Nursing III N205 206 EXAM with Questions and
Answers/Plus a Rationale Updated 2026 A+/Instant
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EXAM COVERAGE
1. Advanced Medical-Surgical Nursing Concepts and Complex Multi-System Alterations
2. Pharmacological Therapy and Critical Care Drug Administration
3. Pathophysiological Assessment and Clinical Judgment
4. Nursing Process, Priority Setting, and Delegation in Acute Care Settings
5. Evidence-Based Practice, Patient Safety, and Quality Improvement
1. A patient with acute respiratory distress syndrome (ARDS) is mechanically ventilated with PEEP
set at 12 cm H2O. The patient suddenly develops hypotension, tracheal deviation to the left, and
absent breath sounds on the right side. Which of the following is the immediate priority nursing
action?
A. Administer a rapid intravenous fluid bolus of 500 mL normal saline.
B. Prepare for immediate needle decompression of the right chest.
C. Increase the fraction of inspired oxygen (FiO2) to 1.0.
D. Suction the endotracheal tube to clear potential mucous plugging.
CORRECT ANSWER : B
Rationale: The patient's presentation of sudden hypotension, tracheal deviation, and absent
breath sounds on the contralateral side indicates a life-threatening tension pneumothorax, a
known complication of high PEEP. Immediate needle decompression relieves intrapleural
pressure before definitive chest tube insertion. Fluid boluses, increasing FiO2, or suctioning will
not address the mechanical mediastinal shift and obstructive shock.
2. A patient admitted with severe acute pancreatitis develops a decreasing urine output of 15 mL/hr
over the past 3 hours, a heart rate of 122 bpm, and a mean arterial pressure (MAP) of 60 mm Hg.
, The central venous pressure (CVP) is 2 mm Hg. Which order should the nurse anticipate
implementing first?
A. Administer intravenous furosemide 40 mg.
B. Initiate an aggressive isotonic crystalloid fluid resuscitation protocol.
C. Begin a continuous dopamine infusion for renal vasodilation.
D. Prepare the patient for emergency endoscopic retrograde cholangiopancreatography (ERCP).
CORRECT ANSWER : B
Rationale: Severe acute pancreatitis causes massive third-spacing of fluids, leading to
hypovolemic shock and acute kidney injury as evidenced by low urine output, tachycardia,
hypotension, and low CVP. Aggressive fluid resuscitation is the cornerstone of early
management to restore tissue perfusion. Furosemide would worsen hypovolemia, dopamine is no
longer recommended for renal protection, and ERCP is premature without hemodynamic
stabilization unless biliary obstruction with cholangitis is present.
3. A nurse is caring for a client receiving a continuous heparin infusion for a pulmonary embolism.
The baseline aPTT is 30 seconds. The current aPTT value drawn 6 hours after a rate adjustment
is 95 seconds. According to the hospital protocol, the nurse should immediately:
A. Stop the heparin infusion for 1 hour, then restart at a decreased rate per protocol.
B. Increase the infusion rate by 2 units/kg/hour.
C. Stop the infusion and notify the healthcare provider for potential protamine sulfate
administration.
D. Draw a repeat aPTT in 2 hours while continuing the current infusion rate.
CORRECT ANSWER : C
Rationale: An aPTT of 95 seconds significantly exceeds the therapeutic range (typically 1.5 to
2.5 times the control, or roughly 46 to 75 seconds), placing the patient at high risk for major
hemorrhage. Standard safety protocols for critically elevated aPTT values usually mandate
stopping the infusion and notifying the provider, with protamine sulfate reserved for active
bleeding or extreme elevations. Simply waiting or increasing the rate is unsafe.
4. A client with chronic heart failure presents with acute decompensation, dyspnea, orthopnea, and
pink, frothy sputum. The blood pressure is 168/98 mm Hg and the heart rate is 110 bpm. Which
of the following collaborative interventions should the nurse perform first?
A. Administer sublingual nitroglycerin as ordered.
, B. Apply non-invasive positive pressure ventilation (NIPPV) with CPAP/BiPAP.
