NSG 430/ NSG430 Adult Health Nursing II Final
Exam Questions & Answers | Latest Update 2025/2026
| Graded A+ | 100% Correct Solutions | GCU
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers
40% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a
burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV)
fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24
hours? Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
d. 11200 ml
a. 14000 ml
A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following
aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose
begins to normalize. In addition to glucose monitoring, which of the following electrolytes
requires close monitoring?
Select one:
a. Chloride
b. Sodium
c. Potassium
d. Calcium
,c. Potassium
The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital
signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min,
respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen
by non-rebreather mask. An IV has been established and the patient has been given lorazepam,
but the seizures continue. What is the next nursing priority?
Select one:
a. Obtain stat portable chest x-ray.
b. Administer phenytoin.
c. Administer 2nd lorazepam dose.
d. Obtain stat serum electrolytes.
b. Administer phenytoin.
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury
c. After the emergent phase of the injury
, After receiving the handoff report from the day shift charge nurse, which patient should the
evening charge nurse assess first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the patient's
noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement
via an intra-arterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What
is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments
d. Frequent neurological assessments
The charge nurse assigns patients based on their acuity and the level of experience of the critical
care nurses on duty. This is an example of implementation of:
Select one:
a. Healthy work environment
Exam Questions & Answers | Latest Update 2025/2026
| Graded A+ | 100% Correct Solutions | GCU
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers
40% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a
burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV)
fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24
hours? Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
d. 11200 ml
a. 14000 ml
A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following
aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose
begins to normalize. In addition to glucose monitoring, which of the following electrolytes
requires close monitoring?
Select one:
a. Chloride
b. Sodium
c. Potassium
d. Calcium
,c. Potassium
The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital
signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min,
respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen
by non-rebreather mask. An IV has been established and the patient has been given lorazepam,
but the seizures continue. What is the next nursing priority?
Select one:
a. Obtain stat portable chest x-ray.
b. Administer phenytoin.
c. Administer 2nd lorazepam dose.
d. Obtain stat serum electrolytes.
b. Administer phenytoin.
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury
c. After the emergent phase of the injury
, After receiving the handoff report from the day shift charge nurse, which patient should the
evening charge nurse assess first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the patient's
noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement
via an intra-arterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What
is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments
d. Frequent neurological assessments
The charge nurse assigns patients based on their acuity and the level of experience of the critical
care nurses on duty. This is an example of implementation of:
Select one:
a. Healthy work environment
