, NSG 430 Exam 4 – Adult Health Nursing II
Actual Questions & Answers (GCU) 100%
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Q1. A patient with sepsis develops hypotension that is unresponsive to fluid
resuscitation. The nurse anticipates which medication to maintain blood pressure?
A. Furosemide
B. Nitroglycerin
C. Norepinephrine
D. Sodium nitroprusside
Answer: C. Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor for septic shock. The patient has
received 2 L of IV normal saline (CVP 10 mm Hg) but remains hypotensive at 82/40 mm
Hg, indicating the need for vasopressor support . Norepinephrine increases systemic
vascular resistance to improve blood pressure.
Q2. The nurse is caring for a patient in cardiogenic shock. Which assessment
finding indicates the patient may be developing multiple organ dysfunction
syndrome (MODS)?
A. The patient's serum creatinine level is elevated
B. The patient reports intermittent chest pressure
C. The patient's extremities are cool and pulses are weak
D. The patient has bilateral crackles throughout lung fields
Answer: A. The patient's serum creatinine level is elevated
Rationale: Elevated serum creatinine indicates acute kidney injury, which is a sign of
developing MODS. In a patient with cardiogenic shock, poor perfusion leads to renal
failure . Cool extremities and weak pulses are expected in cardiogenic shock. Crackles
indicate pulmonary congestion from left-sided heart failure.
,Q3. What is SIRS (Systemic Inflammatory Response Syndrome)?
A. A localized inflammatory response to injury
B. A systemic inflammatory response to a variety of insults
C. A genetic disorder affecting the immune system
D. A chronic autoimmune condition
Answer: B. A systemic inflammatory response to a variety of insults
Rationale: SIRS is a systemic inflammatory response to a variety of insults including
infection, ischemia, infarction, and injury. Triggers include mechanical tissue trauma
(burns, crush injuries, surgery), abscess formation, ischemic or necrotic tissue, and
microbial invasion .
Q4. What is MODS (Multiple Organ Dysfunction Syndrome)?
A. A single organ failure that resolves with treatment
B. Failure of two or more organ systems where homeostasis cannot be maintained
without intervention
C. A temporary dysfunction of the liver only
D. A chronic progressive disease of the lungs
Answer: B. Failure of two or more organ systems where homeostasis cannot be
maintained without intervention
Rationale: MODS is the failure of two or more organ systems. Homeostasis cannot be
maintained without intervention. It results from SIRS and is a progressive deterioration
of organ function .
Q5. Which assessment finding in a patient with septic shock indicates the most
urgent need for intervention?
A. Heart rate of 110 beats/min
B. Respiratory rate of 24 breaths/min
, C. Mean arterial pressure (MAP) of 52 mm Hg
D. Temperature of 101.2°F (38.4°C)
Answer: C. Mean arterial pressure (MAP) of 52 mm Hg
Rationale: A MAP <65 mm Hg indicates inadequate organ perfusion. This requires
immediate intervention with fluid resuscitation and vasopressors. MAP is calculated as:
(2 × diastolic + systolic) / 3. Normal MAP is 70-100 mm Hg.
Q6. A patient with septic shock is receiving IV fluids. Which finding indicates fluid
resuscitation has been effective?
A. Heart rate decreases from 120 to 90 beats/min
B. Blood pressure increases from 80/50 to 110/70 mm Hg
C. Urine output increases to 40 mL/hr
D. All of the above
Answer: D. All of the above
Rationale: Effective fluid resuscitation in shock is indicated by improving heart rate
(toward normal), increasing blood pressure, and urine output >30 mL/hr. All of these
findings indicate improved perfusion.
Q7. A patient with neurogenic shock after a spinal cord injury has a heart rate of
50 beats/min and blood pressure of 85/50 mm Hg. Which intervention is most
appropriate?
A. Administer IV fluids and atropine
B. Place patient in Trendelenburg position
C. Administer nitroprusside
D. Prepare for surgery
Answer: A. Administer IV fluids and atropine
Rationale: Neurogenic shock results from loss of sympathetic tone, causing
hypotension and bradycardia. Treatment includes IV fluids and atropine for bradycardia.
