NUR 425 Final Exam: Acute & Chronic Health Disruptions
In Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with ARDS is on mechanical ventilation with PEEP set at 15 cm H2O. Which assessment finding
is most concerning to the nurse?
A. Respiratory rate of 22 breaths per minute
B. Slightly increased crackles in lung bases
C. PaO2 level of 65 mmHg
D. Blood pressure drop from 120/80 to 90/60 mmHg
Ans: D
Explanation: High levels of PEEP increase intrathoracic pressure which can significantly decrease
venous return to the heart. This reduction in preload often leads to a drop in cardiac output and systemic
blood pressure. The nurse must prioritize hemodynamic stability when adjusting ventilator pressures for
ARDS patients. A blood pressure of 90/60 mmHg indicates possible shock or severe hemodynamic
compromise. Immediate intervention is required to prevent organ hypoperfusion and secondary injury.
2. The nurse is caring for a patient who has suffered 45% TBSA burns. Using the Parkland formula
(4mL/kg/%TBSA), the patient weighs 80kg. How much fluid should be administered in the first 8 hours?
A. 14,400 mL
B. 10,800 mL
C. 3,600 mL
D. 7,200 mL
Ans: D
,Explanation: The Parkland formula calculates the total 24-hour fluid requirement for burn resuscitation.
In this case, 4 mL x 80 kg x 45 percent equals a total of 14,400 mL. Protocol dictates that half of this total
volume must be infused within the first 8 hours post-injury. Therefore, the nurse should set the pump to
deliver 7,200 mL during this initial window. Monitoring urine output is the gold standard for evaluating
the effectiveness of this fluid resuscitation.
3. A patient is admitted with septic shock. Which of the following orders should the nurse implement first
according to the Sepsis Six bundle?
A. Administer a 30 mL/kg bolus of crystalloids
B. Apply high-flow oxygen via non-rebreather mask
C. Obtain blood cultures from two separate sites
D. Start broad-spectrum antibiotics
Ans: B
Explanation: The priority in any emergency situation is the patient’s airway, breathing, and circulation.
Applying oxygen is the most immediate action to support cellular oxygenation during a state of shock.
While blood cultures and antibiotics are critical, they follow the stabilization of oxygen delivery. Fluid
resuscitation is also vital but cannot be effective if the patient is severely hypoxic. The nurse must ensure
adequate oxygenation before proceeding with the remainder of the sepsis bundle components.
4. A patient in the ICU has an ICP monitor showing a reading of 25 mmHg. Which nursing intervention is the
highest priority?
A. Cluster nursing activities to allow for rest
B. Place the patient in Trendelenburg position
C. Suction the patient to clear the airway
, D. Administer prescribed Mannitol (Osmitrol) via IV
Ans: D
Explanation: An intracranial pressure (ICP) of 25 mmHg is significantly elevated and requires urgent
pharmacological intervention. Mannitol is an osmotic diuretic that works by pulling fluid from the brain
tissue into the vascular space. This action effectively reduces cerebral edema and lowers the pressure
inside the skull. Clustering care or suctioning could further increase ICP and should be avoided during a
spike. Elevating the head of the bed rather than Trendelenburg is the correct positioning for ICP
management.
5. A patient with acute kidney injury (AKI) presents with a serum potassium of 6.8 mEq/L and EKG changes.
Which medication should the nurse expect to give first to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Calcium gluconate
C. Regular insulin and Dextrose 50%
D. Sodium bicarbonate
Ans: B
Explanation: Hyperkalemia can cause life-threatening cardiac arrhythmias when levels exceed 6.5
mEq/L. Calcium gluconate does not lower potassium but stabilizes the myocardial cell membrane to
prevent lethal rhythms. Insulin and Dextrose work to shift potassium into cells but take longer to act on
the heart. Kayexalate is used for the actual removal of potassium through the GI tract over several hours.