C. Obtain a stat 12-lead electrocardiogram.
D. Administer intravenous metoprolol.
CORRECT ANSWER : B
Rationale: The client is experiencing acute decompensated heart failure with acute pulmonary
edema, evidenced by frothy sputum and hypertension. Applying NIPPV rapidly decreases
preload and afterload, improves oxygenation, and reduces the work of breathing, making it a
primary stabilization intervention. While nitroglycerin and an ECG are important, optimizing
gas exchange and airway support via NIPPV takes priority.
5. A nurse is evaluating a client receiving total parenteral nutrition (TPN) through a peripherally
inserted central catheter (PICC). Which finding requires immediate intervention by the nurse?
A. The blood glucose level is 152 mg/dL.
B. The TPN solution bag has been infusing for 32 hours and has 100 mL remaining.
C. The transparent dressing over the insertion site is intact and clean.
D. The client reports mild fatigue and thirst.
CORRECT ANSWER : B
Rationale: TPN solutions have a high dextrose and amino acid content, making them an ideal
culture medium for bacterial and fungal growth. To prevent catheter-related bloodstream
infections, TPN bags and tubing must be changed every 24 hours regardless of the remaining
volume. A blood glucose of 152 mg/dL requires monitoring or sliding-scale insulin, but is
expected and less acutely dangerous than microbial proliferation.
6. A client in the neurological intensive care unit following a traumatic brain injury has an
intracranial pressure (ICP) of 22 mm Hg and a cerebral perfusion pressure (CPP) of 55 mm Hg.
Which nursing action is most appropriate to improve the CPP?
A. Lower the head of the bed to a flat position to increase cerebral blood flow.
B. Administer an osmotic diuretic such as mannitol as prescribed.
C. Encourage active range-of-motion exercises to prevent contractures.
D. Suction the endotracheal tube vigorously for 30 seconds to clear secretions.
CORRECT ANSWER : B
, Rationale: Cerebral perfusion pressure is calculated as Mean Arterial Pressure minus
Intracranial Pressure (CPP = MAP - ICP). A CPP of 55 mm Hg is below the target minimum of
60 to 70 mm Hg, and ICP is elevated above 20 mm Hg. Administering mannitol reduces cerebral
edema, thereby lowering ICP and raising CPP. Lowering the head of the bed, physical
stimulation, and suctioning all increase ICP and worsen perfusion.
7. A client with end-stage liver disease and cirrhosis is admitted with hepatic encephalopathy.
Which of the following dietary and pharmacological modifications should the nurse anticipate?
A. High-protein diet to promote liver tissue regeneration combined with scheduled lactulose.
B. Restriction of dietary protein combined with lactulose and rifaximin administration.
C. Complete elimination of all carbohydrates and administration of intravenous neomycin.
D. Administration of high-dose fat-soluble vitamins along with unrestricted high-fat intake.
CORRECT ANSWER : B
Rationale: Hepatic encephalopathy is caused by the accumulation of neurotoxins such as
ammonia in the bloodstream due to impaired hepatic metabolism. Management includes
lactulose to trap and eliminate ammonia via the GI tract, rifaximin to reduce ammonia-
producing gut bacteria, and short-term moderate protein restriction if encephalopathy is severe,
though modern guidelines favor balanced protein with plant-based sources.
8. A client with diabetic ketoacidosis (DKA) is receiving regular insulin via continuous IV infusion
and IV normal saline. The current blood glucose is 245 mg/dL. Which medication addition
should the nurse anticipate next?
A. Discontinuing the IV insulin infusion completely.
B. Adding 5% dextrose to the IV fluids.
C. Administering a bolus of 50% dextrose in water.
D. Switching the insulin to a long-acting subcutaneous formulation immediately.
CORRECT ANSWER : B
Rationale: When blood glucose drops to 200 to 250 mg/dL in a client with DKA, 5% dextrose is
added to the IV infusion (e.g., D5W with 0.45% NS) to prevent rapid hypoglycemia and cerebral
edema while continuing insulin to clear the anion gap ketoacidosis. Stopping insulin prematurely
will worsen ketosis, and a D50 bolus is excessive.
9. A client is receiving a unit of packed red blood cells (PRBCs) and develops chills, fever, lower
back pain, and hemoglobinuria 15 minutes into the transfusion. What is the nurse's first action?
