NR 330 Exam 3: Adult Health II - Chamberlain University
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with a traumatic brain injury (TBI) presents with a blood pressure of 180/60 mmHg, a heart rate
of 48 beats/min, and irregular respirations. Which nursing action is the highest priority?
A. Prepare for immediate endotracheal intubation.
B. Administer a bolus of intravenous normal saline.
C. Elevate the head of the bed to 30 degrees and notify the surgeon.
D. Administer scheduled antihypertensive medication.
Correct Answer: C
Rationale: The patient is exhibiting Cushing’s triad, which is a late sign of significantly increased
intracranial pressure. Elevating the head of the bed promotes venous drainage and is a critical first-line
intervention. Notifying the surgeon is essential because this presentation indicates possible brain
herniation. Administering antihypertensives without surgical consultation may dangerously lower
cerebral perfusion pressure. The primary goal is to stabilize intracranial pressure to prevent further
neurological damage.
2. A client with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L and ECG changes
showing peaked T waves. Which medication should the nurse expect to administer first to protect the
heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Regular insulin and IV dextrose
C. Calcium gluconate
,D. Sodium bicarbonate
Correct Answer: C
Rationale: In the presence of severe hyperkalemia with ECG changes, calcium gluconate is the priority to
stabilize the myocardial cell membrane. While insulin and dextrose help shift potassium into the cells,
they do not act as quickly to prevent cardiac arrest as calcium does. Kayexalate is used for the actual
removal of potassium but takes hours to work. Sodium bicarbonate is an adjunctive therapy and not the
primary emergency stabilizer. Protecting the heart from lethal arrhythmias is the immediate nursing
concern.
3. The nurse is caring for a patient with cirrhosis who is experiencing hepatic encephalopathy. What is the
primary rationale for administering lactulose to this patient?
A. To reduce the risk of gastrointestinal bleeding from esophageal varices.
B. To decrease the production of ammonia by intestinal bacteria.
C. To promote the excretion of ammonia through the stool.
D. To improve the patient’s appetite and nutritional status.
Correct Answer: C
Rationale: Lactulose works by trapping ammonia in the gut and facilitating its excretion through
frequent bowel movements. This reduction in serum ammonia levels is vital for improving the
neurological symptoms of hepatic encephalopathy. The nurse should monitor the patient for 2-3 soft
stools per day to ensure therapeutic efficacy. Reducing ammonia production is actually a secondary effect
of antibiotic therapy rather than lactulose itself. Consistent monitoring of mental status is the best way to
evaluate the medication’s success.
, 4. A patient with a T6 spinal cord injury reports a sudden, pounding headache and nasal congestion. The
blood pressure is 210/110 mmHg. What is the first action the nurse should take?
A. Sit the patient upright at a 90-degree angle.
B. Administer prescribed nifedipine sublingually.
C. Check the patient’s bladder for distension.
D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: The patient’s symptoms are classic indicators of autonomic dysreflexia, a life-threatening
emergency in spinal cord injuries. The absolute first action is to sit the patient upright to utilize
orthostatic hypotension to lower the blood pressure. After positioning, the nurse should assess for the
triggering cause, which is most commonly a full bladder or impacted bowel. Administering medication or
calling the provider should occur only after immediate safety positioning is performed. Failure to act
quickly can result in a hemorrhagic stroke or seizure.
5. The nurse observes that the dialysate drainage (effluent) from a patient’s peritoneal dialysis is cloudy.
What should the nurse suspect first?
A. Normal find during the first week of therapy
B. Fibrin clot in the catheter
C. Peritonitis
D. A perforated bowel
Correct Answer: C
Rationale: Cloudy effluent is the earliest and most common sign of peritonitis in patients undergoing
peritoneal dialysis. The nurse should immediately collect a sample of the drainage for culture and
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with a traumatic brain injury (TBI) presents with a blood pressure of 180/60 mmHg, a heart rate
of 48 beats/min, and irregular respirations. Which nursing action is the highest priority?
A. Prepare for immediate endotracheal intubation.
B. Administer a bolus of intravenous normal saline.
C. Elevate the head of the bed to 30 degrees and notify the surgeon.
D. Administer scheduled antihypertensive medication.
Correct Answer: C
Rationale: The patient is exhibiting Cushing’s triad, which is a late sign of significantly increased
intracranial pressure. Elevating the head of the bed promotes venous drainage and is a critical first-line
intervention. Notifying the surgeon is essential because this presentation indicates possible brain
herniation. Administering antihypertensives without surgical consultation may dangerously lower
cerebral perfusion pressure. The primary goal is to stabilize intracranial pressure to prevent further
neurological damage.
2. A client with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L and ECG changes
showing peaked T waves. Which medication should the nurse expect to administer first to protect the
heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Regular insulin and IV dextrose
C. Calcium gluconate
,D. Sodium bicarbonate
Correct Answer: C
Rationale: In the presence of severe hyperkalemia with ECG changes, calcium gluconate is the priority to
stabilize the myocardial cell membrane. While insulin and dextrose help shift potassium into the cells,
they do not act as quickly to prevent cardiac arrest as calcium does. Kayexalate is used for the actual
removal of potassium but takes hours to work. Sodium bicarbonate is an adjunctive therapy and not the
primary emergency stabilizer. Protecting the heart from lethal arrhythmias is the immediate nursing
concern.
3. The nurse is caring for a patient with cirrhosis who is experiencing hepatic encephalopathy. What is the
primary rationale for administering lactulose to this patient?
A. To reduce the risk of gastrointestinal bleeding from esophageal varices.
B. To decrease the production of ammonia by intestinal bacteria.
C. To promote the excretion of ammonia through the stool.
D. To improve the patient’s appetite and nutritional status.
Correct Answer: C
Rationale: Lactulose works by trapping ammonia in the gut and facilitating its excretion through
frequent bowel movements. This reduction in serum ammonia levels is vital for improving the
neurological symptoms of hepatic encephalopathy. The nurse should monitor the patient for 2-3 soft
stools per day to ensure therapeutic efficacy. Reducing ammonia production is actually a secondary effect
of antibiotic therapy rather than lactulose itself. Consistent monitoring of mental status is the best way to
evaluate the medication’s success.
, 4. A patient with a T6 spinal cord injury reports a sudden, pounding headache and nasal congestion. The
blood pressure is 210/110 mmHg. What is the first action the nurse should take?
A. Sit the patient upright at a 90-degree angle.
B. Administer prescribed nifedipine sublingually.
C. Check the patient’s bladder for distension.
D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: The patient’s symptoms are classic indicators of autonomic dysreflexia, a life-threatening
emergency in spinal cord injuries. The absolute first action is to sit the patient upright to utilize
orthostatic hypotension to lower the blood pressure. After positioning, the nurse should assess for the
triggering cause, which is most commonly a full bladder or impacted bowel. Administering medication or
calling the provider should occur only after immediate safety positioning is performed. Failure to act
quickly can result in a hemorrhagic stroke or seizure.
5. The nurse observes that the dialysate drainage (effluent) from a patient’s peritoneal dialysis is cloudy.
What should the nurse suspect first?
A. Normal find during the first week of therapy
B. Fibrin clot in the catheter
C. Peritonitis
D. A perforated bowel
Correct Answer: C
Rationale: Cloudy effluent is the earliest and most common sign of peritonitis in patients undergoing
peritoneal dialysis. The nurse should immediately collect a sample of the drainage for culture and
