NUR 3463 Exam 4: Adult Health Acute Care
Verified & Updated Questions and Answers -
Rasmussen University
1. A patient with septic shock is receiving aggressive fluid resuscitation. Which
assessment finding indicates that the fluid therapy is effective?
A. Mean arterial pressure (MAP) of 65 mmHg
B. Heart rate of 110 beats/min
C. Urine output of 15 mL/hr
D. Peripheral pulses +1
Answer: A
Explanation: A MAP of at least 65 mmHg is a primary goal in septic shock resuscitation to
ensure adequate organ perfusion. Urine output should ideally be >0.5 mL/kg/hr (approx
30 mL/hr).
2. A patient on a mechanical ventilator triggers the high-pressure alarm. What is
the nurse’s first action?
A. Auscultate the patient’s breath sounds
B. Increase the oxygen concentration to 100%
C. Call the respiratory therapist to check the machine
D. Disconnect the patient and manually ventilate
Answer: A
Explanation: High-pressure alarms are often caused by secretions, biting the tube, or
pneumothorax. Assessing the patient’s airway and breath sounds is the priority to identify
the cause.
,3. Which electrolyte imbalance is a patient with acute kidney injury (AKI) most
at risk for developing in the oliguric phase?
A. Hypokalemia
B. Hypernatremia
C. Hypophosphatemia
D. Hyperkalemia
Answer: D
Explanation: In AKI, the kidneys cannot excrete potassium, leading to hyperkalemia, which
can cause life-threatening cardiac arrhythmias.
4. A patient is admitted with 40% total body surface area (TBSA) burns. Using
the Parkland formula, half of the calculated fluid must be administered within
how many hours from the time of injury?
A. 24 hours
B. 8 hours
C. 4 hours
D. 12 hours
Answer: B
Explanation: The Parkland formula dictates that the first half of the total 24-hour fluid
requirement is given within the first 8 hours post-burn injury.
5. Which clinical manifestation is most characteristic of neurogenic shock?
A. Bradycardia and hypotension
B. Tachycardia and hypertension
C. Cool, clammy skin
D. Increased systemic vascular resistance
Answer: A
Explanation: Neurogenic shock involves the loss of sympathetic tone, leading to
vasodilation (hypotension) and a lack of compensatory tachycardia (bradycardia).
, 6. A patient with cirrhosis has a high ammonia level and is confused. Which
medication should the nurse expect to administer?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
Answer: C
Explanation: Lactulose promotes the excretion of ammonia through the stool, helping to
reduce hepatic encephalopathy symptoms.
7. In a patient with Acute Respiratory Distress Syndrome (ARDS), what is the
purpose of using Positive End-Expiratory Pressure (PEEP)?
A. To increase the fraction of inspired oxygen (FiO2)
B. To prevent alveolar collapse and improve oxygenation
C. To decrease the work of breathing
D. To reduce the risk of barotrauma
Answer: B
Explanation: PEEP keeps the alveoli open at the end of expiration, allowing for better gas
exchange and recruitment of collapsed alveoli.
8. Which finding in a patient with a chest tube requires immediate intervention?
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Occasional bubbling in the suction control chamber
D. Drainage of 50 mL in the first hour post-insertion
Answer: A
Explanation: Continuous bubbling in the water-seal chamber indicates an air leak in the
system or the patient’s pleural space.
Verified & Updated Questions and Answers -
Rasmussen University
1. A patient with septic shock is receiving aggressive fluid resuscitation. Which
assessment finding indicates that the fluid therapy is effective?
A. Mean arterial pressure (MAP) of 65 mmHg
B. Heart rate of 110 beats/min
C. Urine output of 15 mL/hr
D. Peripheral pulses +1
Answer: A
Explanation: A MAP of at least 65 mmHg is a primary goal in septic shock resuscitation to
ensure adequate organ perfusion. Urine output should ideally be >0.5 mL/kg/hr (approx
30 mL/hr).
2. A patient on a mechanical ventilator triggers the high-pressure alarm. What is
the nurse’s first action?
A. Auscultate the patient’s breath sounds
B. Increase the oxygen concentration to 100%
C. Call the respiratory therapist to check the machine
D. Disconnect the patient and manually ventilate
Answer: A
Explanation: High-pressure alarms are often caused by secretions, biting the tube, or
pneumothorax. Assessing the patient’s airway and breath sounds is the priority to identify
the cause.
,3. Which electrolyte imbalance is a patient with acute kidney injury (AKI) most
at risk for developing in the oliguric phase?
A. Hypokalemia
B. Hypernatremia
C. Hypophosphatemia
D. Hyperkalemia
Answer: D
Explanation: In AKI, the kidneys cannot excrete potassium, leading to hyperkalemia, which
can cause life-threatening cardiac arrhythmias.
4. A patient is admitted with 40% total body surface area (TBSA) burns. Using
the Parkland formula, half of the calculated fluid must be administered within
how many hours from the time of injury?
A. 24 hours
B. 8 hours
C. 4 hours
D. 12 hours
Answer: B
Explanation: The Parkland formula dictates that the first half of the total 24-hour fluid
requirement is given within the first 8 hours post-burn injury.
5. Which clinical manifestation is most characteristic of neurogenic shock?
A. Bradycardia and hypotension
B. Tachycardia and hypertension
C. Cool, clammy skin
D. Increased systemic vascular resistance
Answer: A
Explanation: Neurogenic shock involves the loss of sympathetic tone, leading to
vasodilation (hypotension) and a lack of compensatory tachycardia (bradycardia).
, 6. A patient with cirrhosis has a high ammonia level and is confused. Which
medication should the nurse expect to administer?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
Answer: C
Explanation: Lactulose promotes the excretion of ammonia through the stool, helping to
reduce hepatic encephalopathy symptoms.
7. In a patient with Acute Respiratory Distress Syndrome (ARDS), what is the
purpose of using Positive End-Expiratory Pressure (PEEP)?
A. To increase the fraction of inspired oxygen (FiO2)
B. To prevent alveolar collapse and improve oxygenation
C. To decrease the work of breathing
D. To reduce the risk of barotrauma
Answer: B
Explanation: PEEP keeps the alveoli open at the end of expiration, allowing for better gas
exchange and recruitment of collapsed alveoli.
8. Which finding in a patient with a chest tube requires immediate intervention?
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Occasional bubbling in the suction control chamber
D. Drainage of 50 mL in the first hour post-insertion
Answer: A
Explanation: Continuous bubbling in the water-seal chamber indicates an air leak in the
system or the patient’s pleural space.
