NR 341/ NR341 COMPLEX ADULT HEALTH EXAM 1 LATEST REAL EXAM
QUESTIONS AND CORRECT ANSWERS | A+ GRADE ASSURED
Question 1
A nurse is caring for a client in the intensive care unit (ICU) who is experiencing hypovolemic
shock. Which of the following is the nurse's priority intervention?
A) Administering a broad-spectrum antibiotic.
B) Elevating the client's legs to improve venous return.
C) Administering rapid intravenous fluid resuscitation.
D) Initiating vasopressor medications.
E) Preparing for intubation.
Correct Answer: C) Administering rapid intravenous fluid resuscitation.
Rationale: The immediate priority in hypovolemic shock is to restore circulating blood volume
rapidly with IV fluids (e.g., isotonic crystalloids) to improve tissue perfusion and blood pressure.
Question 2
A client with acute respiratory distress syndrome (ARDS) is experiencing severe hypoxemia.
The nurse understands that this is primarily due to:
A) Bronchospasm.
B) Increased alveolar ventilation.
C) Intrapulmonary shunting.
D) Decreased pulmonary artery pressure.
E) Metabolic alkalosis.
Correct Answer: C) Intrapulmonary shunting.
Rationale: In ARDS, widespread alveolar collapse and fluid filling lead to severe
intrapulmonary shunting, where blood passes through unventilated lung areas without picking
up oxygen, causing refractory hypoxemia.
Question 3
A nurse is assessing a client with sepsis who has developed systemic inflammatory response
syndrome (SIRS). Which of the following is a classic criterion for SIRS?
A) Bradycardia (<60 bpm).
B) Core body temperature <36°C (96.8°F) or >38°C (100.4°F).
C) Hypertension (>140/90 mmHg).
D) Normal white blood cell count.
E) Metabolic alkalosis.
Correct Answer: B) Core body temperature <36°C (96.8°F) or >38°C (100.4°F).
,Rationale: One of the criteria for SIRS is an abnormal core body temperature (either fever or
hypothermia). Other criteria include tachycardia, tachypnea, and an abnormal white blood cell
count.
Question 4
A client's arterial blood gas (ABG) results are: pH 7.25, PaCO2 55 mmHg, HCO3- 24 mEq/L.
This indicates which acid-base imbalance?
A) Metabolic acidosis, uncompensated.
B) Respiratory acidosis, uncompensated.
C) Metabolic alkalosis, uncompensated.
D) Respiratory alkalosis, uncompensated.
E) Respiratory acidosis, partially compensated.
Correct Answer: B) Respiratory acidosis, uncompensated.
Rationale: The pH is acidic, the PaCO2 is high (indicating a primary respiratory problem), and
the HCO3- is within normal limits, signifying uncompensated respiratory acidosis.
Question 5
A nurse is caring for a client with hyperkalemia. Which of the following is the most life-
threatening complication of hyperkalemia?
A) Muscle weakness.
B) Gastrointestinal cramping.
C) Cardiac dysrhythmias.
D) Paresthesias.
E) Oliguria.
Correct Answer: C) Cardiac dysrhythmias.
Rationale: Severe hyperkalemia can cause life-threatening cardiac conduction abnormalities
and dysrhythmias, including ventricular fibrillation and asystole.
Question 6
A client with a myocardial infarction (MI) is experiencing chest pain. The nurse understands that
the pain of an MI is primarily caused by:
A) Pericardial inflammation.
B) Smooth muscle spasm.
C) Myocardial ischemia.
D) Neuralgia.
E) Anxiety.
Correct Answer: C) Myocardial ischemia.
,Rationale: The pain of a myocardial infarction is caused by prolonged ischemia (lack of blood
flow and oxygen) to the heart muscle, leading to cellular injury and necrosis.
Question 7
A nurse is assessing a client in cardiogenic shock. Which of the following assessment findings
should the nurse expect?
A) Warm, flushed skin.
B) Bounding peripheral pulses.
C) Hypotension and decreased cardiac output.
D) Increased urine output.
E) Bradycardia.
Correct Answer: C) Hypotension and decreased cardiac output.
Rationale: Cardiogenic shock is characterized by the heart's inability to pump sufficient blood
to meet the body's demands, leading to decreased cardiac output, hypotension, and signs of
poor perfusion.
Question 8
A client is receiving mechanical ventilation. To prevent ventilator-associated pneumonia (VAP),
which intervention is essential?
A) Maintaining the head of the bed flat.
