NR 330 Exam 4: Adult Health II - Chamberlain University
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient is admitted with suspected sepsis. The nurse notes a blood pressure of 88/50 mmHg, a heart
rate of 115 bpm, and a serum lactate level of 4.5 mmol/L. According to the 1-hour sepsis bundle, which
action should the nurse prioritize first?
A. Administering broad-spectrum antibiotics
B. Initiating a 30 mL/kg rapid fluid bolus of crystalloids
C. Obtaining blood cultures from two different sites
D. Starting norepinephrine to maintain a MAP > 65 mmHg
Correct Answer: B
Rationale: Fluid resuscitation is the immediate priority for a patient in septic shock with hypotension
and elevated lactate. This patient meets the criteria for septic shock due to the lactate level above 4
mmol/L and persistent hypotension. Crystalloid fluids are essential to restore intravascular volume and
improve tissue perfusion before other interventions. While cultures and antibiotics are critical, they
should follow or happen concurrently with volume replacement in an unstable patient. Successful fluid
resuscitation is the first step in stabilizing the hemodynamic status of the patient.
2. A nurse is caring for a client with HIV who has a CD4+ T-cell count of 180 cells/mm3. Which of the
following conditions, if present, would confirm a diagnosis of AIDS?
A. Recurrent vaginal yeast infections
B. Chronic lymphadenopathy
C. Pneumocystis jirovecii pneumonia (PCP)
,D. Persistent oral hairy leukoplakia
Correct Answer: C
Rationale: A diagnosis of AIDS is confirmed when a person with HIV has a CD4+ count below 200
cells/mm3 or develops an AIDS-defining clinical condition. Pneumocystis jirovecii pneumonia is
classified as an opportunistic infection and is a primary AIDS-defining illness. Other conditions like oral
leukoplakia or yeast infections may occur earlier in the HIV progression but do not definitively mark the
transition to AIDS. Monitoring CD4+ counts is essential for clinicians to determine when to initiate
prophylactic treatments for these infections. Understanding these clinical markers is vital for appropriate
staging and management of the patient’s immune health.
3. Ten days after a kidney transplant, a patient develops a fever, tenderness at the graft site, and a sudden
decrease in urine output. Which type of rejection is most likely occurring?
A. Hyperacute rejection
B. Graft-versus-host disease
C. Chronic rejection
D. Acute rejection
Correct Answer: D
Rationale: Acute rejection typically occurs within the first few weeks to months following a transplant. It
is characterized by clinical signs such as fever, organ tenderness, and decreased function of the
transplanted organ. Hyperacute rejection happens within minutes to hours and is caused by pre-existing
antibodies, while chronic rejection occurs over years. Unlike hyperacute rejection, acute rejection can
often be reversed with increased doses of immunosuppressant therapy. Nurses must remain vigilant for
these signs to ensure prompt medical intervention and preservation of the graft.
,4. A patient in the Intensive Care Unit is experiencing Multiple Organ Dysfunction Syndrome (MODS). Which
physiological finding indicates the development of secondary MODS?
A. Acute renal failure immediately following a direct trauma
B. Myocardial infarction causing cardiogenic shock
C. Development of ARDS in a patient who was hospitalized for a bowel obstruction
D. Localized infection causing skin breakdown
Correct Answer: C
Rationale: Secondary MODS is characterized by organ failure that occurs as a result of a systemic
inflammatory response syndrome (SIRS) triggered by a remote injury or illness. In this scenario, the
bowel obstruction (the initial insult) leads to a systemic response that causes the lungs to fail (ARDS),
which is distant from the original site. Primary MODS, conversely, is a direct result of a specific insult
where the organ fails immediately. Understanding the trigger of SIRS is crucial for identifying patients at
high risk for secondary multisystem failure. Early recognition of these inflammatory markers allows for
more aggressive supportive care to prevent further decline.
