NSG430 Final Exam V2 | NSG 430 Adult
Health Nursing II | Grand Canyon
University
1. A patient with a potassium level of 6.2 mEq/L is admitted to the unit. Which ECG change
should the nurse expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia is characterized by tall, peaked T waves on an ECG as the first
sign of cardiac instability. As potassium levels continue to rise, the QRS complex may
widen, eventually leading to cardiac arrest. The nurse must monitor the heart rhythm
closely and prepare for pharmacological interventions like calcium gluconate or insulin
with dextrose.
2. The nurse is caring for a patient with Syndrome of Inappropriate Antidiuretic Hormone
(SIADH). Which intervention is a priority?
A. Encouraging oral fluid intake
B. Administering hypotonic IV fluids
,C. Increasing dietary sodium intake rapidly
D. Restricting fluid intake to 800-1000 mL/day
Answer: D
Rationale: Fluid restriction is the primary treatment for SIADH to prevent further dilution
of serum sodium. Over-restoration of fluids can lead to worsening hyponatremia and
cerebral edema. The nurse should also monitor daily weights and neurologic status to
assess the effectiveness of the treatment plan.
3. A patient is brought to the Emergency Department in hypovolemic shock. Which clinical
finding should the nurse expect to assess?
A. Bradycardia and hypertension
B. Warm, dry skin and bounding pulses
C. Tachycardia and hypotension
D. Increased urine output and bradypnea
Answer: C
Rationale: Hypovolemic shock results in decreased circulating volume, leading to a
compensatory increase in heart rate (tachycardia) to maintain cardiac output. As
compensation fails, blood pressure drops (hypotension) due to insufficient volume. Other
signs include cool, clammy skin and decreased urine output as the body shunts blood to
vital organs.
, 4. When assessing a patient for septic shock, which finding indicates the compensatory
‘warm’ phase?
A. Hyperdynamic state with warm, flushed skin
B. Decreased cardiac output
C. Cool, mottled extremities
D. Hypothermia and bradycardia
Answer: A
Rationale: The early or ‘warm’ phase of septic shock is characterized by vasodilation and a
high cardiac output, making the skin feel warm and flushed. This hyperdynamic state
occurs as the body attempts to compensate for systemic infection. If untreated, the patient
will eventually progress to the cold phase, characterized by multisystem organ failure.
5. A patient has suffered partial-thickness burns to both legs and the entire back. Using the
Rule of Nines, what is the estimated total body surface area (TBSA) affected?
A. 36%
B. 54%
C. 45%
D. 63%
Answer: B
Health Nursing II | Grand Canyon
University
1. A patient with a potassium level of 6.2 mEq/L is admitted to the unit. Which ECG change
should the nurse expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia is characterized by tall, peaked T waves on an ECG as the first
sign of cardiac instability. As potassium levels continue to rise, the QRS complex may
widen, eventually leading to cardiac arrest. The nurse must monitor the heart rhythm
closely and prepare for pharmacological interventions like calcium gluconate or insulin
with dextrose.
2. The nurse is caring for a patient with Syndrome of Inappropriate Antidiuretic Hormone
(SIADH). Which intervention is a priority?
A. Encouraging oral fluid intake
B. Administering hypotonic IV fluids
,C. Increasing dietary sodium intake rapidly
D. Restricting fluid intake to 800-1000 mL/day
Answer: D
Rationale: Fluid restriction is the primary treatment for SIADH to prevent further dilution
of serum sodium. Over-restoration of fluids can lead to worsening hyponatremia and
cerebral edema. The nurse should also monitor daily weights and neurologic status to
assess the effectiveness of the treatment plan.
3. A patient is brought to the Emergency Department in hypovolemic shock. Which clinical
finding should the nurse expect to assess?
A. Bradycardia and hypertension
B. Warm, dry skin and bounding pulses
C. Tachycardia and hypotension
D. Increased urine output and bradypnea
Answer: C
Rationale: Hypovolemic shock results in decreased circulating volume, leading to a
compensatory increase in heart rate (tachycardia) to maintain cardiac output. As
compensation fails, blood pressure drops (hypotension) due to insufficient volume. Other
signs include cool, clammy skin and decreased urine output as the body shunts blood to
vital organs.
, 4. When assessing a patient for septic shock, which finding indicates the compensatory
‘warm’ phase?
A. Hyperdynamic state with warm, flushed skin
B. Decreased cardiac output
C. Cool, mottled extremities
D. Hypothermia and bradycardia
Answer: A
Rationale: The early or ‘warm’ phase of septic shock is characterized by vasodilation and a
high cardiac output, making the skin feel warm and flushed. This hyperdynamic state
occurs as the body attempts to compensate for systemic infection. If untreated, the patient
will eventually progress to the cold phase, characterized by multisystem organ failure.
5. A patient has suffered partial-thickness burns to both legs and the entire back. Using the
Rule of Nines, what is the estimated total body surface area (TBSA) affected?
A. 36%
B. 54%
C. 45%
D. 63%
Answer: B
