Adult Health Nursing III – Advanced Adult
Health Nursing Exam Review
Question 1
A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who
is on mechanical ventilation. The client's plateau pressure is 35 cm H₂O. Which
intervention should the nurse anticipate?
A) Increase tidal volume to improve oxygenation
B) Decrease tidal volume and consider prone positioning
C) Increase PEEP to 20 cm H₂O
D) Decrease FiO₂ to 21%
Correct Answer: B) Decrease tidal volume and consider prone positioning
Rationale: Plateau pressure >30 cm H₂O indicates increased risk of barotrauma.
Decreasing tidal volume and implementing prone positioning improve oxygenation
while reducing ventilator-induced lung injury. High plateau pressures correlate
with increased mortality in ARDS.
Question 2
A client with heart failure has a pulmonary artery wedge pressure (PAWP) of 22
mm Hg and cardiac index of 1.8 L/min/m². Which classification of heart failure
does the nurse anticipate?
,A) Warm and dry
B) Warm and wet
C) Cold and dry
D) Cold and wet
Correct Answer: D) Cold and wet
Rationale: Cold and wet profile indicates low cardiac index (<2.2 L/min/m²) with
elevated filling pressures (PAWP >18 mm Hg). This represents cardiogenic shock
with pulmonary congestion, requiring inotropic support and diuresis.
Question 3
A nurse is assessing a client with severe sepsis who has a lactate level of 4.5
mmol/L. Which intervention is the priority?
A) Administer broad-spectrum antibiotics
B) Obtain blood cultures
C) Begin fluid resuscitation with 30 mL/kg crystalloid
D) Start norepinephrine infusion
Correct Answer: C) Begin fluid resuscitation with 30 mL/kg crystalloid
Rationale: Elevated lactate indicates tissue hypoperfusion. Fluid resuscitation with
30 mL/kg crystalloid is the initial priority in sepsis management. Antibiotics and
cultures should follow, but perfusion must be restored first.
,Question 4
A client with increased intracranial pressure has a Glasgow Coma Scale score of 6.
Which intervention should the nurse implement first?
A) Administer mannitol as prescribed
B) Prepare for endotracheal intubation
C) Elevate the head of the bed to 30 degrees
D) Perform frequent neurologic assessments
Correct Answer: B) Prepare for endotracheal intubation
Rationale: GCS ≤8 indicates severe neurologic impairment and loss of airway
protective reflexes. Endotracheal intubation is required to secure the airway and
prevent aspiration. Hyperventilation may also be used temporarily to reduce ICP.
Question 5
A nurse is caring for a client with a spinal cord injury at T4 who develops a severe
headache, hypertension, and bradycardia during bladder catheterization. Which
action should the nurse take first?
A) Administer antihypertensive medication
B) Stop the catheterization and empty the bladder
C) Place the client in Trendelenburg position
D) Increase the rate of IV fluids
Correct Answer: B) Stop the catheterization and empty the bladder
, Rationale: Autonomic dysreflexia is triggered by bladder distention or
manipulation. The first action is to stop the triggering stimulus and empty the
bladder. Antihypertensives are used if symptoms persist after removing the trigger.
Question 6
A client with acute myocardial infarction develops ventricular fibrillation. Which
intervention should the nurse implement first?
A) Administer amiodarone
B) Begin CPR and prepare for defibrillation
C) Administer epinephrine
D) Prepare for temporary pacing
Correct Answer: B) Begin CPR and prepare for defibrillation
Rationale: Ventricular fibrillation is a lethal rhythm requiring immediate
defibrillation. CPR is initiated while preparing the defibrillator. Early defibrillation
is the most important determinant of survival in VF.
Question 7
A nurse is assessing a client with a chest tube who suddenly develops tracheal
deviation, hypotension, and absent breath sounds on the right. Which action should
the nurse take first?
A) Notify the healthcare provider
B) Assist with needle decompression
Health Nursing Exam Review
Question 1
A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who
is on mechanical ventilation. The client's plateau pressure is 35 cm H₂O. Which
intervention should the nurse anticipate?
A) Increase tidal volume to improve oxygenation
B) Decrease tidal volume and consider prone positioning
C) Increase PEEP to 20 cm H₂O
D) Decrease FiO₂ to 21%
Correct Answer: B) Decrease tidal volume and consider prone positioning
Rationale: Plateau pressure >30 cm H₂O indicates increased risk of barotrauma.
Decreasing tidal volume and implementing prone positioning improve oxygenation
while reducing ventilator-induced lung injury. High plateau pressures correlate
with increased mortality in ARDS.
Question 2
A client with heart failure has a pulmonary artery wedge pressure (PAWP) of 22
mm Hg and cardiac index of 1.8 L/min/m². Which classification of heart failure
does the nurse anticipate?
,A) Warm and dry
B) Warm and wet
C) Cold and dry
D) Cold and wet
Correct Answer: D) Cold and wet
Rationale: Cold and wet profile indicates low cardiac index (<2.2 L/min/m²) with
elevated filling pressures (PAWP >18 mm Hg). This represents cardiogenic shock
with pulmonary congestion, requiring inotropic support and diuresis.
Question 3
A nurse is assessing a client with severe sepsis who has a lactate level of 4.5
mmol/L. Which intervention is the priority?
A) Administer broad-spectrum antibiotics
B) Obtain blood cultures
C) Begin fluid resuscitation with 30 mL/kg crystalloid
D) Start norepinephrine infusion
Correct Answer: C) Begin fluid resuscitation with 30 mL/kg crystalloid
Rationale: Elevated lactate indicates tissue hypoperfusion. Fluid resuscitation with
30 mL/kg crystalloid is the initial priority in sepsis management. Antibiotics and
cultures should follow, but perfusion must be restored first.
,Question 4
A client with increased intracranial pressure has a Glasgow Coma Scale score of 6.
Which intervention should the nurse implement first?
A) Administer mannitol as prescribed
B) Prepare for endotracheal intubation
C) Elevate the head of the bed to 30 degrees
D) Perform frequent neurologic assessments
Correct Answer: B) Prepare for endotracheal intubation
Rationale: GCS ≤8 indicates severe neurologic impairment and loss of airway
protective reflexes. Endotracheal intubation is required to secure the airway and
prevent aspiration. Hyperventilation may also be used temporarily to reduce ICP.
Question 5
A nurse is caring for a client with a spinal cord injury at T4 who develops a severe
headache, hypertension, and bradycardia during bladder catheterization. Which
action should the nurse take first?
A) Administer antihypertensive medication
B) Stop the catheterization and empty the bladder
C) Place the client in Trendelenburg position
D) Increase the rate of IV fluids
Correct Answer: B) Stop the catheterization and empty the bladder
, Rationale: Autonomic dysreflexia is triggered by bladder distention or
manipulation. The first action is to stop the triggering stimulus and empty the
bladder. Antihypertensives are used if symptoms persist after removing the trigger.
Question 6
A client with acute myocardial infarction develops ventricular fibrillation. Which
intervention should the nurse implement first?
A) Administer amiodarone
B) Begin CPR and prepare for defibrillation
C) Administer epinephrine
D) Prepare for temporary pacing
Correct Answer: B) Begin CPR and prepare for defibrillation
Rationale: Ventricular fibrillation is a lethal rhythm requiring immediate
defibrillation. CPR is initiated while preparing the defibrillator. Early defibrillation
is the most important determinant of survival in VF.
Question 7
A nurse is assessing a client with a chest tube who suddenly develops tracheal
deviation, hypotension, and absent breath sounds on the right. Which action should
the nurse take first?
A) Notify the healthcare provider
B) Assist with needle decompression