Answers/Plus a Rationale Updated 2026 A+/Instant
Download PDF
EXAM COVERAGE
1. Advanced Medical-Surgical Nursing Concepts and Complex Multi-System Alterations
2. Pharmacological Therapy and Critical Care Drug Administration
3. Pathophysiological Assessment and Clinical Judgment
4. Nursing Process, Priority Setting, and Delegation in Acute Care Settings
5. Evidence-Based Practice, Patient Safety, and Quality Improvement
1. A patient with acute respiratory distress syndrome (ARDS) is mechanically ventilated with PEEP
set at 12 cm H2O. The patient suddenly develops hypotension, tracheal deviation to the left, and
absent breath sounds on the right side. Which of the following is the immediate priority nursing
action?
A. Administer a rapid intravenous fluid bolus of 500 mL normal saline.
B. Prepare for immediate needle decompression of the right chest.
C. Increase the fraction of inspired oxygen (FiO2) to 1.0.
D. Suction the endotracheal tube to clear potential mucous plugging.
CORRECT ANSWER : B
Rationale: The patient's presentation of sudden hypotension, tracheal deviation, and absent
breath sounds on the contralateral side indicates a life-threatening tension pneumothorax, a
known complication of high PEEP. Immediate needle decompression relieves intrapleural
pressure before definitive chest tube insertion. Fluid boluses, increasing FiO2, or suctioning will
not address the mechanical mediastinal shift and obstructive shock.
2. A patient admitted with severe acute pancreatitis develops a decreasing urine output of 15 mL/hr
over the past 3 hours, a heart rate of 122 bpm, and a mean arterial pressure (MAP) of 60 mm Hg.
, The central venous pressure (CVP) is 2 mm Hg. Which order should the nurse anticipate
implementing first?
A. Administer intravenous furosemide 40 mg.
B. Initiate an aggressive isotonic crystalloid fluid resuscitation protocol.
C. Begin a continuous dopamine infusion for renal vasodilation.
D. Prepare the patient for emergency endoscopic retrograde cholangiopancreatography (ERCP).
CORRECT ANSWER : B
Rationale: Severe acute pancreatitis causes massive third-spacing of fluids, leading to
hypovolemic shock and acute kidney injury as evidenced by low urine output, tachycardia,
hypotension, and low CVP. Aggressive fluid resuscitation is the cornerstone of early
management to restore tissue perfusion. Furosemide would worsen hypovolemia, dopamine is no
longer recommended for renal protection, and ERCP is premature without hemodynamic
stabilization unless biliary obstruction with cholangitis is present.
3. A nurse is caring for a client receiving a continuous heparin infusion for a pulmonary embolism.
The baseline aPTT is 30 seconds. The current aPTT value drawn 6 hours after a rate adjustment
is 95 seconds. According to the hospital protocol, the nurse should immediately:
A. Stop the heparin infusion for 1 hour, then restart at a decreased rate per protocol.
B. Increase the infusion rate by 2 units/kg/hour.
C. Stop the infusion and notify the healthcare provider for potential protamine sulfate
administration.
D. Draw a repeat aPTT in 2 hours while continuing the current infusion rate.
CORRECT ANSWER : C
Rationale: An aPTT of 95 seconds significantly exceeds the therapeutic range (typically 1.5 to
2.5 times the control, or roughly 46 to 75 seconds), placing the patient at high risk for major
hemorrhage. Standard safety protocols for critically elevated aPTT values usually mandate
stopping the infusion and notifying the provider, with protamine sulfate reserved for active
bleeding or extreme elevations. Simply waiting or increasing the rate is unsafe.
4. A client with chronic heart failure presents with acute decompensation, dyspnea, orthopnea, and
pink, frothy sputum. The blood pressure is 168/98 mm Hg and the heart rate is 110 bpm. Which
of the following collaborative interventions should the nurse perform first?
A. Administer sublingual nitroglycerin as ordered.
, B. Apply non-invasive positive pressure ventilation (NIPPV) with CPAP/BiPAP.