The immediate goal when EKG changes are present is to protect the heart from arrest.
In Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with ARDS is on mechanical ventilation with PEEP set at 15 cm H2O. Which assessment finding
is most concerning to the nurse?
A. Respiratory rate of 22 breaths per minute
B. Slightly increased crackles in lung bases
C. PaO2 level of 65 mmHg
D. Blood pressure drop from 120/80 to 90/60 mmHg
Ans: D
Explanation: High levels of PEEP increase intrathoracic pressure which can significantly decrease
venous return to the heart. This reduction in preload often leads to a drop in cardiac output and systemic
blood pressure. The nurse must prioritize hemodynamic stability when adjusting ventilator pressures for
ARDS patients. A blood pressure of 90/60 mmHg indicates possible shock or severe hemodynamic
compromise. Immediate intervention is required to prevent organ hypoperfusion and secondary injury.
2. The nurse is caring for a patient who has suffered 45% TBSA burns. Using the Parkland formula
(4mL/kg/%TBSA), the patient weighs 80kg. How much fluid should be administered in the first 8 hours?
A. 14,400 mL
B. 10,800 mL
C. 3,600 mL
D. 7,200 mL
Ans: D
,Explanation: The Parkland formula calculates the total 24-hour fluid requirement for burn resuscitation.
In this case, 4 mL x 80 kg x 45 percent equals a total of 14,400 mL. Protocol dictates that half of this total
volume must be infused within the first 8 hours post-injury. Therefore, the nurse should set the pump to
deliver 7,200 mL during this initial window. Monitoring urine output is the gold standard for evaluating
the effectiveness of this fluid resuscitation.
3. A patient is admitted with septic shock. Which of the following orders should the nurse implement first
according to the Sepsis Six bundle?
A. Administer a 30 mL/kg bolus of crystalloids
B. Apply high-flow oxygen via non-rebreather mask
C. Obtain blood cultures from two separate sites
D. Start broad-spectrum antibiotics
Ans: B
Explanation: The priority in any emergency situation is the patient’s airway, breathing, and circulation.
Applying oxygen is the most immediate action to support cellular oxygenation during a state of shock.
While blood cultures and antibiotics are critical, they follow the stabilization of oxygen delivery. Fluid
resuscitation is also vital but cannot be effective if the patient is severely hypoxic. The nurse must ensure
adequate oxygenation before proceeding with the remainder of the sepsis bundle components.
4. A patient in the ICU has an ICP monitor showing a reading of 25 mmHg. Which nursing intervention is the
highest priority?
A. Cluster nursing activities to allow for rest
B. Place the patient in Trendelenburg position
C. Suction the patient to clear the airway
, D. Administer prescribed Mannitol (Osmitrol) via IV
Ans: D
Explanation: An intracranial pressure (ICP) of 25 mmHg is significantly elevated and requires urgent
pharmacological intervention. Mannitol is an osmotic diuretic that works by pulling fluid from the brain
tissue into the vascular space. This action effectively reduces cerebral edema and lowers the pressure
inside the skull. Clustering care or suctioning could further increase ICP and should be avoided during a
spike. Elevating the head of the bed rather than Trendelenburg is the correct positioning for ICP
management.
5. A patient with acute kidney injury (AKI) presents with a serum potassium of 6.8 mEq/L and EKG changes.
Which medication should the nurse expect to give first to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Calcium gluconate
C. Regular insulin and Dextrose 50%
D. Sodium bicarbonate
Ans: B
Explanation: Hyperkalemia can cause life-threatening cardiac arrhythmias when levels exceed 6.5
mEq/L. Calcium gluconate does not lower potassium but stabilizes the myocardial cell membrane to
prevent lethal rhythms. Insulin and Dextrose work to shift potassium into cells but take longer to act on
the heart. Kayexalate is used for the actual removal of potassium through the GI tract over several hours.
The immediate goal when EKG changes are present is to protect the heart from arrest.
