NSG430 Exam 3 V1 NSG430 Exam 3 V1
NSG 430 Exam 3 V1
1. A patient arrives at the emergency department with suspected ischemic stroke. Which
diagnostic test is the priority to perform first?
A. Non-contrast Computed Tomography (CT) scan
B. Magnetic Resonance Imaging (MRI)
C. Carotid Ultrasound
D. Electroencephalogram (EEG)
Answer: A
Rationale: A non-contrast CT scan is the priority to differentiate between an ischemic and
a hemorrhagic stroke. This distinction is critical because the treatments for the two types
of stroke are vastly different. Rapid imaging ensures that thrombolytic therapy can be
initiated quickly if the patient qualifies.
2. A nurse is caring for a patient experiencing a tonic-clonic seizure. What is the most
important action for the nurse to take?
A. Insert a padded tongue blade into the patient’s mouth.
B. Turn the patient to a side-lying position.
C. Restrain the patient’s limbs to prevent injury.
,D. Administer oral anticonvulsants immediately.
Answer: B
Rationale: Turning the patient to a side-lying position helps maintain a patent airway and
prevents aspiration of saliva or emesis. It is vital to never force anything into the mouth of a
seizing patient as it can cause dental or soft tissue injury. The nurse should also protect the
head and clear the area of hazards.
3. When assessing a patient using the Glasgow Coma Scale (GCS), the nurse finds the patient
opens eyes to sound, uses inappropriate words, and withdraws from pain. What is the GCS
score?
A. 9
B. 10
C. 11
D. 12
Answer: B
Rationale: The score is calculated as Eye opening to sound (3), Inappropriate words (3),
and Withdrawal from pain (4), totaling 10. The GCS is a standardized tool used to assess
neurological status and level of consciousness. A score of 8 or less typically indicates a
severe brain injury.
, 4. A patient with a lower leg fracture reports severe pain that is not relieved by prescribed
morphine. The nurse notes the leg is pale and the pedal pulse is weak. What is the priority
nursing action?
A. Apply a warm compress to the leg.
B. Notify the healthcare provider immediately.
C. Elevate the leg above the level of the heart.
D. Encourage the patient to perform range-of-motion exercises.
Answer: B
Rationale: These signs are indicative of compartment syndrome, which is a surgical
emergency. Delayed treatment can lead to permanent nerve damage or limb loss. The
nurse must notify the provider immediately and should not elevate the limb above heart
level as this can further decrease arterial perfusion.
5. A patient with sickle cell anemia is admitted for a vaso-occlusive crisis. Which intervention
should the nurse prioritize?
A. Applying cold compresses to painful joints.
B. Administering IV fluids for hydration.
C. Restricting fluid intake to prevent edema.
D. Encouring vigorous physical activity.
Answer: B
NSG 430 Exam 3 V1
1. A patient arrives at the emergency department with suspected ischemic stroke. Which
diagnostic test is the priority to perform first?
A. Non-contrast Computed Tomography (CT) scan
B. Magnetic Resonance Imaging (MRI)
C. Carotid Ultrasound
D. Electroencephalogram (EEG)
Answer: A
Rationale: A non-contrast CT scan is the priority to differentiate between an ischemic and
a hemorrhagic stroke. This distinction is critical because the treatments for the two types
of stroke are vastly different. Rapid imaging ensures that thrombolytic therapy can be
initiated quickly if the patient qualifies.
2. A nurse is caring for a patient experiencing a tonic-clonic seizure. What is the most
important action for the nurse to take?
A. Insert a padded tongue blade into the patient’s mouth.
B. Turn the patient to a side-lying position.
C. Restrain the patient’s limbs to prevent injury.
,D. Administer oral anticonvulsants immediately.
Answer: B
Rationale: Turning the patient to a side-lying position helps maintain a patent airway and
prevents aspiration of saliva or emesis. It is vital to never force anything into the mouth of a
seizing patient as it can cause dental or soft tissue injury. The nurse should also protect the
head and clear the area of hazards.
3. When assessing a patient using the Glasgow Coma Scale (GCS), the nurse finds the patient
opens eyes to sound, uses inappropriate words, and withdraws from pain. What is the GCS
score?
A. 9
B. 10
C. 11
D. 12
Answer: B
Rationale: The score is calculated as Eye opening to sound (3), Inappropriate words (3),
and Withdrawal from pain (4), totaling 10. The GCS is a standardized tool used to assess
neurological status and level of consciousness. A score of 8 or less typically indicates a
severe brain injury.
, 4. A patient with a lower leg fracture reports severe pain that is not relieved by prescribed
morphine. The nurse notes the leg is pale and the pedal pulse is weak. What is the priority
nursing action?
A. Apply a warm compress to the leg.
B. Notify the healthcare provider immediately.
C. Elevate the leg above the level of the heart.
D. Encourage the patient to perform range-of-motion exercises.
Answer: B
Rationale: These signs are indicative of compartment syndrome, which is a surgical
emergency. Delayed treatment can lead to permanent nerve damage or limb loss. The
nurse must notify the provider immediately and should not elevate the limb above heart
level as this can further decrease arterial perfusion.
5. A patient with sickle cell anemia is admitted for a vaso-occlusive crisis. Which intervention
should the nurse prioritize?
A. Applying cold compresses to painful joints.
B. Administering IV fluids for hydration.
C. Restricting fluid intake to prevent edema.
D. Encouring vigorous physical activity.
Answer: B
