NUR 3463 Final Exam: Adult Health Acute Care
Verified & Updated Questions and Answers -
Rasmussen University
1. A patient with a suspected myocardial infarction (MI) arrives in the ED. Which
of the following is the priority intervention?
A. Obtaining a 12-lead electrocardiogram (ECG)
B. Administering a dose of sublingual nitroglycerin
C. Drawing blood for troponin levels
D. Starting a large-bore IV line
Answer: A
Explanation: Obtaining a 12-lead ECG is the priority to determine if the patient is having a
STEMI, which dictates the immediate course of treatment. This should be done within 10
minutes of arrival.
2. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Jugular venous distention (JVD)
B. Dyspnea on exertion
C. Crackles in the lungs
D. Paroxysmal nocturnal dyspnea
Answer: A
Explanation: Right-sided heart failure leads to systemic congestion, evidenced by JVD,
peripheral edema, and hepatomegaly. The other options are signs of left-sided heart failure.
,3. A patient is diagnosed with Acute Respiratory Distress Syndrome (ARDS).
Which of the following is a hallmark pathophysiology of this condition?
A. Non-cardiogenic pulmonary edema
B. Increased lung compliance
C. Alveolar hypoventilation due to airway obstruction
D. High pulmonary capillary wedge pressure (PCWP)
Answer: A
Explanation: ARDS is characterized by non-cardiogenic pulmonary edema resulting from
increased capillary permeability. PCWP is typically low or normal because the fluid is not
caused by heart failure.
4. A nurse is caring for a patient on a mechanical ventilator. The high-pressure
alarm sounds. Which of the following should the nurse assess for first?
A. Secretions in the airway needing suctioning
B. Extubation of the endotracheal tube
C. A leak in the ventilator circuit
D. The patient being disconnected from the oxygen source
Answer: A
Explanation: High-pressure alarms are triggered by increased resistance, such as
secretions, coughing, biting the tube, or kinking. Leaks or disconnections trigger low-
pressure alarms.
5. A patient is admitted with Diabetic Ketoacidosis (DKA). Which lab value is
most consistent with this diagnosis?
A. Blood glucose 900 mg/dL and pH 7.40
B. Blood glucose 450 mg/dL and pH 7.25
C. Serum bicarbonate of 24 mEq/L
D. Negative ketones in the urine
Answer: B
, Explanation: DKA involves hyperglycemia (usually >250) and metabolic acidosis (pH
<7.30). Glucose levels >600 with a normal pH are more indicative of HHS.
6. Which assessment finding is a priority for a nurse monitoring a patient with
increased intracranial pressure (ICP)?
A. A Glasglow Coma Scale (GCS) score that drops from 12 to 10
B. Increased heart rate and decreased blood pressure
C. Complaints of a mild headache
D. Reactive pupils at 3mm
Answer: A
Explanation: A decrease in GCS score is a significant indicator of neurological
deterioration and worsening ICP. Cushing’s triad (late sign) involves increased systolic BP
and decreased HR.
7. When managing a patient in Septic Shock, which is the priority goal within the
first hour of treatment?
A. Starting physical therapy
B. Initiating enteral feedings
C. Ordering a chest X-ray
D. Administering a large fluid bolus (30 mL/kg)
Answer: D
Explanation: Initial management of sepsis includes aggressive fluid resuscitation to
restore perfusion, along with obtaining cultures and starting broad-spectrum antibiotics.
Verified & Updated Questions and Answers -
Rasmussen University
1. A patient with a suspected myocardial infarction (MI) arrives in the ED. Which
of the following is the priority intervention?
A. Obtaining a 12-lead electrocardiogram (ECG)
B. Administering a dose of sublingual nitroglycerin
C. Drawing blood for troponin levels
D. Starting a large-bore IV line
Answer: A
Explanation: Obtaining a 12-lead ECG is the priority to determine if the patient is having a
STEMI, which dictates the immediate course of treatment. This should be done within 10
minutes of arrival.
2. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Jugular venous distention (JVD)
B. Dyspnea on exertion
C. Crackles in the lungs
D. Paroxysmal nocturnal dyspnea
Answer: A
Explanation: Right-sided heart failure leads to systemic congestion, evidenced by JVD,
peripheral edema, and hepatomegaly. The other options are signs of left-sided heart failure.
,3. A patient is diagnosed with Acute Respiratory Distress Syndrome (ARDS).
Which of the following is a hallmark pathophysiology of this condition?
A. Non-cardiogenic pulmonary edema
B. Increased lung compliance
C. Alveolar hypoventilation due to airway obstruction
D. High pulmonary capillary wedge pressure (PCWP)
Answer: A
Explanation: ARDS is characterized by non-cardiogenic pulmonary edema resulting from
increased capillary permeability. PCWP is typically low or normal because the fluid is not
caused by heart failure.
4. A nurse is caring for a patient on a mechanical ventilator. The high-pressure
alarm sounds. Which of the following should the nurse assess for first?
A. Secretions in the airway needing suctioning
B. Extubation of the endotracheal tube
C. A leak in the ventilator circuit
D. The patient being disconnected from the oxygen source
Answer: A
Explanation: High-pressure alarms are triggered by increased resistance, such as
secretions, coughing, biting the tube, or kinking. Leaks or disconnections trigger low-
pressure alarms.
5. A patient is admitted with Diabetic Ketoacidosis (DKA). Which lab value is
most consistent with this diagnosis?
A. Blood glucose 900 mg/dL and pH 7.40
B. Blood glucose 450 mg/dL and pH 7.25
C. Serum bicarbonate of 24 mEq/L
D. Negative ketones in the urine
Answer: B
, Explanation: DKA involves hyperglycemia (usually >250) and metabolic acidosis (pH
<7.30). Glucose levels >600 with a normal pH are more indicative of HHS.
6. Which assessment finding is a priority for a nurse monitoring a patient with
increased intracranial pressure (ICP)?
A. A Glasglow Coma Scale (GCS) score that drops from 12 to 10
B. Increased heart rate and decreased blood pressure
C. Complaints of a mild headache
D. Reactive pupils at 3mm
Answer: A
Explanation: A decrease in GCS score is a significant indicator of neurological
deterioration and worsening ICP. Cushing’s triad (late sign) involves increased systolic BP
and decreased HR.
7. When managing a patient in Septic Shock, which is the priority goal within the
first hour of treatment?
A. Starting physical therapy
B. Initiating enteral feedings
C. Ordering a chest X-ray
D. Administering a large fluid bolus (30 mL/kg)
Answer: D
Explanation: Initial management of sepsis includes aggressive fluid resuscitation to
restore perfusion, along with obtaining cultures and starting broad-spectrum antibiotics.
