NSG430 Questions and Answers Grade A+
1. The nurse admits a patient to the emergency department (ED) with a suspected
cervical spine injury. What is the priority nursing action?
Select one:
a. Remove cervical collar upon arrival to the ED.
b. Prepare for immediate endotracheal intubation.
c. Keep the neck in the hyperextended position.
d. Maintain proper head and neck alignment.
d. Maintain proper head and neck alignment.
2. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of
20 mm Hg and a CPP of 55 mm Hg. What is the best interpretation by the nurse?
Select one:
a. ICP is high; CPP is low.
b. Both pressures are low.
c. Both pressures are high.
d. ICP is high; CPP is normal.
a. ICP is high; CPP is low.
3. 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.
4. While caring for a patient with a closed head injury, the nurse assesses the patient to
be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18
breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial
pressure (ICP) in this patient, what is (are) the priority nursing action(s)?
Select one:
a. Maintain neutral head alignment and avoid extreme hip flexion.
,b. Ensure adequate periods of rest between nursing interventions.
c. Reduce ambient room temperature and administer antipyretics.
d. Insert an oral airway and monitor respiratory rate and depth.
b. Ensure adequate periods of rest between nursing interventions.
5. The physician has ordered Dopamine to be administered @ a rate of 5 mcg/kg/min.
The patient weighs 145 pounds and the drug is sent to the unit as Dopamine 400 mg in
250 mL D5W. The nurse will set the infusion pump @ ________mL/hr
*Round to the nearest mL at the end of the equation
50mL/hr
A patient has been admitted to the ICU for alcohol withdrawl and is ordered lorazepam
10 mg/hr. The pharmacy has sent lorazepam 120 mg in 600 mL of D5W. The nurse will
infuse the medication on the infusion pump @ the rate of _______ mL/hr
2.05mL/hr
The patient has hypokalemia and is to receive an IV infusion of potassium chloride. The
physician orders the KCl to infuse at a rate of 2 mEq/hr. The pharmacy sends KCL
40mEq/L in D5W. The nurse will set the infusion pump @ ________ mL/hr
50mL/hr
The physician has ordered nitroglycerin for a patient with chest pain at a rate of 10
mcg/min. The pharmacy provides Nitroglycerin 25 mg in 250 mL of D5W. The nurse will
set the infusion pump @ a rate of _______ mL/hr.
0.1mL/hr
6. During the treatment and management of the trauma patient, maintaining tissue
perfusion, oxygenation, and nutritional support are strategies to prevent
Select one:
a. Multisystem organ dysfunction.
b. Wound infection
c. Disseminated intravascular coagulation.
d. Septic shock.
a. Multisystem organ dysfunction.
7. The nurse has admitted a patient to the ED following a fall from a first-floor hotel
balcony. The patient smells of alcohol and begins to vomit in the ED. Which of the
following interventions is most appropriate?
Select one:
a. Prepare to suction the oropharynx while maintaining cervical spine immobilization.
, b. Send a specimen of the emesis to the laboratory for analysis of blood alcohol
content.
c. Insert an oral airway to prevent aspiration and to protect the airway.
d. Offer the patient an emesis basin so that you can measure the amount of emesis.
a. Prepare to suction the oropharynx while maintaining cervical spine immobilization.
8. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a
motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary
survey of this patient upon arrival to the ED
Select one:
a. Involves turning the patient from side to side to get a look at his back.
b. Includes a cervical spine x-ray study to determine the presence of a fracture.
c. Is done quickly in the first few minutes to get a baseline assessment and establish
priorities.
d. Is a methodical head-to-toe assessment identifying injuries and treatment priorities.
c. Is done quickly in the first few minutes to get a baseline assessment and establish
priorities.
9. The nurse is caring for patient who has been struck by lightning. Because of the
nature of the injury, the nurse assesses the patient for which of the following?
Select one:
a. Infection
b. Central nervous system deficits
c. Contractures
d. Stress ulcers
b. Central nervous system deficits
10.A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters
over the arms, chest, and neck; and red, painful oral mucous membranes. The patient
should be further evaluated for which possible non-burn-injured skin disorder?
Select one:
a. Necrotizing soft tissue infection
b. Graft-versus-host disease
c. Staphylococcal scalded skin syndrome
d. Toxic epidermal necrolysis
d. Toxic epidermal necrolysis
1. The nurse admits a patient to the emergency department (ED) with a suspected
cervical spine injury. What is the priority nursing action?
