1
NSG 4100 Exam 4 Review: Updated 2026
Questions and Answers
1. What is standard precautions? - ANSWER Appropriate hand hygiene, glove
use. Designed for all patients. Primary strategy for preventing hospital
acquired infections
2. What is Transmission Based Precautions? - ANSWER Designed care for
patients with known or suspected infectious diseases:
ex: Airborne, droplet, or contact
3. Nursing interventions for Domestic Violence in the emergency room? -
ANSWER -Separate patient
-Asking assessment questions in private
-Nurses needs to recognize signs of abuse
*Don't judge
4. What is Mass casualty planning? - ANSWER -Incident in which there are a
mass number of injuries & Deaths in one location that is caused by an
outside incidence
5. A catastrophic disaster has occurred 5 miles from the hospital you are
working in. The hospital's disaster plan is activated & the wounded are
brought to the hospital. You are helping triage the survivors. One of the
wounded is able to walk around and has minor lacerations on the arms, hand,
chest and legs. You would place what color tag on this survivor? -
ANSWER Green
6. While triaging the wounded from a disaster, you note that one of the
wounded is not breathing, radial pulse is absent, capillary refill >2 seconds
and does not respond to your commands. What color tag is assigned? -
ANSWER Black
7. Sucking chest wound, spinal cord injury, airway obstruction, hemothorax,
shock, Alcohol Withdrawal Syndrome, Violence, abuse, neglect, SI, 2ND &
3rd degree burns 15-40% TBSA
8. PPE:
, 2
9. Level A - ANSWER **HIGHEST level of protection
-Vapor Tight Suit, Self-Contained Breathing, Apparatus, suit buddy to help
wIth donning and doffing, chemical resistant gloves & boots (used for
EBOLA)
PPE:
10.Level B - ANSWER Similiar to level A minus the vapor tight suit
PPE:
11.Level C - ANSWER -Air puffed head bubble
-Air purified respiratory, Chemical-Resistant coverall with splash hood
-Chemical Resistant suit/gloves
PPE:
12.Level D - ANSWER Standar precautions / typical work uniform
13.Which of the following is indicative of worsening condition? - ANSWER
Pupil size changing from 5 to 9mm
(sign of increased ICP)
14.Which position is best best for patient who is at risk for increased ICP? -
ANSWER Semi Fowler position
15.The pt w fibromyalgia is suffering from pain at 12 of the 18 identification
sites, including the neck & upper back & knees. The pt also reports non-
refreshing sleep, depression, & being anxious when dealing w multiple
tasks. The nurse should teach this pt about what treatments? Select all that
apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern - ANSWER B, D, E
16.The nurse caring for a client w a head injury would recognize which
assessment finding as early signs of increased ICP? Select all that apply:
a. Kussmaul breathing
b. Projectile vomiting
c. Weakness in one extremity
d. Headache not aggravated by movement of straining
, 3
e. Decreased urine output
f. Papilledema - ANSWER A, C, D
17.A nurse caring for a client diagnosed to have head injury. Which of the
following situations needs intervention by the nurse?
a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3
hours in the evening
d. The head of bed is elevated at 30 degree angle - ANSWER C
18.The critical care nurse is caring for a client w a head injury secondary to a
motorcycle accident who, on morning rounds, is responsive to painful
stimulus and assumes decorticate posturing. Two hours later, which data
would warrant immediate intervention by the nurse?
a. The client has purposeful movement when the nurse rubs the sternum
b. The client extends the upper and lower extremities in response to
painful stimuli
c. The client is aimlessly thrashing in the bed when a noxious stimuli is
applied - ANSWER B
19.The nurse is caring for clients in the ED. Which client should the nurse
assess first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ANSWER
A
20.A female pt has experienced an episode of myasthenic crisis. The nurse
would assess whether the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ANSWER C
21.A pt is being admitted to the neurologic ICU following an acute head injury
that has resulted in cerebral edema. When planning this pt's care, the nurse
would expect to administer what priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
, 4
b. Furosemide (Lasix)
c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ANSWER C
22.The nurse is caring for a pt who is postoperative following a craniotomy.