5. A client is prescribed Cyclosporine following a liver transplant. Which laboratory value should the nurse
monitor most closely to detect a common adverse effect of this medication?
A. Serum Potassium
B. Partial Thromboplastin Time (PTT)
C. Serum Amylase
D. Serum Creatinine
Correct Answer: D
, Rationale: Cyclosporine is a potent calcineurin inhibitor used to prevent organ rejection, but it is highly
nephrotoxic. Monitoring serum creatinine and blood urea nitrogen (BUN) is essential to assess for drug-
induced kidney injury. Nephrotoxicity is one of the most common and limiting side effects of long-term
cyclosporine therapy. While other electrolytes may shift, the direct impact on renal filtration is the
primary concern for the nursing team. Regular therapeutic drug monitoring is also required to ensure
levels stay within the narrow therapeutic index.
6. A patient with systemic lupus erythematosus (SLE) is experiencing a flare. Which clinical manifestation is
most characteristic of an acute exacerbation of this autoimmune disorder?
A. Generalized jaundice and scleral icterus
B. Progressive muscle wasting in the lower extremities
C. Sudden onset of watery diarrhea and abdominal cramping
D. A butterfly-shaped rash across the bridge of the nose and cheeks
Correct Answer: D
Rationale: The malar or ‘butterfly’ rash is a classic diagnostic sign of systemic lupus erythematosus and
often worsens during acute flares. SLE is a multisystem autoimmune disease that causes widespread
inflammation and tissue damage. Other symptoms during a flare can include joint pain, fever, and
photosensitivity. It is important for the nurse to educate the patient on avoiding UV light, which can
trigger these cutaneous manifestations. Monitoring for systemic involvement, particularly renal and
cardiovascular symptoms, is also a priority during a flare.
7. Which hemodynamic profile is characteristic of the ‘hyperdynamic’ or early phase of septic shock?
A. Low Cardiac Output (CO) and High Systemic Vascular Resistance (SVR)
B. High Cardiac Output (CO) and Low Systemic Vascular Resistance (SVR)
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient is admitted with suspected sepsis. The nurse notes a blood pressure of 88/50 mmHg, a heart
rate of 115 bpm, and a serum lactate level of 4.5 mmol/L. According to the 1-hour sepsis bundle, which
action should the nurse prioritize first?
A. Administering broad-spectrum antibiotics
B. Initiating a 30 mL/kg rapid fluid bolus of crystalloids
C. Obtaining blood cultures from two different sites
D. Starting norepinephrine to maintain a MAP > 65 mmHg
Correct Answer: B
Rationale: Fluid resuscitation is the immediate priority for a patient in septic shock with hypotension
and elevated lactate. This patient meets the criteria for septic shock due to the lactate level above 4
mmol/L and persistent hypotension. Crystalloid fluids are essential to restore intravascular volume and
improve tissue perfusion before other interventions. While cultures and antibiotics are critical, they
should follow or happen concurrently with volume replacement in an unstable patient. Successful fluid
resuscitation is the first step in stabilizing the hemodynamic status of the patient.
2. A nurse is caring for a client with HIV who has a CD4+ T-cell count of 180 cells/mm3. Which of the
following conditions, if present, would confirm a diagnosis of AIDS?
A. Recurrent vaginal yeast infections
B. Chronic lymphadenopathy
C. Pneumocystis jirovecii pneumonia (PCP)
,D. Persistent oral hairy leukoplakia
Correct Answer: C
Rationale: A diagnosis of AIDS is confirmed when a person with HIV has a CD4+ count below 200
cells/mm3 or develops an AIDS-defining clinical condition. Pneumocystis jirovecii pneumonia is
classified as an opportunistic infection and is a primary AIDS-defining illness. Other conditions like oral
leukoplakia or yeast infections may occur earlier in the HIV progression but do not definitively mark the
transition to AIDS. Monitoring CD4+ counts is essential for clinicians to determine when to initiate
prophylactic treatments for these infections. Understanding these clinical markers is vital for appropriate
staging and management of the patient’s immune health.
