,NSG 430 Exam 4 | Adult Health Nursing II | Grand
Canyon University | Q & A | 2026/2027 Edition (PDF)
1. The nurse is caring for a patient in cardiogenic shock. Which assessment finding would indicate that
the patient may be developing multiple organ dysfunction syndrome (MODS)?
A) The patient's extremities are cool and pulses are weak
B) The patient reports intermittent chest pressure
C) The patient's serum creatinine level is elevated
D) The patient has bilateral crackles throughout lung fields
Correct Answer: The patient's serum creatinine level is elevated
Rationale: MODS reflects failure of two or more organ systems. In cardiogenic shock, a rising creatinine
suggests renal hypoperfusion and acute kidney injury, indicating progression toward MODS. Cool
extremities, weak pulses, and crackles are expected in shock or heart failure but do not alone confirm
additional organ failure.
2. A patient recovering from heart surgery develops pericarditis and complains of level 6 chest pain with
deep breathing. Which PRN medication is most appropriate?
A) IV fentanyl 1 mg
B) IV morphine sulfate 4 mg
C) Oral ibuprofen (Motrin) 600 mg
D) Oral acetaminophen (Tylenol) 650 mg
Correct Answer: Oral ibuprofen (Motrin) 600 mg
Rationale: Pericarditis pain is inflammatory and responds best to NSAIDs, which reduce pericardial
inflammation. Opioids and acetaminophen may relieve pain but do not treat the underlying
inflammatory process as effectively.
3. The nurse is assessing a patient with suspected sepsis. Which findings meet the criteria for systemic
inflammatory response syndrome (SIRS)?
,A) Temperature 99.0°F, heart rate 80, respiratory rate 18
B) Temperature 101.2°F, heart rate 95, respiratory rate 22, WBC 14,000
C) Temperature 98.6°F, heart rate 72, respiratory rate 16, WBC 8,000
D) Temperature 100.4°F, heart rate 88, respiratory rate 20, WBC 11,000
Correct Answer: Temperature 101.2°F, heart rate 95, respiratory rate 22, WBC 14,000
Rationale: SIRS criteria require two or more of the following: temperature >100.4°F or <96.8°F, heart
rate >90, respiratory rate >20, WBC >12,000 or <4,000, or PaCO2 <32 mmHg. The correct option shows
elevated temperature, tachycardia, tachypnea, and elevated WBC.
4. A patient with septic shock has a mean arterial pressure (MAP) of 55 mm Hg despite fluid
resuscitation. Which medication should the nurse anticipate administering?
A) Norepinephrine
B) Dobutamine
C) Sodium nitroprusside
D) Epinephrine
Correct Answer: Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor for septic shock to restore MAP to ≥65 mm Hg.
Dobutamine is used for cardiogenic shock, sodium nitroprusside is a vasodilator, and epinephrine is used
for anaphylaxis or cardiac arrest.
5. The nurse is caring for a burn-injured patient who weighs 154 pounds (70 kg), and the burn injury
covers 40% of total body surface area (TBSA). Using the Parkland formula, what is the total fluid
requirement for the first 24 hours?
A) 5,600 mL
B) 11,200 mL
C) 16,800 mL
D) 22,400 mL
, Correct Answer: 11,200 mL
Rationale: The Parkland formula is: 4 mL × weight (kg) × % TBSA = total fluid in the first 24 hours. For this
patient: 4 × 70 × 40 = 11,200 mL. Half is given in the first 8 hours, and the remaining half over the next
16 hours.
6. A patient with a 50% TBSA burn is receiving IV fluid resuscitation. Which assessment finding indicates
adequate fluid resuscitation?
A) Heart rate 120 beats/min
B) Urine output 30 mL/hr
C) Blood pressure 90/60 mm Hg
D) Central venous pressure 4 mm Hg
Correct Answer: Urine output 30 mL/hr
Rationale: Urine output of 0.5–1 mL/kg/hr (approximately 30 mL/hr for a 70-kg patient) is the most
reliable indicator of adequate fluid resuscitation in burn patients. Tachycardia, hypotension, and low
CVP indicate inadequate resuscitation.
7. A patient is diagnosed with disseminated intravascular coagulation (DIC). Which laboratory finding is
most consistent with this condition?
A) Elevated platelet count
B) Elevated fibrinogen level
C) Elevated D-dimer and low platelets
D) Decreased prothrombin time
Correct Answer: Elevated D-dimer and low platelets
Rationale: DIC is characterized by widespread clotting and subsequent bleeding. Laboratory findings
include low platelets, elevated D-dimer, low fibrinogen, and prolonged PT/PTT. Elevated D-dimer
indicates fibrinolysis, and low platelets indicate consumption.
