NSG430 Final Exam V3 | NSG 430 Adult
Health Nursing II | Grand Canyon
University
1. A patient in the Intensive Care Unit (ICU) is diagnosed with Acute Respiratory Distress
Syndrome (ARDS). The nurse understands that the primary physiological change in ARDS is:
A. Increased compliance of the lung tissue
B. Damage to the alveolar-capillary membrane
C. Decreased capillary permeability
D. Excessive production of surfactant
Answer: B
Rationale: ARDS is characterized by significant damage to the alveolar-capillary
membrane, which leads to non-cardiogenic pulmonary edema. This damage allows fluid to
leak into the alveoli, severely impairing gas exchange. As a result, patients experience
refractory hypoxemia despite high levels of oxygen administration.
2. A nurse is caring for a patient who has a chest tube following a lobectomy. The nurse notes
continuous bubbling in the water-seal chamber. What should the nurse suspect?
A. The lung has fully re-expanded
B. Normal functioning of the drainage system
C. An air leak in the system
,D. The suction pressure is too high
Answer: C
Rationale: Continuous bubbling in the water-seal chamber typically indicates an air leak
either in the patient’s pleural space or within the drainage tubing itself. Intermittent
bubbling is normal during expiration or coughing in a patient with a pneumothorax, but
continuous bubbling is not. The nurse must systematically check all connections and the
insertion site to locate the source.
3. A patient with a traumatic brain injury is showing signs of increased intracranial pressure
(ICP). Which of the following is an early clinical manifestation of increased ICP?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Change in the level of consciousness
D. Decerebrate posturing
Answer: C
Rationale: A change in the level of consciousness (LOC) is the most sensitive and earliest
indicator of increased ICP. Other signs like Cushing’s triad (widening pulse pressure,
bradycardia, and irregular respirations) are late signs that suggest brainstem herniation is
imminent. It is critical for the nurse to detect subtle changes in orientation or alertness to
prevent further neurological damage.
,4. A nurse is assessing a patient with acute pancreatitis. Which of the following laboratory
findings is most characteristic of this condition?
A. Decreased serum lipase
B. Increased serum calcium
C. Increased serum amylase
D. Decreased white blood cell count
Answer: C
Rationale: Serum amylase and lipase levels are typically elevated in patients with acute
pancreatitis due to the inflammatory process within the pancreas. Amylase rises early but
returns to normal within 48 to 72 hours, whereas lipase stays elevated longer. In contrast,
serum calcium levels often decrease in severe cases due to fat necrosis and saponification.
5. A patient is admitted with septic shock. Which of the following hemodynamic parameters
would the nurse expect to find?
A. High Systemic Vascular Resistance (SVR)
B. Increased Central Venous Pressure (CVP)
C. Normal Mean Arterial Pressure (MAP)
D. Decreased Systemic Vascular Resistance (SVR)
Answer: D
, Rationale: Septic shock is a distributive shock characterized by massive vasodilation,
which results in a significantly decreased Systemic Vascular Resistance (SVR). This
vasodilation leads to relative hypovolemia even if the total fluid volume is normal. The
primary goal of management is to restore vascular tone and provide adequate fluid
resuscitation to maintain perfusion.
6. A nurse is caring for a patient who sustained a high cervical spinal cord injury (C3-C5).
Which of the following is the priority assessment?
A. Bladder distension
B. Respiratory effort
C. Deep vein thrombosis
D. Muscle strength in the lower extremities
Answer: B
Rationale: Injuries at the C3 through C5 level involve the phrenic nerve, which controls the
diaphragm and is essential for spontaneous breathing. Patients with these injuries are at
high risk for respiratory failure and may require mechanical ventilation. Airway
management and respiratory assessment always take priority over other musculoskeletal
or excretory assessments in the acute phase.
7. Which of the following is the priority intervention for a patient experiencing Autonomic
Dysreflexia?
A. Administer pain medication
Health Nursing II | Grand Canyon
University
1. A patient in the Intensive Care Unit (ICU) is diagnosed with Acute Respiratory Distress
Syndrome (ARDS). The nurse understands that the primary physiological change in ARDS is:
A. Increased compliance of the lung tissue
B. Damage to the alveolar-capillary membrane
C. Decreased capillary permeability
D. Excessive production of surfactant
Answer: B
Rationale: ARDS is characterized by significant damage to the alveolar-capillary
membrane, which leads to non-cardiogenic pulmonary edema. This damage allows fluid to
leak into the alveoli, severely impairing gas exchange. As a result, patients experience
refractory hypoxemia despite high levels of oxygen administration.
2. A nurse is caring for a patient who has a chest tube following a lobectomy. The nurse notes
continuous bubbling in the water-seal chamber. What should the nurse suspect?
A. The lung has fully re-expanded
B. Normal functioning of the drainage system
C. An air leak in the system
,D. The suction pressure is too high
Answer: C
Rationale: Continuous bubbling in the water-seal chamber typically indicates an air leak
either in the patient’s pleural space or within the drainage tubing itself. Intermittent
bubbling is normal during expiration or coughing in a patient with a pneumothorax, but
continuous bubbling is not. The nurse must systematically check all connections and the
insertion site to locate the source.
3. A patient with a traumatic brain injury is showing signs of increased intracranial pressure
(ICP). Which of the following is an early clinical manifestation of increased ICP?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Change in the level of consciousness
D. Decerebrate posturing
Answer: C
Rationale: A change in the level of consciousness (LOC) is the most sensitive and earliest
indicator of increased ICP. Other signs like Cushing’s triad (widening pulse pressure,
bradycardia, and irregular respirations) are late signs that suggest brainstem herniation is
imminent. It is critical for the nurse to detect subtle changes in orientation or alertness to
prevent further neurological damage.
,4. A nurse is assessing a patient with acute pancreatitis. Which of the following laboratory
findings is most characteristic of this condition?
A. Decreased serum lipase
B. Increased serum calcium
C. Increased serum amylase
D. Decreased white blood cell count
Answer: C
Rationale: Serum amylase and lipase levels are typically elevated in patients with acute
pancreatitis due to the inflammatory process within the pancreas. Amylase rises early but
returns to normal within 48 to 72 hours, whereas lipase stays elevated longer. In contrast,
serum calcium levels often decrease in severe cases due to fat necrosis and saponification.
5. A patient is admitted with septic shock. Which of the following hemodynamic parameters
would the nurse expect to find?
A. High Systemic Vascular Resistance (SVR)
B. Increased Central Venous Pressure (CVP)
C. Normal Mean Arterial Pressure (MAP)
D. Decreased Systemic Vascular Resistance (SVR)
Answer: D
, Rationale: Septic shock is a distributive shock characterized by massive vasodilation,
which results in a significantly decreased Systemic Vascular Resistance (SVR). This
vasodilation leads to relative hypovolemia even if the total fluid volume is normal. The
primary goal of management is to restore vascular tone and provide adequate fluid
resuscitation to maintain perfusion.
6. A nurse is caring for a patient who sustained a high cervical spinal cord injury (C3-C5).
Which of the following is the priority assessment?
A. Bladder distension
B. Respiratory effort
C. Deep vein thrombosis
D. Muscle strength in the lower extremities
Answer: B
Rationale: Injuries at the C3 through C5 level involve the phrenic nerve, which controls the
diaphragm and is essential for spontaneous breathing. Patients with these injuries are at
high risk for respiratory failure and may require mechanical ventilation. Airway
management and respiratory assessment always take priority over other musculoskeletal
or excretory assessments in the acute phase.
7. Which of the following is the priority intervention for a patient experiencing Autonomic
Dysreflexia?
A. Administer pain medication