When writing the plan of care, the nurse identifies a diagnosis of deficient
fluid volume r/t fluid restriction & osmotic diuretic use. What would be an
appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - ANSWER B
23.A pt who has been on long-term phenytoin (Dilantin) therapy is admitted to
the unit. In light of the adverse of effects of this medication, the nurse should
prioritize which of the following in the pt's plan of care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - ANSWER C
24.A nurse is admitting a pt w a severe migraine headache and a hx of acute
coronary syndrome. What migraine medication would the nurse question for
this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - ANSWER C
25.The nurse is caring for a pt w increased ICP. The pt has a nursing dx of
ineffective cerebral tissue perfusion. What would be an expected outcome
that the nurse would document for this diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
c. pays attention to grooming
d. obeys commands w appropriate motor responses - ANSWER D
26.A pt exhibiting an altered LOC due to blunt-force trauma to the head is
admitted to the ED. The physician determines the pt's injury is causing
NSG 4100 Exam 4 Review: Updated 2026
Questions and Answers
1. What is standard precautions? - ANSWER Appropriate hand hygiene, glove
use. Designed for all patients. Primary strategy for preventing hospital
acquired infections
2. What is Transmission Based Precautions? - ANSWER Designed care for
patients with known or suspected infectious diseases:
ex: Airborne, droplet, or contact
3. Nursing interventions for Domestic Violence in the emergency room? -
ANSWER -Separate patient
-Asking assessment questions in private
-Nurses needs to recognize signs of abuse
*Don't judge
4. What is Mass casualty planning? - ANSWER -Incident in which there are a
mass number of injuries & Deaths in one location that is caused by an
outside incidence
5. A catastrophic disaster has occurred 5 miles from the hospital you are
working in. The hospital's disaster plan is activated & the wounded are
brought to the hospital. You are helping triage the survivors. One of the
wounded is able to walk around and has minor lacerations on the arms, hand,
chest and legs. You would place what color tag on this survivor? -
ANSWER Green
6. While triaging the wounded from a disaster, you note that one of the
wounded is not breathing, radial pulse is absent, capillary refill >2 seconds
and does not respond to your commands. What color tag is assigned? -
ANSWER Black
7. Sucking chest wound, spinal cord injury, airway obstruction, hemothorax,
shock, Alcohol Withdrawal Syndrome, Violence, abuse, neglect, SI, 2ND &
3rd degree burns 15-40% TBSA
8. PPE:
, 2
9. Level A - ANSWER **HIGHEST level of protection
-Vapor Tight Suit, Self-Contained Breathing, Apparatus, suit buddy to help
wIth donning and doffing, chemical resistant gloves & boots (used for
EBOLA)
PPE:
10.Level B - ANSWER Similiar to level A minus the vapor tight suit
PPE:
11.Level C - ANSWER -Air puffed head bubble
-Air purified respiratory, Chemical-Resistant coverall with splash hood
-Chemical Resistant suit/gloves
PPE:
12.Level D - ANSWER Standar precautions / typical work uniform
13.Which of the following is indicative of worsening condition? - ANSWER
Pupil size changing from 5 to 9mm
(sign of increased ICP)
14.Which position is best best for patient who is at risk for increased ICP? -
ANSWER Semi Fowler position
15.The pt w fibromyalgia is suffering from pain at 12 of the 18 identification
sites, including the neck & upper back & knees. The pt also reports non-
refreshing sleep, depression, & being anxious when dealing w multiple
tasks. The nurse should teach this pt about what treatments? Select all that
apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern - ANSWER B, D, E
16.The nurse caring for a client w a head injury would recognize which
assessment finding as early signs of increased ICP? Select all that apply:
a. Kussmaul breathing
b. Projectile vomiting
c. Weakness in one extremity
d. Headache not aggravated by movement of straining
, 3
e. Decreased urine output
f. Papilledema - ANSWER A, C, D
17.A nurse caring for a client diagnosed to have head injury. Which of the
following situations needs intervention by the nurse?
a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3
hours in the evening
d. The head of bed is elevated at 30 degree angle - ANSWER C
18.The critical care nurse is caring for a client w a head injury secondary to a
motorcycle accident who, on morning rounds, is responsive to painful
stimulus and assumes decorticate posturing. Two hours later, which data
would warrant immediate intervention by the nurse?
a. The client has purposeful movement when the nurse rubs the sternum
b. The client extends the upper and lower extremities in response to
painful stimuli
c. The client is aimlessly thrashing in the bed when a noxious stimuli is
applied - ANSWER B
19.The nurse is caring for clients in the ED. Which client should the nurse
assess first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ANSWER
A
20.A female pt has experienced an episode of myasthenic crisis. The nurse
would assess whether the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ANSWER C
21.A pt is being admitted to the neurologic ICU following an acute head injury
that has resulted in cerebral edema. When planning this pt's care, the nurse
would expect to administer what priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
, 4
b. Furosemide (Lasix)
c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ANSWER C
22.The nurse is caring for a pt who is postoperative following a craniotomy.
When writing the plan of care, the nurse identifies a diagnosis of deficient
fluid volume r/t fluid restriction & osmotic diuretic use. What would be an
appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - ANSWER B
23.A pt who has been on long-term phenytoin (Dilantin) therapy is admitted to
the unit. In light of the adverse of effects of this medication, the nurse should
prioritize which of the following in the pt's plan of care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - ANSWER C
24.A nurse is admitting a pt w a severe migraine headache and a hx of acute
coronary syndrome. What migraine medication would the nurse question for
this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - ANSWER C
25.The nurse is caring for a pt w increased ICP. The pt has a nursing dx of
ineffective cerebral tissue perfusion. What would be an expected outcome
that the nurse would document for this diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
c. pays attention to grooming
d. obeys commands w appropriate motor responses - ANSWER D
26.A pt exhibiting an altered LOC due to blunt-force trauma to the head is
admitted to the ED. The physician determines the pt's injury is causing