3. Ten days after a kidney transplant, a patient develops a fever, tenderness at the graft site, and a sudden
decrease in urine output. Which type of rejection is most likely occurring?
A. Hyperacute rejection
B. Graft-versus-host disease
C. Chronic rejection
D. Acute rejection
Correct Answer: D
Rationale: Acute rejection typically occurs within the first few weeks to months following a transplant. It
is characterized by clinical signs such as fever, organ tenderness, and decreased function of the
transplanted organ. Hyperacute rejection happens within minutes to hours and is caused by pre-existing
antibodies, while chronic rejection occurs over years. Unlike hyperacute rejection, acute rejection can
often be reversed with increased doses of immunosuppressant therapy. Nurses must remain vigilant for
these signs to ensure prompt medical intervention and preservation of the graft.
,4. A patient in the Intensive Care Unit is experiencing Multiple Organ Dysfunction Syndrome (MODS). Which
physiological finding indicates the development of secondary MODS?
A. Acute renal failure immediately following a direct trauma
B. Myocardial infarction causing cardiogenic shock
C. Development of ARDS in a patient who was hospitalized for a bowel obstruction
D. Localized infection causing skin breakdown
Correct Answer: C
Rationale: Secondary MODS is characterized by organ failure that occurs as a result of a systemic
inflammatory response syndrome (SIRS) triggered by a remote injury or illness. In this scenario, the
bowel obstruction (the initial insult) leads to a systemic response that causes the lungs to fail (ARDS),
which is distant from the original site. Primary MODS, conversely, is a direct result of a specific insult
where the organ fails immediately. Understanding the trigger of SIRS is crucial for identifying patients at
high risk for secondary multisystem failure. Early recognition of these inflammatory markers allows for
more aggressive supportive care to prevent further decline.
5. A client is prescribed Cyclosporine following a liver transplant. Which laboratory value should the nurse
monitor most closely to detect a common adverse effect of this medication?
A. Serum Potassium
B. Partial Thromboplastin Time (PTT)
C. Serum Amylase
D. Serum Creatinine
Correct Answer: D
, Rationale: Cyclosporine is a potent calcineurin inhibitor used to prevent organ rejection, but it is highly
nephrotoxic. Monitoring serum creatinine and blood urea nitrogen (BUN) is essential to assess for drug-
induced kidney injury. Nephrotoxicity is one of the most common and limiting side effects of long-term
cyclosporine therapy. While other electrolytes may shift, the direct impact on renal filtration is the
primary concern for the nursing team. Regular therapeutic drug monitoring is also required to ensure
levels stay within the narrow therapeutic index.
6. A patient with systemic lupus erythematosus (SLE) is experiencing a flare. Which clinical manifestation is
most characteristic of an acute exacerbation of this autoimmune disorder?
A. Generalized jaundice and scleral icterus
B. Progressive muscle wasting in the lower extremities
C. Sudden onset of watery diarrhea and abdominal cramping
D. A butterfly-shaped rash across the bridge of the nose and cheeks
Correct Answer: D
Rationale: The malar or ‘butterfly’ rash is a classic diagnostic sign of systemic lupus erythematosus and
often worsens during acute flares. SLE is a multisystem autoimmune disease that causes widespread
inflammation and tissue damage. Other symptoms during a flare can include joint pain, fever, and
photosensitivity. It is important for the nurse to educate the patient on avoiding UV light, which can
trigger these cutaneous manifestations. Monitoring for systemic involvement, particularly renal and
cardiovascular symptoms, is also a priority during a flare.
7. Which hemodynamic profile is characteristic of the ‘hyperdynamic’ or early phase of septic shock?
A. Low Cardiac Output (CO) and High Systemic Vascular Resistance (SVR)
B. High Cardiac Output (CO) and Low Systemic Vascular Resistance (SVR)
