, NSG 3130 Advanced Exam 4 Prep: Master
Nursing Fundamentals Practice Questions &
Detailed Explanations
Subject: Nursing Fundamentals (Exam 4)
Question 1: A client is diagnosed with acute respiratory distress syndrome (ARDS) and is being
mechanically ventilated. The nurse notes the peak inspiratory pressure (PIP) has increased from
25 cm H2O to 40 cm H2O, and the high-pressure alarm is sounding. What is the most
appropriate priority intervention by the nurse?
A) Increase the fraction of inspired oxygen (FiO2) setting.
B) Assess for secretions in the airway and suction the client.
C) Increase the sedation level to reduce patient-ventilator dyssynchrony.
D) Disconnect the ventilator and perform manual ventilation with an Ambu bag.
Correct Answer: B) Assess for secretions in the airway and suction the client.
Explanation: An increase in PIP signifies increased airway resistance or decreased pulmonary
compliance. Assessing for mucus plugs or secretions is a high-priority, non-invasive assessment.
Option D is only appropriate if there is an equipment failure or an immediate threat to the
airway that cannot be resolved. Option A does not address the underlying mechanical pressure
issue. Option C is a secondary intervention if dyssynchrony is confirmed.
Question 2: A client on a medical-surgical unit is receiving intravenous potassium chloride (KCl)
20 mEq in 100 mL of 0.9% Normal Saline via a peripheral line. The nurse notes the site is
erythematous and the client reports a burning sensation. What is the nurse's priority action?
A) Slow the infusion rate by 50% and reassess in 15 minutes.
B) Stop the infusion immediately and disconnect the IV tubing.
C) Flush the IV with 10 mL of normal saline to check for patency.
D) Apply a warm compress to the site to increase peripheral perfusion.
Correct Answer: B) Stop the infusion immediately and disconnect the IV tubing.
Explanation: Potassium chloride is a potent vesicant. Erythema and burning at the site indicate
potential extravasation, which can lead to severe tissue necrosis. The infusion must be stopped
, immediately to limit the amount of potassium entering the subcutaneous tissue. Flushing the line
(C) could push more vesicant into the tissue.
Question 3: A nurse is caring for a client who is postoperative for a total hip arthroplasty. The
nurse notices the client's affected leg is suddenly shortened, internally rotated, and the client
reports sudden, intense hip pain. What is the most likely complication, and what is the nursing
priority?
A) Fat embolism; notify the rapid response team.
B) Dislocation of the prosthesis; notify the surgeon immediately.
C) Deep vein thrombosis; apply sequential compression devices.
D) Surgical site infection; initiate broad-spectrum antibiotics.
Correct Answer: B) Dislocation of the prosthesis; notify the surgeon immediately.
Explanation: Shortening of the limb and internal rotation are classic clinical indicators of a hip
prosthesis dislocation. This is a medical emergency that requires immediate surgical reduction.
Fat embolism (A) would present with respiratory distress and petechiae.
Question 4: During an assessment of a client with a history of heart failure, the nurse auscultates
an S3 heart sound. What is the best physiological explanation for this finding?
A) Turbulent flow across a stenotic mitral valve during diastole.
B) Aortic regurgitation resulting from chronic hypertension.
C) Early diastolic filling into a dilated, non-compliant ventricle.
D) Atrial contraction against a stiff, hypertrophied ventricle.
Correct Answer: C) Early diastolic filling into a dilated, non-compliant ventricle.
Explanation: An S3, or "ventricular gallop," occurs when blood enters a ventricle that is already
overfilled or has poor compliance during early diastole, causing the ventricle to vibrate. An S4
(D) is associated with atrial contraction against a stiff/hypertrophied ventricle.
Question 5: A client is receiving a continuous infusion of heparin for a deep vein thrombosis
(DVT). The nurse notes the client’s activated partial thromboplastin time (aPTT) is 120 seconds
(Control 25-35 seconds). What is the appropriate nursing action?
A) Continue the infusion as ordered, as this is the therapeutic range.
B) Stop the infusion and notify the provider for a potential dosage adjustment.
