s respiratory status
B. Suction the patient’s airway
C. Check for kinks in the ventilator tubing
D. Manually ventilate the patient with a bag-valve-mask
Answer: A
Rationale: The first step when an alarm sounds is always to assess the patient to ensure
they are ventilating and are not in immediate distress. High-pressure alarms can be caused
by coughing, biting the tube, or secretions, but a physical assessment determines the
severity of the issue. If the cause is not immediately found and the patient is distressed,
manual ventilation would be the next step.
, 4. Which hemodynamic parameter is most indicative of cardiogenic shock?
A. Increased Pulmonary Artery Wedge Pressure (PAWP)
B. Increased Cardiac Index
C. Decreased Central Venous Pressure (CVP)
D. Decreased Systemic Vascular Resistance (SVR)
Answer: A
Rationale: In cardiogenic shock, the heart’s pumping ability is compromised, leading to a
backup of blood into the pulmonary circulation. This results in an increased PAWP,
reflecting high left-ventricular end-diastolic pressure. Conversely, the cardiac index will be
low and the SVR will be high as the body tries to compensate.
5. What is the primary goal of applying Positive End-Expiratory Pressure (PEEP) in a patient
with ARDS?
A. To increase the fraction of inspired oxygen (FiO2)
B. To prevent ventilator-associated pneumonia
C. To keep alveoli open and improve gas exchange
D. To decrease the work of breathing by decreasing tidal volume
Answer: C
Rationale: PEEP provides pressure at the end of expiration to prevent alveolar collapse
and recruit previously collapsed alveoli. This increases the surface area available for gas
