, NSG 430 Exam 3 – Adult Health Nursing II
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Question 1: A patient with hypovolemic shock is receiving IV fluids. Which finding
indicates that fluid resuscitation is effective?
A. Heart rate 120 bpm
B. Urine output 25 mL/hour
C. Central venous pressure (CVP) 8 mm Hg
D. Blood pressure 92/60 mm Hg
Answer: C
Rationale: CVP is a measure of right ventricular preload. Normal CVP is 2-8 mm Hg. A
CVP of 8 mm Hg indicates adequate volume status. Tachycardia, oliguria, and
hypotension indicate continued hypovolemia .
Question 2: The nurse is caring for a patient in septic shock. Which intervention is the
priority?
A. Administer antipyretics
B. Initiate broad-spectrum antibiotics
C. Apply cooling blankets
D. Insert a Foley catheter
Answer: B
Rationale: In septic shock, early antibiotic administration (within 1 hour) is critical for
survival. Antibiotics should be given after blood cultures are obtained. Fluids and
vasopressors are also important, but antibiotics target the underlying cause .
Question 3: Which finding indicates the patient is progressing from sepsis to severe
sepsis?
,A. Heart rate 100
B. Fever
C. Acute kidney injury
D. Respiratory rate 22
Answer: C
Rationale: Acute kidney injury indicates organ dysfunction, meeting criteria for severe
sepsis. Tachycardia, fever, and tachypnea are signs of sepsis but do not alone indicate
progression to severe sepsis .
Question 4: A patient in hypovolemic shock is receiving isotonic crystalloids. What is the
priority assessment?
A. Serum potassium
B. Lung sounds
C. Blood glucose
D. Temperature
Answer: B
Rationale: Isotonic crystalloid resuscitation can lead to fluid overload. The nurse should
monitor for crackles, which indicate pulmonary edema. Electrolytes, glucose, and
temperature are important but not the priority .
Question 5: What fluid is given first for hypovolemic shock?
A. Isotonic crystalloids (normal saline, lactated Ringer's)
B. Colloids (albumin)
C. Hypertonic saline
D. Blood products
Answer: A
Rationale: Isotonic crystalloids are the first-line fluids for hypovolemic shock. Colloids
may be used after crystalloids. Blood products are given for hemorrhagic shock .
, Question 6: A patient has lost 15-30% of blood volume. Which compensatory response
does the nurse expect?
A. Increased heart rate and respiratory rate
B. Decreased heart rate
C. Hypotension
D. Increased urine output
Answer: A
Rationale: Sympathetic nervous system response to volume loss includes tachycardia,
tachypnea, and anxiety. Decreased urine output and decreased stroke volume also occur
.
Question 7: Which statement about albumin in shock is correct?
A. Albumin coats the inner lining of vessels to prevent fluid from leaking out
B. Albumin causes fluid to shift out of vessels
C. Albumin is contraindicated in shock
D. Normal albumin level is 1.5-2.5 g/dL
Answer: A
Rationale: Albumin maintains oncotic pressure and coats vessel walls to prevent fluid
leakage. Normal albumin is 3.5-5.0 g/dL. Loss of albumin during hemorrhage
contributes to fluid shifting out of vessels .
Question 8: The nurse is caring for a patient in neurogenic shock. Which finding is
expected?
A. Hypotension and bradycardia
B. Hypertension and tachycardia
C. Warm, dry skin
D. Tachypnea
Answer: A
Actual Questions & Answers (GCU) 100%
Guarantee Pass
Question 1: A patient with hypovolemic shock is receiving IV fluids. Which finding
indicates that fluid resuscitation is effective?
A. Heart rate 120 bpm
B. Urine output 25 mL/hour
C. Central venous pressure (CVP) 8 mm Hg
D. Blood pressure 92/60 mm Hg
Answer: C
Rationale: CVP is a measure of right ventricular preload. Normal CVP is 2-8 mm Hg. A
CVP of 8 mm Hg indicates adequate volume status. Tachycardia, oliguria, and
hypotension indicate continued hypovolemia .
Question 2: The nurse is caring for a patient in septic shock. Which intervention is the
priority?
A. Administer antipyretics
B. Initiate broad-spectrum antibiotics
C. Apply cooling blankets
D. Insert a Foley catheter
Answer: B
Rationale: In septic shock, early antibiotic administration (within 1 hour) is critical for
survival. Antibiotics should be given after blood cultures are obtained. Fluids and
vasopressors are also important, but antibiotics target the underlying cause .
Question 3: Which finding indicates the patient is progressing from sepsis to severe
sepsis?
,A. Heart rate 100
B. Fever
C. Acute kidney injury
D. Respiratory rate 22
Answer: C
Rationale: Acute kidney injury indicates organ dysfunction, meeting criteria for severe
sepsis. Tachycardia, fever, and tachypnea are signs of sepsis but do not alone indicate
progression to severe sepsis .
Question 4: A patient in hypovolemic shock is receiving isotonic crystalloids. What is the
priority assessment?
A. Serum potassium
B. Lung sounds
C. Blood glucose
D. Temperature
Answer: B
Rationale: Isotonic crystalloid resuscitation can lead to fluid overload. The nurse should
monitor for crackles, which indicate pulmonary edema. Electrolytes, glucose, and
temperature are important but not the priority .
Question 5: What fluid is given first for hypovolemic shock?
A. Isotonic crystalloids (normal saline, lactated Ringer's)
B. Colloids (albumin)
C. Hypertonic saline
D. Blood products
Answer: A
Rationale: Isotonic crystalloids are the first-line fluids for hypovolemic shock. Colloids
may be used after crystalloids. Blood products are given for hemorrhagic shock .
, Question 6: A patient has lost 15-30% of blood volume. Which compensatory response
does the nurse expect?
A. Increased heart rate and respiratory rate
B. Decreased heart rate
C. Hypotension
D. Increased urine output
Answer: A
Rationale: Sympathetic nervous system response to volume loss includes tachycardia,
tachypnea, and anxiety. Decreased urine output and decreased stroke volume also occur
.
Question 7: Which statement about albumin in shock is correct?
A. Albumin coats the inner lining of vessels to prevent fluid from leaking out
B. Albumin causes fluid to shift out of vessels
C. Albumin is contraindicated in shock
D. Normal albumin level is 1.5-2.5 g/dL
Answer: A
Rationale: Albumin maintains oncotic pressure and coats vessel walls to prevent fluid
leakage. Normal albumin is 3.5-5.0 g/dL. Loss of albumin during hemorrhage
contributes to fluid shifting out of vessels .
Question 8: The nurse is caring for a patient in neurogenic shock. Which finding is
expected?
A. Hypotension and bradycardia
B. Hypertension and tachycardia
C. Warm, dry skin
D. Tachypnea
Answer: A
