NUR 216 EXAM 4 ULTIMATE TEST BANK
COMPREHENSIVE QUESTIONS &
RATIONALES
This comprehensive practice exam bundle is meticulously
designed to mirror advanced nursing health assessment and
critical care curricula. Every multiple-choice question features
highlighted answers and detailed, bolded rationales to
streamline complex clinical synthesis and ensure maximum
conceptual retention. It serves as an essential, high-yielding
study resource for students aiming to master high-stakes
module exams and excel in NCLEX-style critical thinking.
1. A patient with acute respiratory distress
syndrome (ARDS) is placed in the prone
position. Which finding best indicates that this
intervention is effective?
A. Decreased secretions
B. Increased PaO2/FiO2 ratio
C. Reduced airway pressure
D. Increased respiratory rate
Answer: B
Rationale: Prone positioning improves
oxygenation by recruiting collapsed alveoli and
improving ventilation-perfusion matching. An
increased PaO2/FiO2 ratio directly measures
improved lung oxygenation efficiency.
,2. Which laboratory value requires immediate
intervention in a patient receiving a continuous
heparin infusion for deep vein thrombosis
(DVT)?
A. aPTT of 70 seconds
B. Platelet count of 85,000/mm³
C. INR of 1.2
D. Hemoglobin of 13.5 g/dL
Answer: B
Rationale: A drop in platelets below
100,000/mm³ or a 50% drop from baseline
strongly suggests Heparin-Induced
Thrombocytopenia (HIT). This requires
immediate cessation of heparin.
3. A patient is admitted with a spinal cord injury at
the T4 level. The nurse notes a BP of 190/100
mmHg, heart rate of 48 bpm, and severe
headache. What is the priority nursing action?
A. Administer an IV antihypertensive
B. Check the patient for fecal impaction or a
kinked urinary catheter
C. Place the patient in a supine position
D. Notify the healthcare provider immediately
Answer: B
, Rationale: These symptoms indicate autonomic
dysreflexia, a medical emergency triggered by
noxious stimuli below the injury level. Elevating
the head of the bed and removing the trigger
(bladder or bowel distension) is the immediate
priority.
4. Which assessment finding is most
characteristic of a patient in the compensatory
stage of shock?
A. Mottled skin and lethargy
B. Cool, clammy skin and tachycardia
C. Respiratory acidosis and anuria
D. Hypotension and bradycardia
Answer: B
Rationale: In the compensatory stage, the
sympathetic nervous system triggers
vasoconstriction and diverts blood to vital
organs. This results in tachycardia and cool,
clammy skin.
5. A patient with liver cirrhosis presents with a
prolonged prothrombin time (PT). Which
medication should the nurse anticipate
administering?
A. Protamine sulfate
, B. Vitamin K
C. Heparin
D. Vitamin B12
Answer: B
Rationale: The liver synthesizes vitamin K-
dependent clotting factors. Cirrhosis impairs
this production, and vitamin K supplementation
helps correct the deficiency.
6. While monitoring a chest tube drainage system,
the nurse notes continuous bubbling in the
water seal chamber. How should the nurse
interpret this finding?
A. The lung has fully re-expanded.
B. There is an air leak in the system.
C. The suction pressure is too high.
D. This is a normal and expected finding.
Answer: B
Rationale: Continuous bubbling in the water
seal chamber indicates an air leak between the
patient and the chamber. Intermittent bubbling
during expiration or coughing is normal.
7. A patient with chronic kidney disease (CKD)
reports severe muscle weakness and ECG
changes showing tall, peaked T waves. Which
COMPREHENSIVE QUESTIONS &
RATIONALES
This comprehensive practice exam bundle is meticulously
designed to mirror advanced nursing health assessment and
critical care curricula. Every multiple-choice question features
highlighted answers and detailed, bolded rationales to
streamline complex clinical synthesis and ensure maximum
conceptual retention. It serves as an essential, high-yielding
study resource for students aiming to master high-stakes
module exams and excel in NCLEX-style critical thinking.
1. A patient with acute respiratory distress
syndrome (ARDS) is placed in the prone
position. Which finding best indicates that this
intervention is effective?
A. Decreased secretions
B. Increased PaO2/FiO2 ratio
C. Reduced airway pressure
D. Increased respiratory rate
Answer: B
Rationale: Prone positioning improves
oxygenation by recruiting collapsed alveoli and
improving ventilation-perfusion matching. An
increased PaO2/FiO2 ratio directly measures
improved lung oxygenation efficiency.
,2. Which laboratory value requires immediate
intervention in a patient receiving a continuous
heparin infusion for deep vein thrombosis
(DVT)?
A. aPTT of 70 seconds
B. Platelet count of 85,000/mm³
C. INR of 1.2
D. Hemoglobin of 13.5 g/dL
Answer: B
Rationale: A drop in platelets below
100,000/mm³ or a 50% drop from baseline
strongly suggests Heparin-Induced
Thrombocytopenia (HIT). This requires
immediate cessation of heparin.
3. A patient is admitted with a spinal cord injury at
the T4 level. The nurse notes a BP of 190/100
mmHg, heart rate of 48 bpm, and severe
headache. What is the priority nursing action?
A. Administer an IV antihypertensive
B. Check the patient for fecal impaction or a
kinked urinary catheter
C. Place the patient in a supine position
D. Notify the healthcare provider immediately
Answer: B
, Rationale: These symptoms indicate autonomic
dysreflexia, a medical emergency triggered by
noxious stimuli below the injury level. Elevating
the head of the bed and removing the trigger
(bladder or bowel distension) is the immediate
priority.
4. Which assessment finding is most
characteristic of a patient in the compensatory
stage of shock?
A. Mottled skin and lethargy
B. Cool, clammy skin and tachycardia
C. Respiratory acidosis and anuria
D. Hypotension and bradycardia
Answer: B
Rationale: In the compensatory stage, the
sympathetic nervous system triggers
vasoconstriction and diverts blood to vital
organs. This results in tachycardia and cool,
clammy skin.
5. A patient with liver cirrhosis presents with a
prolonged prothrombin time (PT). Which
medication should the nurse anticipate
administering?
A. Protamine sulfate
, B. Vitamin K
C. Heparin
D. Vitamin B12
Answer: B
Rationale: The liver synthesizes vitamin K-
dependent clotting factors. Cirrhosis impairs
this production, and vitamin K supplementation
helps correct the deficiency.
6. While monitoring a chest tube drainage system,
the nurse notes continuous bubbling in the
water seal chamber. How should the nurse
interpret this finding?
A. The lung has fully re-expanded.
B. There is an air leak in the system.
C. The suction pressure is too high.
D. This is a normal and expected finding.
Answer: B
Rationale: Continuous bubbling in the water
seal chamber indicates an air leak between the
patient and the chamber. Intermittent bubbling
during expiration or coughing is normal.
7. A patient with chronic kidney disease (CKD)
reports severe muscle weakness and ECG
changes showing tall, peaked T waves. Which