C. Obtain a stat 12-lead electrocardiogram.
D. Administer intravenous metoprolol.
CORRECT ANSWER : B
Rationale: The client is experiencing acute decompensated heart failure with acute pulmonary
edema, evidenced by frothy sputum and hypertension. Applying NIPPV rapidly decreases
preload and afterload, improves oxygenation, and reduces the work of breathing, making it a
primary stabilization intervention. While nitroglycerin and an ECG are important, optimizing
gas exchange and airway support via NIPPV takes priority.
5. A nurse is evaluating a client receiving total parenteral nutrition (TPN) through a peripherally
inserted central catheter (PICC). Which finding requires immediate intervention by the nurse?
A. The blood glucose level is 152 mg/dL.
B. The TPN solution bag has been infusing for 32 hours and has 100 mL remaining.
C. The transparent dressing over the insertion site is intact and clean.
D. The client reports mild fatigue and thirst.
CORRECT ANSWER : B
Rationale: TPN solutions have a high dextrose and amino acid content, making them an ideal
culture medium for bacterial and fungal growth. To prevent catheter-related bloodstream
infections, TPN bags and tubing must be changed every 24 hours regardless of the remaining
volume. A blood glucose of 152 mg/dL requires monitoring or sliding-scale insulin, but is
expected and less acutely dangerous than microbial proliferation.
6. A client in the neurological intensive care unit following a traumatic brain injury has an
intracranial pressure (ICP) of 22 mm Hg and a cerebral perfusion pressure (CPP) of 55 mm Hg.
Which nursing action is most appropriate to improve the CPP?
A. Lower the head of the bed to a flat position to increase cerebral blood flow.
B. Administer an osmotic diuretic such as mannitol as prescribed.
C. Encourage active range-of-motion exercises to prevent contractures.
D. Suction the endotracheal tube vigorously for 30 seconds to clear secretions.
CORRECT ANSWER : B
, Rationale: Cerebral perfusion pressure is calculated as Mean Arterial Pressure minus
Intracranial Pressure (CPP = MAP - ICP). A CPP of 55 mm Hg is below the target minimum of
60 to 70 mm Hg, and ICP is elevated above 20 mm Hg. Administering mannitol reduces cerebral
edema, thereby lowering ICP and raising CPP. Lowering the head of the bed, physical
stimulation, and suctioning all increase ICP and worsen perfusion.
7. A client with end-stage liver disease and cirrhosis is admitted with hepatic encephalopathy.
Which of the following dietary and pharmacological modifications should the nurse anticipate?
A. High-protein diet to promote liver tissue regeneration combined with scheduled lactulose.
B. Restriction of dietary protein combined with lactulose and rifaximin administration.
C. Complete elimination of all carbohydrates and administration of intravenous neomycin.
D. Administration of high-dose fat-soluble vitamins along with unrestricted high-fat intake.
CORRECT ANSWER : B
Rationale: Hepatic encephalopathy is caused by the accumulation of neurotoxins such as
ammonia in the bloodstream due to impaired hepatic metabolism. Management includes
lactulose to trap and eliminate ammonia via the GI tract, rifaximin to reduce ammonia-
producing gut bacteria, and short-term moderate protein restriction if encephalopathy is severe,
though modern guidelines favor balanced protein with plant-based sources.
8. A client with diabetic ketoacidosis (DKA) is receiving regular insulin via continuous IV infusion
and IV normal saline. The current blood glucose is 245 mg/dL. Which medication addition
should the nurse anticipate next?
A. Discontinuing the IV insulin infusion completely.
B. Adding 5% dextrose to the IV fluids.
C. Administering a bolus of 50% dextrose in water.
D. Switching the insulin to a long-acting subcutaneous formulation immediately.
CORRECT ANSWER : B
Rationale: When blood glucose drops to 200 to 250 mg/dL in a client with DKA, 5% dextrose is
added to the IV infusion (e.g., D5W with 0.45% NS) to prevent rapid hypoglycemia and cerebral
edema while continuing insulin to clear the anion gap ketoacidosis. Stopping insulin prematurely
will worsen ketosis, and a D50 bolus is excessive.
9. A client is receiving a unit of packed red blood cells (PRBCs) and develops chills, fever, lower
back pain, and hemoglobinuria 15 minutes into the transfusion. What is the nurse's first action?