Select one:
a. Remove cervical collar upon arrival to the ED.
b. Prepare for immediate endotracheal intubation.
c. Keep the neck in the hyperextended position.
d. Maintain proper head and neck alignment.
d. Maintain proper head and neck alignment.
2. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of
20 mm Hg and a CPP of 55 mm Hg. What is the best interpretation by the nurse?
Select one:
a. ICP is high; CPP is low.
b. Both pressures are low.
c. Both pressures are high.
d. ICP is high; CPP is normal.
a. ICP is high; CPP is low.
3. 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.
4. While caring for a patient with a closed head injury, the nurse assesses the patient to
be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18
breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial
pressure (ICP) in this patient, what is (are) the priority nursing action(s)?
Select one:
a. Maintain neutral head alignment and avoid extreme hip flexion.
,b. Ensure adequate periods of rest between nursing interventions.
c. Reduce ambient room temperature and administer antipyretics.
d. Insert an oral airway and monitor respiratory rate and depth.
b. Ensure adequate periods of rest between nursing interventions.
5. The physician has ordered Dopamine to be administered @ a rate of 5 mcg/kg/min.
The patient weighs 145 pounds and the drug is sent to the unit as Dopamine 400 mg in
250 mL D5W. The nurse will set the infusion pump @ ________mL/hr
*Round to the nearest mL at the end of the equation
50mL/hr
A patient has been admitted to the ICU for alcohol withdrawl and is ordered lorazepam
10 mg/hr. The pharmacy has sent lorazepam 120 mg in 600 mL of D5W. The nurse will
infuse the medication on the infusion pump @ the rate of _______ mL/hr
2.05mL/hr
The patient has hypokalemia and is to receive an IV infusion of potassium chloride. The
physician orders the KCl to infuse at a rate of 2 mEq/hr. The pharmacy sends KCL
40mEq/L in D5W. The nurse will set the infusion pump @ ________ mL/hr
50mL/hr
The physician has ordered nitroglycerin for a patient with chest pain at a rate of 10
mcg/min. The pharmacy provides Nitroglycerin 25 mg in 250 mL of D5W. The nurse will
set the infusion pump @ a rate of _______ mL/hr.
0.1mL/hr
6. During the treatment and management of the trauma patient, maintaining tissue
perfusion, oxygenation, and nutritional support are strategies to prevent
Select one:
a. Multisystem organ dysfunction.
b. Wound infection
c. Disseminated intravascular coagulation.
d. Septic shock.
a. Multisystem organ dysfunction.
7. The nurse has admitted a patient to the ED following a fall from a first-floor hotel
balcony. The patient smells of alcohol and begins to vomit in the ED. Which of the
following interventions is most appropriate?
Select one:
a. Prepare to suction the oropharynx while maintaining cervical spine immobilization.
, b. Send a specimen of the emesis to the laboratory for analysis of blood alcohol
content.
c. Insert an oral airway to prevent aspiration and to protect the airway.
d. Offer the patient an emesis basin so that you can measure the amount of emesis.
a. Prepare to suction the oropharynx while maintaining cervical spine immobilization.
8. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a
motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary
survey of this patient upon arrival to the ED
Select one:
a. Involves turning the patient from side to side to get a look at his back.
b. Includes a cervical spine x-ray study to determine the presence of a fracture.
c. Is done quickly in the first few minutes to get a baseline assessment and establish
priorities.
d. Is a methodical head-to-toe assessment identifying injuries and treatment priorities.
c. Is done quickly in the first few minutes to get a baseline assessment and establish
priorities.
9. The nurse is caring for patient who has been struck by lightning. Because of the
nature of the injury, the nurse assesses the patient for which of the following?
Select one:
a. Infection
b. Central nervous system deficits
c. Contractures
d. Stress ulcers
b. Central nervous system deficits
10.A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters
over the arms, chest, and neck; and red, painful oral mucous membranes. The patient
should be further evaluated for which possible non-burn-injured skin disorder?
Select one:
a. Necrotizing soft tissue infection
b. Graft-versus-host disease
c. Staphylococcal scalded skin syndrome
d. Toxic epidermal necrolysis
d. Toxic epidermal necrolysis
