NSG 3850 NURSING EXAM 4 QUESTIONS
WITH CORRECT ANSWERS – GALEN
COLLEGE OF NURSING (U.S.) |
COMPLETE VERIFIED ANSWERS
2026/2027
1. A patient with a traumatic brain injury (TBI) has a Glasgow Coma Scale (GCS) score of 6.
Which intervention is the priority for the nurse?
A. Monitor intracranial pressure via an intraventricular catheter.
B. Maintain the head of the bed at 15 degrees to minimize hip flexion.
C. Assess for signs of autonomic dysreflexia every 4 hours.
D. Prepare for immediate endotracheal intubation and mechanical ventilation.
Answer: D
Conceptual Explanation: A GCS of 8 or less indicates severe brain injury and requires
airway protection through intubation because the patient likely cannot maintain their own
airway or ventilation.
2. When caring for a patient in the compensatory stage of shock, which clinical finding should
the nurse expect?
A. Metabolic acidosis with a decreased respiratory rate.
,B. Narrowing pulse pressure and cool, clammy skin.
C. Lethargy and profound hypotension.
D. Hyperkalemia and decreased urine output below 5 mL/hr.
Answer: B
Conceptual Explanation: In the compensatory stage, the body uses the SNS to maintain
cardiac output, resulting in vasoconstriction (cool skin) and an increase in diastolic
pressure, which narrows the pulse pressure.
3. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation. The nurse notes the ‘High Pressure’ alarm is sounding. What is the most
appropriate initial action?
A. Disconnect the patient and manually ventilate with a bag-valve-mask.
B. Increase the oxygen concentration to 100% via the ventilator.
C. Auscultate the patient’s breath sounds for possible pneumothorax or secretions.
D. Administer a sedative to reduce the patient’s anxiety and ventilator fighting.
Answer: C
Conceptual Explanation: High-pressure alarms are triggered by increased resistance. The
nurse should first assess the patient for causes such as biting the tube, secretions, or a
pneumothorax before taking more invasive actions.
, 4. A nurse is caring for a patient with an acute spinal cord injury at C4. The patient suddenly
reports a severe headache and has a blood pressure of 190/110. What is the first action the
nurse should take?
A. Administer prescribed PRN hydralazine.
B. Lower the head of the bed to the flat position.
C. Sit the patient upright to lower blood pressure.
D. Perform a digital rectal exam to check for impaction.
Answer: C
Conceptual Explanation: These are classic signs of Autonomic Dysreflexia. The priority is
to sit the patient up to help lower the blood pressure through orthostatic effects before
identifying the noxious stimulus (like a full bladder or bowel).
5. In a patient with Acute Kidney Injury (AKI), which electrolyte abnormality is the most
immediate threat to life?
A. Hypocalcemia
B. Hyperkalemia
C. Hypermagnesemia
D. Hyponatremia
Answer: B
WITH CORRECT ANSWERS – GALEN
COLLEGE OF NURSING (U.S.) |
COMPLETE VERIFIED ANSWERS
2026/2027
1. A patient with a traumatic brain injury (TBI) has a Glasgow Coma Scale (GCS) score of 6.
Which intervention is the priority for the nurse?
A. Monitor intracranial pressure via an intraventricular catheter.
B. Maintain the head of the bed at 15 degrees to minimize hip flexion.
C. Assess for signs of autonomic dysreflexia every 4 hours.
D. Prepare for immediate endotracheal intubation and mechanical ventilation.
Answer: D
Conceptual Explanation: A GCS of 8 or less indicates severe brain injury and requires
airway protection through intubation because the patient likely cannot maintain their own
airway or ventilation.
2. When caring for a patient in the compensatory stage of shock, which clinical finding should
the nurse expect?
A. Metabolic acidosis with a decreased respiratory rate.
,B. Narrowing pulse pressure and cool, clammy skin.
C. Lethargy and profound hypotension.
D. Hyperkalemia and decreased urine output below 5 mL/hr.
Answer: B
Conceptual Explanation: In the compensatory stage, the body uses the SNS to maintain
cardiac output, resulting in vasoconstriction (cool skin) and an increase in diastolic
pressure, which narrows the pulse pressure.
3. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation. The nurse notes the ‘High Pressure’ alarm is sounding. What is the most
appropriate initial action?
A. Disconnect the patient and manually ventilate with a bag-valve-mask.
B. Increase the oxygen concentration to 100% via the ventilator.
C. Auscultate the patient’s breath sounds for possible pneumothorax or secretions.
D. Administer a sedative to reduce the patient’s anxiety and ventilator fighting.
Answer: C
Conceptual Explanation: High-pressure alarms are triggered by increased resistance. The
nurse should first assess the patient for causes such as biting the tube, secretions, or a
pneumothorax before taking more invasive actions.
, 4. A nurse is caring for a patient with an acute spinal cord injury at C4. The patient suddenly
reports a severe headache and has a blood pressure of 190/110. What is the first action the
nurse should take?
A. Administer prescribed PRN hydralazine.
B. Lower the head of the bed to the flat position.
C. Sit the patient upright to lower blood pressure.
D. Perform a digital rectal exam to check for impaction.
Answer: C
Conceptual Explanation: These are classic signs of Autonomic Dysreflexia. The priority is
to sit the patient up to help lower the blood pressure through orthostatic effects before
identifying the noxious stimulus (like a full bladder or bowel).
5. In a patient with Acute Kidney Injury (AKI), which electrolyte abnormality is the most
immediate threat to life?
A. Hypocalcemia
B. Hyperkalemia
C. Hypermagnesemia
D. Hyponatremia
Answer: B