Nursing Fundamentals Practice Questions &
Detailed Explanations
Subject: Nursing Fundamentals (Exam 4)
Question 1: A client is diagnosed with acute respiratory distress syndrome (ARDS) and is being
mechanically ventilated. The nurse notes the peak inspiratory pressure (PIP) has increased from
25 cm H2O to 40 cm H2O, and the high-pressure alarm is sounding. What is the most
appropriate priority intervention by the nurse?
A) Increase the fraction of inspired oxygen (FiO2) setting.
B) Assess for secretions in the airway and suction the client.
C) Increase the sedation level to reduce patient-ventilator dyssynchrony.
D) Disconnect the ventilator and perform manual ventilation with an Ambu bag.
Correct Answer: B) Assess for secretions in the airway and suction the client.
Explanation: An increase in PIP signifies increased airway resistance or decreased pulmonary
compliance. Assessing for mucus plugs or secretions is a high-priority, non-invasive assessment.
Option D is only appropriate if there is an equipment failure or an immediate threat to the
airway that cannot be resolved. Option A does not address the underlying mechanical pressure
issue. Option C is a secondary intervention if dyssynchrony is confirmed.
Question 2: A client on a medical-surgical unit is receiving intravenous potassium chloride (KCl)
20 mEq in 100 mL of 0.9% Normal Saline via a peripheral line. The nurse notes the site is
erythematous and the client reports a burning sensation. What is the nurse's priority action?
A) Slow the infusion rate by 50% and reassess in 15 minutes.
B) Stop the infusion immediately and disconnect the IV tubing.
C) Flush the IV with 10 mL of normal saline to check for patency.
D) Apply a warm compress to the site to increase peripheral perfusion.
Correct Answer: B) Stop the infusion immediately and disconnect the IV tubing.
Explanation: Potassium chloride is a potent vesicant. Erythema and burning at the site indicate
potential extravasation, which can lead to severe tissue necrosis. The infusion must be stopped
, immediately to limit the amount of potassium entering the subcutaneous tissue. Flushing the line
(C) could push more vesicant into the tissue.
Question 3: A nurse is caring for a client who is postoperative for a total hip arthroplasty. The
nurse notices the client's affected leg is suddenly shortened, internally rotated, and the client
reports sudden, intense hip pain. What is the most likely complication, and what is the nursing
priority?
A) Fat embolism; notify the rapid response team.
B) Dislocation of the prosthesis; notify the surgeon immediately.
C) Deep vein thrombosis; apply sequential compression devices.
D) Surgical site infection; initiate broad-spectrum antibiotics.
Correct Answer: B) Dislocation of the prosthesis; notify the surgeon immediately.
Explanation: Shortening of the limb and internal rotation are classic clinical indicators of a hip
prosthesis dislocation. This is a medical emergency that requires immediate surgical reduction.
Fat embolism (A) would present with respiratory distress and petechiae.
Question 4: During an assessment of a client with a history of heart failure, the nurse auscultates
an S3 heart sound. What is the best physiological explanation for this finding?
A) Turbulent flow across a stenotic mitral valve during diastole.
B) Aortic regurgitation resulting from chronic hypertension.
C) Early diastolic filling into a dilated, non-compliant ventricle.
D) Atrial contraction against a stiff, hypertrophied ventricle.
Correct Answer: C) Early diastolic filling into a dilated, non-compliant ventricle.
Explanation: An S3, or "ventricular gallop," occurs when blood enters a ventricle that is already
overfilled or has poor compliance during early diastole, causing the ventricle to vibrate. An S4
(D) is associated with atrial contraction against a stiff/hypertrophied ventricle.
Question 5: A client is receiving a continuous infusion of heparin for a deep vein thrombosis
(DVT). The nurse notes the client’s activated partial thromboplastin time (aPTT) is 120 seconds
(Control 25-35 seconds). What is the appropriate nursing action?
A) Continue the infusion as ordered, as this is the therapeutic range.
B) Stop the infusion and notify the provider for a potential dosage adjustment.