B) Performing oral care with chlorhexidine.
C) Routine suctioning every hour.
D) Administering prophylactic antibiotics daily.
E) Providing frequent nebulizer treatments.
Correct Answer: B) Performing oral care with chlorhexidine.
Rationale: Performing regular and thorough oral care with an antiseptic solution like
chlorhexidine is a critical intervention to reduce bacterial colonization in the oropharynx and
prevent VAP.
Question 9
A client with acute pancreatitis is experiencing severe abdominal pain. Which laboratory finding
should the nurse anticipate as being significantly elevated?
A) Serum bilirubin.
B) Serum creatinine.
C) Serum amylase and lipase.
D) Blood urea nitrogen (BUN).
E) White blood cell count (WBC) only.
, Correct Answer: C) Serum amylase and lipase.
Rationale: Markedly elevated serum amylase and lipase levels are the hallmark diagnostic
indicators for acute pancreatitis, with lipase being more specific.
Question 10
A nurse is preparing to administer a blood transfusion. What is the most important initial
nursing action?
A) Administering a bolus of normal saline.
B) Verifying blood compatibility with another licensed nurse.
C) Warming the blood to body temperature.
D) Administering an antihistamine pre-transfusion.
E) Obtaining the client's consent for the transfusion.
Correct Answer: B) Verifying blood compatibility with another licensed nurse.
Rationale: Proper client identification and verification of the blood product with another
licensed nurse is the most critical step to prevent a fatal transfusion reaction.
Question 11
A client develops systemic inflammatory response syndrome (SIRS). Which of the following is a
classic criterion for SIRS?
A) Bradycardia (<60 bpm).
B) Heart rate >90 bpm.
C) Hypertension (>140/90 mmHg).
D) Normal white blood cell count.
E) Metabolic alkalosis.
Correct Answer: B) Heart rate >90 bpm.
Rationale: Tachycardia (heart rate >90 bpm) is one of the criteria for SIRS.
Question 12
A client with diabetes insipidus (DI) is experiencing severe polyuria and polydipsia. This
condition is caused by a deficiency in:
A) Insulin.
B) Aldosterone.
C) Antidiuretic hormone (ADH).
D) Thyroid hormone.
E) Cortisol.
Correct Answer: C) Antidiuretic hormone (ADH).
QUESTIONS AND CORRECT ANSWERS | A+ GRADE ASSURED
Question 1
A nurse is caring for a client in the intensive care unit (ICU) who is experiencing hypovolemic
shock. Which of the following is the nurse's priority intervention?
A) Administering a broad-spectrum antibiotic.
B) Elevating the client's legs to improve venous return.
C) Administering rapid intravenous fluid resuscitation.
D) Initiating vasopressor medications.
E) Preparing for intubation.
Correct Answer: C) Administering rapid intravenous fluid resuscitation.
Rationale: The immediate priority in hypovolemic shock is to restore circulating blood volume
rapidly with IV fluids (e.g., isotonic crystalloids) to improve tissue perfusion and blood pressure.
Question 2
A client with acute respiratory distress syndrome (ARDS) is experiencing severe hypoxemia.
The nurse understands that this is primarily due to:
A) Bronchospasm.
B) Increased alveolar ventilation.
C) Intrapulmonary shunting.
D) Decreased pulmonary artery pressure.
E) Metabolic alkalosis.
Correct Answer: C) Intrapulmonary shunting.
Rationale: In ARDS, widespread alveolar collapse and fluid filling lead to severe
intrapulmonary shunting, where blood passes through unventilated lung areas without picking
up oxygen, causing refractory hypoxemia.
Question 3
A nurse is assessing a client with sepsis who has developed systemic inflammatory response
syndrome (SIRS). Which of the following is a classic criterion for SIRS?
A) Bradycardia (<60 bpm).
B) Core body temperature <36°C (96.8°F) or >38°C (100.4°F).
C) Hypertension (>140/90 mmHg).
D) Normal white blood cell count.
E) Metabolic alkalosis.
Correct Answer: B) Core body temperature <36°C (96.8°F) or >38°C (100.4°F).
,Rationale: One of the criteria for SIRS is an abnormal core body temperature (either fever or
hypothermia). Other criteria include tachycardia, tachypnea, and an abnormal white blood cell
count.
Question 4
A client's arterial blood gas (ABG) results are: pH 7.25, PaCO2 55 mmHg, HCO3- 24 mEq/L.
This indicates which acid-base imbalance?
