Exam 3 NUR 445 practice UPDATED
ACTUAL Questions and CORRECT
Answers
1) The nurse is educating the client and their family about the client new diagnosis of ALS.
Which statement my client/family need future education? - CORRECT ANSWER -
Answer: Any statement implying ALS is reversible, cognition is always affected, or that rest
slows progression. ALS affects motor neurons—not cognitive function—and has no cure; focus
on symptom management.
2) A female client is admitted to the ICU with cardiogenic shock following a MI. What treatment
option should the nurse anticipate may be ordered? - CORRECT ANSWER - Answer:
Inotropic agents (e.g., dobutamine), nitrates if blood pressure allows, oxygen, possible
intra‑aortic balloon pump (IABP).
3) The nurse has administered a dose of IM penicillin to a client. Five minute later the client
report SOB and itching. The nurse note strider and raised red rash. What path change is
happening to the client? - CORRECT ANSWER - Answer: Anaphylaxis—type I
hypersensitivity; mast cell degranulation → histamine → bronchoconstriction and urticaria.
4) A client is being admitted with septic shock. Which lavatory test is the priority for the nurse to
obtain before imitating antibiotic therapy? - CORRECT ANSWER - Answer: Serum
lactate (and blood cultures)—elevated lactic acid helps guide resuscitation and identifies organ
hypoperfusion.
5) The nurse assesses a client with brain tumor. Which finding would be consistent with this
diagnosis? - CORRECT ANSWER - Answer: Headache (usually worse in AM), vomiting,
visual changes, seizures, personality changes, focal deficits.
6) The nurse is caring for a client in the emergency department who was brough in with signs of
a stroke. The health care team is determining if the client should be prescribing tissue
plasminogen activator (TPA). Which finding in the client health history should the nurse
understand would exclude them from being eligible for TPA administration? - CORRECT
, ANSWER - answer: Recent major surgery or head trauma, hemorrhagic stroke, current
anticoagulation with high INR (>1.7), uncontrolled hypertension, recent GI bleed.
7) The nurse assesses a client with ICP. What priority action should the nurse complete? -
CORRECT ANSWER - Answer: Head elevation to 30°, maintain neck midline, avoid
suctioning or Valsalva maneuvers, monitor pupil/neurological changes.
8) Which of the following medication classification would most likely help prevent stress ulcer
for a client in the ICU. (SATA) - CORRECT ANSWER - Answer: Proton pump inhibitors
(e.g., pantoprazole); H₂ receptor blockers (e.g., ranitidine); sucralfate.
9) Which classifications listed below are used as treatment to support cardiac output in client
diagnosed with shock? - CORRECT ANSWER - Answer: Inotropic agents (dobutamine,
dobutrex); vasopressors (norepinephrine, dopamine); vasodilators in cardiogenic shock
(nitroprusside).
10) The nurse is caring for a client diagnosed with obstructive shock. Which of the following
assessment finding indicates decrease cardiac output? - CORRECT ANSWER - Answer:
JVD, muffled heart sounds, hypotension (e.g., in tamponade) or pulsus paradoxus; ↓ peripheral
pulses.
11) The nurse recognizes which disorder increase the client risk for obstructive shock? -
CORRECT ANSWER - Answer: Pericardial tamponade, tension pneumothorax, massive
pulmonary embolism, cardiac tamponade.
What is the name of the main type of shock which is characterized by widespread vasodilation
and increase capillary permeability? - CORRECT ANSWER - Answer: Distributive shock
(specifically, septic shock).
13) The nurse cares for the client with sepsis after a crushing injury to the left leg. Based on the
nurses note. What is the nurse's priority intervention to prevent the development of multiple
organ dysfunction (MOD)? - CORRECT ANSWER - Answer: Early fluid resuscitation,
broad‑spectrum antibiotics, oxygenation, hemodynamic monitoring—these are all priorities.
ACTUAL Questions and CORRECT
Answers
1) The nurse is educating the client and their family about the client new diagnosis of ALS.
Which statement my client/family need future education? - CORRECT ANSWER -
Answer: Any statement implying ALS is reversible, cognition is always affected, or that rest
slows progression. ALS affects motor neurons—not cognitive function—and has no cure; focus
on symptom management.
2) A female client is admitted to the ICU with cardiogenic shock following a MI. What treatment
option should the nurse anticipate may be ordered? - CORRECT ANSWER - Answer:
Inotropic agents (e.g., dobutamine), nitrates if blood pressure allows, oxygen, possible
intra‑aortic balloon pump (IABP).
3) The nurse has administered a dose of IM penicillin to a client. Five minute later the client
report SOB and itching. The nurse note strider and raised red rash. What path change is
happening to the client? - CORRECT ANSWER - Answer: Anaphylaxis—type I
hypersensitivity; mast cell degranulation → histamine → bronchoconstriction and urticaria.
4) A client is being admitted with septic shock. Which lavatory test is the priority for the nurse to
obtain before imitating antibiotic therapy? - CORRECT ANSWER - Answer: Serum
lactate (and blood cultures)—elevated lactic acid helps guide resuscitation and identifies organ
hypoperfusion.
5) The nurse assesses a client with brain tumor. Which finding would be consistent with this
diagnosis? - CORRECT ANSWER - Answer: Headache (usually worse in AM), vomiting,
visual changes, seizures, personality changes, focal deficits.
6) The nurse is caring for a client in the emergency department who was brough in with signs of
a stroke. The health care team is determining if the client should be prescribing tissue
plasminogen activator (TPA). Which finding in the client health history should the nurse
understand would exclude them from being eligible for TPA administration? - CORRECT
, ANSWER - answer: Recent major surgery or head trauma, hemorrhagic stroke, current
anticoagulation with high INR (>1.7), uncontrolled hypertension, recent GI bleed.
7) The nurse assesses a client with ICP. What priority action should the nurse complete? -
CORRECT ANSWER - Answer: Head elevation to 30°, maintain neck midline, avoid
suctioning or Valsalva maneuvers, monitor pupil/neurological changes.
8) Which of the following medication classification would most likely help prevent stress ulcer
for a client in the ICU. (SATA) - CORRECT ANSWER - Answer: Proton pump inhibitors
(e.g., pantoprazole); H₂ receptor blockers (e.g., ranitidine); sucralfate.
9) Which classifications listed below are used as treatment to support cardiac output in client
diagnosed with shock? - CORRECT ANSWER - Answer: Inotropic agents (dobutamine,
dobutrex); vasopressors (norepinephrine, dopamine); vasodilators in cardiogenic shock
(nitroprusside).
10) The nurse is caring for a client diagnosed with obstructive shock. Which of the following
assessment finding indicates decrease cardiac output? - CORRECT ANSWER - Answer:
JVD, muffled heart sounds, hypotension (e.g., in tamponade) or pulsus paradoxus; ↓ peripheral
pulses.
11) The nurse recognizes which disorder increase the client risk for obstructive shock? -
CORRECT ANSWER - Answer: Pericardial tamponade, tension pneumothorax, massive
pulmonary embolism, cardiac tamponade.
What is the name of the main type of shock which is characterized by widespread vasodilation
and increase capillary permeability? - CORRECT ANSWER - Answer: Distributive shock
(specifically, septic shock).
13) The nurse cares for the client with sepsis after a crushing injury to the left leg. Based on the
nurses note. What is the nurse's priority intervention to prevent the development of multiple
organ dysfunction (MOD)? - CORRECT ANSWER - Answer: Early fluid resuscitation,
broad‑spectrum antibiotics, oxygenation, hemodynamic monitoring—these are all priorities.
