NSG430 Exam 4 V3 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A nurse is performing triage at the scene of a mass casualty event. Which client should be
assigned a ‘Red’ tag?
A. A client with a sucking chest wound and respiratory distress.
B. A client with a closed fracture of the right tibia.
C. A client with an agonal heart rate and no spontaneous respirations.
D. A client with localized minor burns on both forearms.
Answer: A
Rationale: Red tags represent immediate life-threatening conditions that are treatable. A
sucking chest wound requires immediate intervention to maintain oxygenation and
prevent tension pneumothorax. The analysis of disaster triage requires identifying which
patient has the highest chance of survival with immediate medical attention, whereas
‘Black’ tags are for those unlikely to survive and ‘Green’ for those with minor injuries.
2. The nurse manager is delegating tasks to a Licensed Practical Nurse (LPN). Which of the
following tasks is most appropriate for the LPN?
A. Developing a plan of care for a client with Multiple Organ Dysfunction Syndrome
(MODS).
B. Providing initial education on a new insulin pump for a diabetic client.
,C. Performing a sterile dressing change on a stable post-operative wound.
D. Evaluating the effectiveness of a client’s titration on a norepinephrine drip.
Answer: C
Rationale: LPNs are trained to perform specific technical tasks such as sterile dressing
changes for stable patients. Developing care plans, providing initial education, and
evaluating complex critical care medications are the responsibility of the Registered Nurse
(RN). This distinction ensures that high-acuity assessments remain within the scope of
advanced nursing practice.
3. A patient in the Intensive Care Unit (ICU) is receiving Nitroprusside for a hypertensive crisis.
Which laboratory value should the nurse monitor most closely for toxicity?
A. Serum Potassium levels
B. Blood Urea Nitrogen (BUN)
C. Serum Cyanide levels
D. Platelet count
Answer: C
Rationale: Nitroprusside is metabolized into thiocyanate and cyanide, which can lead to
toxicity with prolonged use or high doses. Monitoring cyanide levels is critical because
toxicity can lead to metabolic acidosis, confusion, and cardiovascular instability. The nurse
must be vigilant in assessing for neurological changes which are often the first sign of this
metabolic complication.
, 4. A client is admitted with suspected Septic Shock. Which of the following orders should the
nurse prioritize first?
A. Infusing a 30 mL/kg bolus of isotonic crystalloids.
B. Administering the first dose of broad-spectrum antibiotics.
C. Obtaining blood cultures from two separate sites.
D. Measuring the client’s hourly urine output via Foley catheter.
Answer: A
Rationale: Fluid resuscitation is the immediate priority in septic shock to restore perfusion
and blood pressure. While cultures and antibiotics are essential, the initial 30 mL/kg bolus
is part of the ‘one-hour bundle’ to treat hypoperfusion. This critical care intervention is
necessary to prevent the progression of multisystem organ failure and maintain cellular
oxygenation.
5. When caring for a client from a Middle Eastern culture, which nursing action demonstrates
cultural competence regarding modesty?
A. Assigning a nurse of the same gender to provide personal care.
B. Encouraging the client to speak English only to ensure safety.
C. Involving the hospital chaplain in all decision-making processes.
D. Limiting all visitors to one hour per day.
Answer: A
Nursing II | Grand Canyon University
1. A nurse is performing triage at the scene of a mass casualty event. Which client should be
assigned a ‘Red’ tag?
A. A client with a sucking chest wound and respiratory distress.
B. A client with a closed fracture of the right tibia.
C. A client with an agonal heart rate and no spontaneous respirations.
D. A client with localized minor burns on both forearms.
Answer: A
Rationale: Red tags represent immediate life-threatening conditions that are treatable. A
sucking chest wound requires immediate intervention to maintain oxygenation and
prevent tension pneumothorax. The analysis of disaster triage requires identifying which
patient has the highest chance of survival with immediate medical attention, whereas
‘Black’ tags are for those unlikely to survive and ‘Green’ for those with minor injuries.
2. The nurse manager is delegating tasks to a Licensed Practical Nurse (LPN). Which of the
following tasks is most appropriate for the LPN?
A. Developing a plan of care for a client with Multiple Organ Dysfunction Syndrome
(MODS).
B. Providing initial education on a new insulin pump for a diabetic client.
,C. Performing a sterile dressing change on a stable post-operative wound.
D. Evaluating the effectiveness of a client’s titration on a norepinephrine drip.
Answer: C
Rationale: LPNs are trained to perform specific technical tasks such as sterile dressing
changes for stable patients. Developing care plans, providing initial education, and
evaluating complex critical care medications are the responsibility of the Registered Nurse
(RN). This distinction ensures that high-acuity assessments remain within the scope of
advanced nursing practice.
3. A patient in the Intensive Care Unit (ICU) is receiving Nitroprusside for a hypertensive crisis.
Which laboratory value should the nurse monitor most closely for toxicity?
A. Serum Potassium levels
B. Blood Urea Nitrogen (BUN)
C. Serum Cyanide levels
D. Platelet count
Answer: C
Rationale: Nitroprusside is metabolized into thiocyanate and cyanide, which can lead to
toxicity with prolonged use or high doses. Monitoring cyanide levels is critical because
toxicity can lead to metabolic acidosis, confusion, and cardiovascular instability. The nurse
must be vigilant in assessing for neurological changes which are often the first sign of this
metabolic complication.
, 4. A client is admitted with suspected Septic Shock. Which of the following orders should the
nurse prioritize first?
A. Infusing a 30 mL/kg bolus of isotonic crystalloids.
B. Administering the first dose of broad-spectrum antibiotics.
C. Obtaining blood cultures from two separate sites.
D. Measuring the client’s hourly urine output via Foley catheter.
Answer: A
Rationale: Fluid resuscitation is the immediate priority in septic shock to restore perfusion
and blood pressure. While cultures and antibiotics are essential, the initial 30 mL/kg bolus
is part of the ‘one-hour bundle’ to treat hypoperfusion. This critical care intervention is
necessary to prevent the progression of multisystem organ failure and maintain cellular
oxygenation.
5. When caring for a client from a Middle Eastern culture, which nursing action demonstrates
cultural competence regarding modesty?
A. Assigning a nurse of the same gender to provide personal care.
B. Encouraging the client to speak English only to ensure safety.
C. Involving the hospital chaplain in all decision-making processes.
D. Limiting all visitors to one hour per day.
Answer: A