A) Metabolic acidosis, uncompensated.
B) Respiratory acidosis, uncompensated.
C) Metabolic alkalosis, uncompensated.
D) Respiratory alkalosis, uncompensated.
E) Respiratory acidosis, partially compensated.
Correct Answer: B) Respiratory acidosis, uncompensated.
Rationale: The pH is acidic, the PaCO2 is high (indicating a primary respiratory problem), and
the HCO3- is within normal limits, signifying uncompensated respiratory acidosis.
Question 5
A nurse is caring for a client with hyperkalemia. Which of the following is the most life-
threatening complication of hyperkalemia?
A) Muscle weakness.
B) Gastrointestinal cramping.
C) Cardiac dysrhythmias.
D) Paresthesias.
E) Oliguria.
Correct Answer: C) Cardiac dysrhythmias.
Rationale: Severe hyperkalemia can cause life-threatening cardiac conduction abnormalities
and dysrhythmias, including ventricular fibrillation and asystole.
Question 6
A client with a myocardial infarction (MI) is experiencing chest pain. The nurse understands that
the pain of an MI is primarily caused by:
A) Pericardial inflammation.
B) Smooth muscle spasm.
C) Myocardial ischemia.
D) Neuralgia.
E) Anxiety.
Correct Answer: C) Myocardial ischemia.
,Rationale: The pain of a myocardial infarction is caused by prolonged ischemia (lack of blood
flow and oxygen) to the heart muscle, leading to cellular injury and necrosis.
Question 7
A nurse is assessing a client in cardiogenic shock. Which of the following assessment findings
should the nurse expect?
A) Warm, flushed skin.
B) Bounding peripheral pulses.
C) Hypotension and decreased cardiac output.
D) Increased urine output.
E) Bradycardia.
Correct Answer: C) Hypotension and decreased cardiac output.
Rationale: Cardiogenic shock is characterized by the heart's inability to pump sufficient blood
to meet the body's demands, leading to decreased cardiac output, hypotension, and signs of
poor perfusion.
Question 8
A client is receiving mechanical ventilation. To prevent ventilator-associated pneumonia (VAP),
which intervention is essential?
A) Maintaining the head of the bed flat.
B) Performing oral care with chlorhexidine.
C) Routine suctioning every hour.
D) Administering prophylactic antibiotics daily.
E) Providing frequent nebulizer treatments.
Correct Answer: B) Performing oral care with chlorhexidine.
Rationale: Performing regular and thorough oral care with an antiseptic solution like
chlorhexidine is a critical intervention to reduce bacterial colonization in the oropharynx and
prevent VAP.
Question 9
A client with acute pancreatitis is experiencing severe abdominal pain. Which laboratory finding
should the nurse anticipate as being significantly elevated?
A) Serum bilirubin.
B) Serum creatinine.
C) Serum amylase and lipase.
D) Blood urea nitrogen (BUN).
E) White blood cell count (WBC) only.
, Correct Answer: C) Serum amylase and lipase.
Rationale: Markedly elevated serum amylase and lipase levels are the hallmark diagnostic
indicators for acute pancreatitis, with lipase being more specific.
Question 10
A nurse is preparing to administer a blood transfusion. What is the most important initial
nursing action?
A) Administering a bolus of normal saline.
B) Verifying blood compatibility with another licensed nurse.
C) Warming the blood to body temperature.
D) Administering an antihistamine pre-transfusion.
E) Obtaining the client's consent for the transfusion.
Correct Answer: B) Verifying blood compatibility with another licensed nurse.
Rationale: Proper client identification and verification of the blood product with another
licensed nurse is the most critical step to prevent a fatal transfusion reaction.
Question 11
A client develops systemic inflammatory response syndrome (SIRS). Which of the following is a
classic criterion for SIRS?
A) Bradycardia (<60 bpm).
B) Heart rate >90 bpm.
C) Hypertension (>140/90 mmHg).
D) Normal white blood cell count.
E) Metabolic alkalosis.
Correct Answer: B) Heart rate >90 bpm.
Rationale: Tachycardia (heart rate >90 bpm) is one of the criteria for SIRS.
Question 12
A client with diabetes insipidus (DI) is experiencing severe polyuria and polydipsia. This
condition is caused by a deficiency in:
A) Insulin.
B) Aldosterone.
C) Antidiuretic hormone (ADH).
D) Thyroid hormone.
E) Cortisol.
Correct Answer: C) Antidiuretic hormone (ADH).
