NUR 425 Final Exam: Acute & Chronic Health Disruptions
In Adults II V2 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). Which clinical finding most
accurately reflects the hallmark characteristic of this condition?
A. Hypoxemia that persists despite increasing oxygen concentrations.
B. Pulmonary edema caused by left-sided heart failure.
C. Decreased lung compliance with normal airway resistance.
D. Hypercapnia resulting from alveolar hypoventilation.
Ans: A
Explanation: Refractory hypoxemia is the classic sign of ARDS where the patient’s arterial oxygen levels
do not improve with supplemental oxygen. This occurs because the alveoli are filled with fluid or have
collapsed, preventing gas exchange. Unlike cardiogenic pulmonary edema, ARDS is characterized by non-
cardiogenic pulmonary edema. The nurse must monitor the PaO2/FiO2 ratio to determine the severity of
the lung injury. Prompt recognition is vital as the condition progresses rapidly to respiratory failure.
2. A patient on mechanical ventilation is triggering the low-pressure alarm. Which action should the nurse
take first?
A. Suction the patient to clear the airway of secretions.
B. Assess the patient and the ventilator circuit for disconnections.
C. Administer a sedative to prevent the patient from fighting the breath.
D. Increase the PEEP setting to stabilize the alveoli.
Ans: B
,Explanation: A low-pressure alarm usually indicates a leak or a disconnection in the ventilator circuit.
The nurse should immediately check the tubing from the patient to the machine to find the source of the
pressure loss. If the nurse cannot find the cause, the patient should be manually ventilated with a bag-
valve mask. This ensures that the patient continues to receive oxygen while the equipment is being
repaired. Safety and continuous oxygenation are the highest priorities in this emergency situation.
3. A patient presents with a burn injury covering the entire left arm and the anterior trunk. Using the Rule of
Nines, what is the estimated Total Body Surface Area (TBSA) burned?
A. 18%
B. 36%
C. 27%
D. 45%
Ans: C
Explanation: The Rule of Nines assigns 9% to the entire arm and 18% to the anterior trunk. Adding
these together results in a total of 27% TBSA for this specific patient. Accurate assessment of burn size is
critical for calculating fluid resuscitation requirements during the first 24 hours. The Parkland formula
relies heavily on this percentage to prevent hypovolemic shock. Nurses must also remember that the
posterior trunk and legs carry different percentage values.
4. The nurse is caring for a patient in the oliguric phase of Acute Kidney Injury (AKI). Which electrolyte
abnormality is most likely to be observed?
A. Hypokalemia
B. Hypernatremia
C. Hyperkalemia
, D. Hypophosphatemia
Ans: C
Explanation: In the oliguric phase, the kidneys are unable to excrete potassium effectively, leading to
hyperkalemia. This condition is dangerous because it can cause life-threatening cardiac arrhythmias. The
nurse should monitor the patient’s EKG for peaked T-waves or a widened QRS complex. Dietary
restrictions of potassium are necessary during this phase of the illness. Medications like Kayexalate or
insulin/glucose may be needed to lower serum potassium levels.
5. A patient with cirrhosis has developed hepatic encephalopathy. What is the primary goal of administering
Lactulose to this patient?
A. To promote the excretion of ammonia through the stool.
B. To increase serum glucose levels and energy.
C. To reduce the risk of spontaneous bacterial peritonitis.
D. To decrease portal vein pressure and prevent varices.
Ans: A
Explanation: Lactulose works by trapping ammonia in the gut and facilitating its excretion via a laxative
effect. High levels of ammonia cross the blood-brain barrier and cause the neurological symptoms seen in
encephalopathy. The nurse should monitor the patient for 2-3 soft stools per day to ensure therapeutic
efficacy. Improvement in mental status is the primary indicator that the medication is working.
Dehydration is a potential side effect due to the increased frequency of bowel movements.
6. A patient is admitted with a blood glucose of 750 mg/dL, ketones in the urine, and an arterial pH of 7.25.
Which condition is the patient most likely experiencing?
