NSG430 Exam 4 V2 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A patient diagnosed with Acute Respiratory Distress Syndrome (ARDS) is receiving
mechanical ventilation with High Positive End-Expiratory Pressure (PEEP). What is the
primary purpose of PEEP in this clinical scenario?
A. To increase the tidal volume delivered with each breath.
B. To prevent alveolar collapse at the end of expiration.
C. To decrease the work of breathing for the patient.
D. To reduce the risk of barotrauma to the lungs.
Answer: B
Rationale: PEEP provides pressure at the end of expiration to keep the alveoli open, which
improves gas exchange. This recruitment of alveoli is essential in ARDS because it increases
the functional residual capacity of the lungs. Without PEEP, the alveoli in an ARDS patient
would collapse, leading to severe shunting and refractory hypoxemia.
2. A nurse is caring for a patient who suddenly develops ventricular fibrillation (VF) on the
cardiac monitor. What is the priority nursing action?
A. Administer an IV bolus of Amiodarone.
B. Defibrillate the patient immediately.
C. Perform an immediate precordial thump.
,D. Initiate high-quality chest compressions.
Answer: B
Rationale: Defibrillation is the most effective treatment for ventricular fibrillation and
should be performed as soon as a defibrillator is available. While CPR provides temporary
circulation, only electricity can convert VF back to a perfusing rhythm. Early defibrillation
is the single most important factor in surviving an out-of-hospital or in-hospital cardiac
arrest involving VF.
3. A patient’s Central Venous Pressure (CVP) reading is 1 mm Hg. Which clinical assessment
finding should the nurse expect to observe?
A. Jugular venous distention.
B. Dry mucous membranes and poor skin turgor.
C. Peripheral edema in the lower extremities.
D. Crackles in the lower lung bases.
Answer: B
Rationale: A CVP of 1 mm Hg is low, indicating hypovolemia or a lack of fluid volume in the
right atrium. Patients with low CVP typically show signs of dehydration, such as dry
mucous membranes, tachycardia, and low urine output. This finding necessitates a fluid
challenge or increased IV fluid administration to restore adequate preload.
, 4. During the primary survey of a trauma patient, the nurse notes that the patient has
asymmetrical chest wall movement. What is the most likely cause?
A. Flail chest.
B. Abdominal hemorrhage.
C. Cardiac tamponade.
D. Neurogenic shock.
Answer: A
Rationale: Flail chest occurs when multiple ribs are fractured in two or more places,
creating a free-floating segment of the chest wall. This causes paradoxical movement where
the segment sinks in during inspiration and bulges out during expiration. This condition
severely impairs ventilation and requires immediate stabilization and often mechanical
ventilation.
5. A patient with terminal cancer is admitted for hospice care. The family asks why the nurse
is continuing to provide morphine even though the patient is unresponsive. What is the
nurse’s best response?
A. Morphine helps keep the patient’s blood pressure stable.
B. The goal is to prevent pain and provide comfort until the end.
C. Morphine will help the patient wake up for a short time.
D. We are legally required to give it every four hours.
Nursing II | Grand Canyon University
1. A patient diagnosed with Acute Respiratory Distress Syndrome (ARDS) is receiving
mechanical ventilation with High Positive End-Expiratory Pressure (PEEP). What is the
primary purpose of PEEP in this clinical scenario?
A. To increase the tidal volume delivered with each breath.
B. To prevent alveolar collapse at the end of expiration.
C. To decrease the work of breathing for the patient.
D. To reduce the risk of barotrauma to the lungs.
Answer: B
Rationale: PEEP provides pressure at the end of expiration to keep the alveoli open, which
improves gas exchange. This recruitment of alveoli is essential in ARDS because it increases
the functional residual capacity of the lungs. Without PEEP, the alveoli in an ARDS patient
would collapse, leading to severe shunting and refractory hypoxemia.
2. A nurse is caring for a patient who suddenly develops ventricular fibrillation (VF) on the
cardiac monitor. What is the priority nursing action?
A. Administer an IV bolus of Amiodarone.
B. Defibrillate the patient immediately.
C. Perform an immediate precordial thump.
,D. Initiate high-quality chest compressions.
Answer: B
Rationale: Defibrillation is the most effective treatment for ventricular fibrillation and
should be performed as soon as a defibrillator is available. While CPR provides temporary
circulation, only electricity can convert VF back to a perfusing rhythm. Early defibrillation
is the single most important factor in surviving an out-of-hospital or in-hospital cardiac
arrest involving VF.
3. A patient’s Central Venous Pressure (CVP) reading is 1 mm Hg. Which clinical assessment
finding should the nurse expect to observe?
A. Jugular venous distention.
B. Dry mucous membranes and poor skin turgor.
C. Peripheral edema in the lower extremities.
D. Crackles in the lower lung bases.
Answer: B
Rationale: A CVP of 1 mm Hg is low, indicating hypovolemia or a lack of fluid volume in the
right atrium. Patients with low CVP typically show signs of dehydration, such as dry
mucous membranes, tachycardia, and low urine output. This finding necessitates a fluid
challenge or increased IV fluid administration to restore adequate preload.
, 4. During the primary survey of a trauma patient, the nurse notes that the patient has
asymmetrical chest wall movement. What is the most likely cause?
A. Flail chest.
B. Abdominal hemorrhage.
C. Cardiac tamponade.
D. Neurogenic shock.
Answer: A
Rationale: Flail chest occurs when multiple ribs are fractured in two or more places,
creating a free-floating segment of the chest wall. This causes paradoxical movement where
the segment sinks in during inspiration and bulges out during expiration. This condition
severely impairs ventilation and requires immediate stabilization and often mechanical
ventilation.
5. A patient with terminal cancer is admitted for hospice care. The family asks why the nurse
is continuing to provide morphine even though the patient is unresponsive. What is the
nurse’s best response?
A. Morphine helps keep the patient’s blood pressure stable.
B. The goal is to prevent pain and provide comfort until the end.
C. Morphine will help the patient wake up for a short time.
D. We are legally required to give it every four hours.
