NSG 4100 Exam 4 Final Answers
SECTION 1: TRAUMA AND EMERGENCY CARE
Question 1
A patient is brought to the emergency department following a motor
vehicle accident. The nurse notes the patient has a deviated trachea to
the right, absent breath sounds on the left, and distended neck veins.
Which condition should the nurse suspect?
A. Tension pneumothorax
B. Cardiac tamponade
C. Pulmonary embolism
D. Aortic dissection
Correct Answer: A
Rationale: Tension pneumothorax is characterized by tracheal deviation
to the contralateral (opposite) side, absent breath sounds on the
affected side, and distended neck veins (jugular venous distention) due
to increased intrathoracic pressure. This is a life-threatening emergency
requiring immediate needle decompression .
,Question 2
The nurse is caring for a patient with a flail chest. Which assessment
finding is most concerning?
A. Paradoxical chest movement
B. Pain with deep breathing
C. Bruising over the chest wall
D. Subcutaneous emphysema
Correct Answer: A
Rationale: Paradoxical chest movement (the affected area moves
inward during inspiration and outward during expiration) is the hallmark
sign of flail chest. This indicates multiple rib fractures that have caused a
segment of the chest wall to become unstable, leading to inadequate
ventilation and potential respiratory failure .
Question 3
A patient with a suspected pelvic fracture is hypotensive. The nurse
should suspect which source of bleeding?
A. Intra-abdominal hemorrhage
B. Retroperitoneal hemorrhage
C. Intrathoracic hemorrhage
D. Subcutaneous hemorrhage
Correct Answer: B
Rationale: Pelvic fractures can cause significant retroperitoneal bleeding
because the pelvic cavity is highly vascular. This bleeding is not easily
,detected externally and can lead to rapid hemodynamic compromise.
Immediate stabilization of the pelvis is critical .
Question 4
During the primary survey of a trauma patient, the nurse identifies a
patent airway but notes the patient is not breathing adequately. What is
the priority intervention?
A. Prepare for intubation
B. Administer oxygen via non-rebreather mask
C. Initiate bag-valve-mask ventilation
D. Position the patient in recovery position
Correct Answer: C
Rationale: If the patient has a patent airway but is not breathing
adequately (apneic or ineffective breathing), the priority intervention is to
initiate bag-valve-mask (BVM) ventilation to provide positive pressure
ventilation and oxygenate the patient while preparing for definitive airway
management .
Question 5
A patient with a traumatic brain injury has an ICP of 28 mmHg. The nurse
should anticipate which intervention?
A. Administer IV fluids at 200 mL/hr
B. Position the patient flat
, C. Administer mannitol 1 g/kg IV
D. Increase PEEP on the ventilator
Correct Answer: C
Rationale: Normal ICP is 5-15 mmHg. ICP of 28 mmHg indicates
increased intracranial pressure requiring intervention. Mannitol (1 g/kg
IV) is an osmotic diuretic that reduces cerebral edema. Hyperventilation,
HOB elevation at 30 degrees, and sedation are also interventions. Fluid
boluses would worsen ICP .
SECTION 2: SHOCK AND HEMODYNAMIC INSTABILITY
Question 6
A patient in septic shock has a central venous pressure (CVP) of 4 mmHg
and mean arterial pressure (MAP) of 55 mmHg. Which intervention
should the nurse anticipate?
A. Start norepinephrine infusion
B. Administer 30 mL/kg IV fluid bolus
C. Administer IV antibiotics
D. Start dobutamine infusion
Correct Answer: B
Rationale: In septic shock, the Surviving Sepsis Campaign recommends
initial fluid resuscitation of 30 mL/kg of crystalloid for hypotension or
lactate ≥ 4 mmol/L. Low CVP indicates hypovolemia, and the priority is
SECTION 1: TRAUMA AND EMERGENCY CARE
Question 1
A patient is brought to the emergency department following a motor
vehicle accident. The nurse notes the patient has a deviated trachea to
the right, absent breath sounds on the left, and distended neck veins.
Which condition should the nurse suspect?
A. Tension pneumothorax
B. Cardiac tamponade
C. Pulmonary embolism
D. Aortic dissection
Correct Answer: A
Rationale: Tension pneumothorax is characterized by tracheal deviation
to the contralateral (opposite) side, absent breath sounds on the
affected side, and distended neck veins (jugular venous distention) due
to increased intrathoracic pressure. This is a life-threatening emergency
requiring immediate needle decompression .
,Question 2
The nurse is caring for a patient with a flail chest. Which assessment
finding is most concerning?
A. Paradoxical chest movement
B. Pain with deep breathing
C. Bruising over the chest wall
D. Subcutaneous emphysema
Correct Answer: A
Rationale: Paradoxical chest movement (the affected area moves
inward during inspiration and outward during expiration) is the hallmark
sign of flail chest. This indicates multiple rib fractures that have caused a
segment of the chest wall to become unstable, leading to inadequate
ventilation and potential respiratory failure .
Question 3
A patient with a suspected pelvic fracture is hypotensive. The nurse
should suspect which source of bleeding?
A. Intra-abdominal hemorrhage
B. Retroperitoneal hemorrhage
C. Intrathoracic hemorrhage
D. Subcutaneous hemorrhage
Correct Answer: B
Rationale: Pelvic fractures can cause significant retroperitoneal bleeding
because the pelvic cavity is highly vascular. This bleeding is not easily
,detected externally and can lead to rapid hemodynamic compromise.
Immediate stabilization of the pelvis is critical .
Question 4
During the primary survey of a trauma patient, the nurse identifies a
patent airway but notes the patient is not breathing adequately. What is
the priority intervention?
A. Prepare for intubation
B. Administer oxygen via non-rebreather mask
C. Initiate bag-valve-mask ventilation
D. Position the patient in recovery position
Correct Answer: C
Rationale: If the patient has a patent airway but is not breathing
adequately (apneic or ineffective breathing), the priority intervention is to
initiate bag-valve-mask (BVM) ventilation to provide positive pressure
ventilation and oxygenate the patient while preparing for definitive airway
management .
Question 5
A patient with a traumatic brain injury has an ICP of 28 mmHg. The nurse
should anticipate which intervention?
A. Administer IV fluids at 200 mL/hr
B. Position the patient flat
, C. Administer mannitol 1 g/kg IV
D. Increase PEEP on the ventilator
Correct Answer: C
Rationale: Normal ICP is 5-15 mmHg. ICP of 28 mmHg indicates
increased intracranial pressure requiring intervention. Mannitol (1 g/kg
IV) is an osmotic diuretic that reduces cerebral edema. Hyperventilation,
HOB elevation at 30 degrees, and sedation are also interventions. Fluid
boluses would worsen ICP .
SECTION 2: SHOCK AND HEMODYNAMIC INSTABILITY
Question 6
A patient in septic shock has a central venous pressure (CVP) of 4 mmHg
and mean arterial pressure (MAP) of 55 mmHg. Which intervention
should the nurse anticipate?
A. Start norepinephrine infusion
B. Administer 30 mL/kg IV fluid bolus
C. Administer IV antibiotics
D. Start dobutamine infusion
Correct Answer: B
Rationale: In septic shock, the Surviving Sepsis Campaign recommends
initial fluid resuscitation of 30 mL/kg of crystalloid for hypotension or
lactate ≥ 4 mmol/L. Low CVP indicates hypovolemia, and the priority is