A. Diabetic Ketoacidosis (DKA)
In Adults II V2 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). Which clinical finding most
accurately reflects the hallmark characteristic of this condition?
A. Hypoxemia that persists despite increasing oxygen concentrations.
B. Pulmonary edema caused by left-sided heart failure.
C. Decreased lung compliance with normal airway resistance.
D. Hypercapnia resulting from alveolar hypoventilation.
Ans: A
Explanation: Refractory hypoxemia is the classic sign of ARDS where the patient’s arterial oxygen levels
do not improve with supplemental oxygen. This occurs because the alveoli are filled with fluid or have
collapsed, preventing gas exchange. Unlike cardiogenic pulmonary edema, ARDS is characterized by non-
cardiogenic pulmonary edema. The nurse must monitor the PaO2/FiO2 ratio to determine the severity of
the lung injury. Prompt recognition is vital as the condition progresses rapidly to respiratory failure.
2. A patient on mechanical ventilation is triggering the low-pressure alarm. Which action should the nurse
take first?
A. Suction the patient to clear the airway of secretions.
B. Assess the patient and the ventilator circuit for disconnections.
C. Administer a sedative to prevent the patient from fighting the breath.
D. Increase the PEEP setting to stabilize the alveoli.
Ans: B
,Explanation: A low-pressure alarm usually indicates a leak or a disconnection in the ventilator circuit.
The nurse should immediately check the tubing from the patient to the machine to find the source of the
pressure loss. If the nurse cannot find the cause, the patient should be manually ventilated with a bag-
valve mask. This ensures that the patient continues to receive oxygen while the equipment is being
repaired. Safety and continuous oxygenation are the highest priorities in this emergency situation.
3. A patient presents with a burn injury covering the entire left arm and the anterior trunk. Using the Rule of
Nines, what is the estimated Total Body Surface Area (TBSA) burned?
A. 18%
B. 36%
C. 27%
D. 45%
Ans: C
Explanation: The Rule of Nines assigns 9% to the entire arm and 18% to the anterior trunk. Adding
these together results in a total of 27% TBSA for this specific patient. Accurate assessment of burn size is
critical for calculating fluid resuscitation requirements during the first 24 hours. The Parkland formula
relies heavily on this percentage to prevent hypovolemic shock. Nurses must also remember that the
posterior trunk and legs carry different percentage values.
4. The nurse is caring for a patient in the oliguric phase of Acute Kidney Injury (AKI). Which electrolyte
abnormality is most likely to be observed?
A. Hypokalemia
B. Hypernatremia
C. Hyperkalemia
, D. Hypophosphatemia
Ans: C
Explanation: In the oliguric phase, the kidneys are unable to excrete potassium effectively, leading to
hyperkalemia. This condition is dangerous because it can cause life-threatening cardiac arrhythmias. The
nurse should monitor the patient’s EKG for peaked T-waves or a widened QRS complex. Dietary
restrictions of potassium are necessary during this phase of the illness. Medications like Kayexalate or
insulin/glucose may be needed to lower serum potassium levels.
5. A patient with cirrhosis has developed hepatic encephalopathy. What is the primary goal of administering
Lactulose to this patient?
A. To promote the excretion of ammonia through the stool.
B. To increase serum glucose levels and energy.
C. To reduce the risk of spontaneous bacterial peritonitis.
D. To decrease portal vein pressure and prevent varices.
Ans: A
Explanation: Lactulose works by trapping ammonia in the gut and facilitating its excretion via a laxative
effect. High levels of ammonia cross the blood-brain barrier and cause the neurological symptoms seen in
encephalopathy. The nurse should monitor the patient for 2-3 soft stools per day to ensure therapeutic
efficacy. Improvement in mental status is the primary indicator that the medication is working.
Dehydration is a potential side effect due to the increased frequency of bowel movements.
6. A patient is admitted with a blood glucose of 750 mg/dL, ketones in the urine, and an arterial pH of 7.25.
Which condition is the patient most likely experiencing?
A. Diabetic Ketoacidosis (DKA)