Canyon University | Q & A | 2026/2027 Edition (PDF)
1. The nurse is caring for a patient in cardiogenic shock. Which assessment finding would indicate that
the patient may be developing multiple organ dysfunction syndrome (MODS)?
A) The patient's extremities are cool and pulses are weak
B) The patient reports intermittent chest pressure
C) The patient's serum creatinine level is elevated
D) The patient has bilateral crackles throughout lung fields
Correct Answer: The patient's serum creatinine level is elevated
Rationale: MODS reflects failure of two or more organ systems. In cardiogenic shock, a rising creatinine
suggests renal hypoperfusion and acute kidney injury, indicating progression toward MODS. Cool
extremities, weak pulses, and crackles are expected in shock or heart failure but do not alone confirm
additional organ failure.
2. A patient recovering from heart surgery develops pericarditis and complains of level 6 chest pain with
deep breathing. Which PRN medication is most appropriate?
A) IV fentanyl 1 mg
B) IV morphine sulfate 4 mg
C) Oral ibuprofen (Motrin) 600 mg
D) Oral acetaminophen (Tylenol) 650 mg
Correct Answer: Oral ibuprofen (Motrin) 600 mg
Rationale: Pericarditis pain is inflammatory and responds best to NSAIDs, which reduce pericardial
inflammation. Opioids and acetaminophen may relieve pain but do not treat the underlying
inflammatory process as effectively.
3. The nurse is assessing a patient with suspected sepsis. Which findings meet the criteria for systemic
inflammatory response syndrome (SIRS)?
,A) Temperature 99.0°F, heart rate 80, respiratory rate 18
B) Temperature 101.2°F, heart rate 95, respiratory rate 22, WBC 14,000
C) Temperature 98.6°F, heart rate 72, respiratory rate 16, WBC 8,000
D) Temperature 100.4°F, heart rate 88, respiratory rate 20, WBC 11,000
Correct Answer: Temperature 101.2°F, heart rate 95, respiratory rate 22, WBC 14,000
Rationale: SIRS criteria require two or more of the following: temperature >100.4°F or <96.8°F, heart
rate >90, respiratory rate >20, WBC >12,000 or <4,000, or PaCO2 <32 mmHg. The correct option shows
elevated temperature, tachycardia, tachypnea, and elevated WBC.
4. A patient with septic shock has a mean arterial pressure (MAP) of 55 mm Hg despite fluid
resuscitation. Which medication should the nurse anticipate administering?
A) Norepinephrine
B) Dobutamine
C) Sodium nitroprusside
D) Epinephrine
Correct Answer: Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor for septic shock to restore MAP to ≥65 mm Hg.
Dobutamine is used for cardiogenic shock, sodium nitroprusside is a vasodilator, and epinephrine is used
for anaphylaxis or cardiac arrest.
5. The nurse is caring for a burn-injured patient who weighs 154 pounds (70 kg), and the burn injury
covers 40% of total body surface area (TBSA). Using the Parkland formula, what is the total fluid
requirement for the first 24 hours?
A) 5,600 mL
B) 11,200 mL
C) 16,800 mL
D) 22,400 mL
, Correct Answer: 11,200 mL
Rationale: The Parkland formula is: 4 mL × weight (kg) × % TBSA = total fluid in the first 24 hours. For this
patient: 4 × 70 × 40 = 11,200 mL. Half is given in the first 8 hours, and the remaining half over the next
16 hours.
6. A patient with a 50% TBSA burn is receiving IV fluid resuscitation. Which assessment finding indicates
adequate fluid resuscitation?
A) Heart rate 120 beats/min
B) Urine output 30 mL/hr
C) Blood pressure 90/60 mm Hg
D) Central venous pressure 4 mm Hg
Correct Answer: Urine output 30 mL/hr
Rationale: Urine output of 0.5–1 mL/kg/hr (approximately 30 mL/hr for a 70-kg patient) is the most
reliable indicator of adequate fluid resuscitation in burn patients. Tachycardia, hypotension, and low
CVP indicate inadequate resuscitation.
7. A patient is diagnosed with disseminated intravascular coagulation (DIC). Which laboratory finding is
most consistent with this condition?
A) Elevated platelet count
B) Elevated fibrinogen level
C) Elevated D-dimer and low platelets
D) Decreased prothrombin time
Correct Answer: Elevated D-dimer and low platelets
Rationale: DIC is characterized by widespread clotting and subsequent bleeding. Laboratory findings
include low platelets, elevated D-dimer, low fibrinogen, and prolonged PT/PTT. Elevated D-dimer
indicates fibrinolysis, and low platelets indicate consumption.