Vasopressors may also be needed.
Actual Questions & Answers (GCU) 100%
Guarantee Pass
Q1. A patient with sepsis develops hypotension that is unresponsive to fluid
resuscitation. The nurse anticipates which medication to maintain blood pressure?
A. Furosemide
B. Nitroglycerin
C. Norepinephrine
D. Sodium nitroprusside
Answer: C. Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor for septic shock. The patient has
received 2 L of IV normal saline (CVP 10 mm Hg) but remains hypotensive at 82/40 mm
Hg, indicating the need for vasopressor support . Norepinephrine increases systemic
vascular resistance to improve blood pressure.
Q2. The nurse is caring for a patient in cardiogenic shock. Which assessment
finding indicates the patient may be developing multiple organ dysfunction
syndrome (MODS)?
A. The patient's serum creatinine level is elevated
B. The patient reports intermittent chest pressure
C. The patient's extremities are cool and pulses are weak
D. The patient has bilateral crackles throughout lung fields
Answer: A. The patient's serum creatinine level is elevated
Rationale: Elevated serum creatinine indicates acute kidney injury, which is a sign of
developing MODS. In a patient with cardiogenic shock, poor perfusion leads to renal
failure . Cool extremities and weak pulses are expected in cardiogenic shock. Crackles
indicate pulmonary congestion from left-sided heart failure.
,Q3. What is SIRS (Systemic Inflammatory Response Syndrome)?
A. A localized inflammatory response to injury
B. A systemic inflammatory response to a variety of insults
C. A genetic disorder affecting the immune system
D. A chronic autoimmune condition
Answer: B. A systemic inflammatory response to a variety of insults
Rationale: SIRS is a systemic inflammatory response to a variety of insults including
infection, ischemia, infarction, and injury. Triggers include mechanical tissue trauma
(burns, crush injuries, surgery), abscess formation, ischemic or necrotic tissue, and
microbial invasion .
Q4. What is MODS (Multiple Organ Dysfunction Syndrome)?
A. A single organ failure that resolves with treatment
B. Failure of two or more organ systems where homeostasis cannot be maintained
without intervention
C. A temporary dysfunction of the liver only
D. A chronic progressive disease of the lungs
Answer: B. Failure of two or more organ systems where homeostasis cannot be
maintained without intervention
Rationale: MODS is the failure of two or more organ systems. Homeostasis cannot be
maintained without intervention. It results from SIRS and is a progressive deterioration
of organ function .
Q5. Which assessment finding in a patient with septic shock indicates the most
urgent need for intervention?
A. Heart rate of 110 beats/min
B. Respiratory rate of 24 breaths/min
, C. Mean arterial pressure (MAP) of 52 mm Hg
D. Temperature of 101.2°F (38.4°C)
Answer: C. Mean arterial pressure (MAP) of 52 mm Hg
Rationale: A MAP <65 mm Hg indicates inadequate organ perfusion. This requires
immediate intervention with fluid resuscitation and vasopressors. MAP is calculated as:
(2 × diastolic + systolic) / 3. Normal MAP is 70-100 mm Hg.
Q6. A patient with septic shock is receiving IV fluids. Which finding indicates fluid
resuscitation has been effective?
A. Heart rate decreases from 120 to 90 beats/min
B. Blood pressure increases from 80/50 to 110/70 mm Hg
C. Urine output increases to 40 mL/hr
D. All of the above
Answer: D. All of the above
Rationale: Effective fluid resuscitation in shock is indicated by improving heart rate
(toward normal), increasing blood pressure, and urine output >30 mL/hr. All of these
findings indicate improved perfusion.
Q7. A patient with neurogenic shock after a spinal cord injury has a heart rate of
50 beats/min and blood pressure of 85/50 mm Hg. Which intervention is most
appropriate?
A. Administer IV fluids and atropine
B. Place patient in Trendelenburg position
C. Administer nitroprusside
D. Prepare for surgery
Answer: A. Administer IV fluids and atropine
Rationale: Neurogenic shock results from loss of sympathetic tone, causing
hypotension and bradycardia. Treatment includes IV fluids and atropine for bradycardia.
Vasopressors may also be needed.
