NUR 445 Exam 2: Acute & Chronic Health Disruptions In
Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with septic shock remains hypotensive after receiving a 30 mL/kg fluid bolus. Which
vasopressor is considered the first-line agent to improve mean arterial pressure (MAP)?
A. Dopamine
B. Norepinephrine
C. Vasopressin
D. Epinephrine
Ans: B
Explanation: Norepinephrine is the primary vasopressor recommended by the Surviving Sepsis
Guidelines for patients who remain hypotensive after fluid resuscitation. It acts mainly on alpha-1
receptors to cause vasoconstriction and increase systemic vascular resistance. While dopamine was used
in the past, it is associated with a higher risk of dysrhythmias. Vasopressin may be added later as an
adjunct to reduce the dose of norepinephrine. The goal is to maintain a MAP of at least 65 mmHg to
ensure adequate end-organ perfusion.
2. Which clinical manifestation would the nurse expect to find in a patient experiencing Beck’s Triad,
suggesting cardiac tamponade?
A. Hypotension, jugular venous distention, and muffled heart sounds
B. Hypertension, bradycardia, and irregular respirations
C. Tachycardia, tachypnea, and peripheral edema
D. Narrow pulse pressure, S3 gallop, and crackles
,Ans: A
Explanation: Beck’s Triad consists of hypotension, jugular venous distention, and muffled heart sounds
which indicates fluid accumulation in the pericardial sac. The increased pressure prevents the heart from
filling properly during diastole, leading to decreased cardiac output. This condition is a medical
emergency that requires immediate pericardiocentesis to relieve the pressure. Distinguishing these signs
from other forms of shock is critical for rapid intervention. The nurse must monitor for these specific
signs following cardiac surgery or trauma.
3. A patient is on mechanical ventilation with a high-pressure alarm sounding. After assessing the patient,
the nurse notes increased secretions and coughing. What is the priority action?
A. Suction the patient’s airway
B. Check for kinks in the ventilator tubing
C. Increase the oxygen concentration to 100%
D. Administer a sedative to the patient
Ans: A
Explanation: A high-pressure alarm on a ventilator often indicates an obstruction such as secretions,
bronchospasm, or the patient biting the tube. Since the assessment revealed secretions and coughing,
suctioning is the most direct intervention to clear the airway. Kinks in the tubing also cause high-
pressure alarms but were not indicated by the patient assessment findings. If suctioning does not resolve
the alarm, further investigation of the circuit is required. The nurse should always assess the patient first
before troubleshooting the machine.
4. In the exudative phase of Acute Respiratory Distress Syndrome (ARDS), what is the primary
pathophysiological change occurring in the lungs?
A. Increased capillary permeability and alveolar edema
, B. Proliferation of fibroblasts leading to scarring
C. Destruction of alveolar-capillary membranes by bacteria
D. Hyperventilation causing respiratory alkalosis
Ans: A
Explanation: The exudative phase of ARDS occurs within 24 to 72 hours of the initial insult and is
characterized by inflammatory damage. This damage leads to increased capillary permeability, allowing
protein-rich fluid to leak into the alveoli. The presence of fluid inhibits gas exchange and inactivates
surfactant, causing alveolar collapse. Patients typically present with severe refractory hypoxemia despite
high levels of oxygen administration. Nursing care focuses on oxygenation and managing the underlying
cause of the inflammation.
5. A patient with Acute Kidney Injury (AKI) has a potassium level of 6.8 mEq/L and ECG changes including
peaked T waves. Which medication should the nurse expect to administer first to stabilize the cardiac
membrane?
A. Sodium Polystyrene Sulfonate
B. Regular Insulin and Dextrose
C. Calcium Gluconate
D. Furosemide
Ans: C
Explanation: Calcium gluconate is administered in severe hyperkalemia to stabilize the myocardial cell
membrane and prevent lethal dysrhythmias. It does not lower the serum potassium level but protects the
heart while other treatments are initiated. After calcium administration, insulin and dextrose are
typically given to shift potassium into the cells. Sodium polystyrene sulfonate works more slowly by
Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with septic shock remains hypotensive after receiving a 30 mL/kg fluid bolus. Which
vasopressor is considered the first-line agent to improve mean arterial pressure (MAP)?
A. Dopamine
B. Norepinephrine
C. Vasopressin
D. Epinephrine
Ans: B
Explanation: Norepinephrine is the primary vasopressor recommended by the Surviving Sepsis
Guidelines for patients who remain hypotensive after fluid resuscitation. It acts mainly on alpha-1
receptors to cause vasoconstriction and increase systemic vascular resistance. While dopamine was used
in the past, it is associated with a higher risk of dysrhythmias. Vasopressin may be added later as an
adjunct to reduce the dose of norepinephrine. The goal is to maintain a MAP of at least 65 mmHg to
ensure adequate end-organ perfusion.
2. Which clinical manifestation would the nurse expect to find in a patient experiencing Beck’s Triad,
suggesting cardiac tamponade?
A. Hypotension, jugular venous distention, and muffled heart sounds
B. Hypertension, bradycardia, and irregular respirations
C. Tachycardia, tachypnea, and peripheral edema
D. Narrow pulse pressure, S3 gallop, and crackles
,Ans: A
Explanation: Beck’s Triad consists of hypotension, jugular venous distention, and muffled heart sounds
which indicates fluid accumulation in the pericardial sac. The increased pressure prevents the heart from
filling properly during diastole, leading to decreased cardiac output. This condition is a medical
emergency that requires immediate pericardiocentesis to relieve the pressure. Distinguishing these signs
from other forms of shock is critical for rapid intervention. The nurse must monitor for these specific
signs following cardiac surgery or trauma.
3. A patient is on mechanical ventilation with a high-pressure alarm sounding. After assessing the patient,
the nurse notes increased secretions and coughing. What is the priority action?
A. Suction the patient’s airway
B. Check for kinks in the ventilator tubing
C. Increase the oxygen concentration to 100%
D. Administer a sedative to the patient
Ans: A
Explanation: A high-pressure alarm on a ventilator often indicates an obstruction such as secretions,
bronchospasm, or the patient biting the tube. Since the assessment revealed secretions and coughing,
suctioning is the most direct intervention to clear the airway. Kinks in the tubing also cause high-
pressure alarms but were not indicated by the patient assessment findings. If suctioning does not resolve
the alarm, further investigation of the circuit is required. The nurse should always assess the patient first
before troubleshooting the machine.
4. In the exudative phase of Acute Respiratory Distress Syndrome (ARDS), what is the primary
pathophysiological change occurring in the lungs?
A. Increased capillary permeability and alveolar edema
, B. Proliferation of fibroblasts leading to scarring
C. Destruction of alveolar-capillary membranes by bacteria
D. Hyperventilation causing respiratory alkalosis
Ans: A
Explanation: The exudative phase of ARDS occurs within 24 to 72 hours of the initial insult and is
characterized by inflammatory damage. This damage leads to increased capillary permeability, allowing
protein-rich fluid to leak into the alveoli. The presence of fluid inhibits gas exchange and inactivates
surfactant, causing alveolar collapse. Patients typically present with severe refractory hypoxemia despite
high levels of oxygen administration. Nursing care focuses on oxygenation and managing the underlying
cause of the inflammation.
5. A patient with Acute Kidney Injury (AKI) has a potassium level of 6.8 mEq/L and ECG changes including
peaked T waves. Which medication should the nurse expect to administer first to stabilize the cardiac
membrane?
A. Sodium Polystyrene Sulfonate
B. Regular Insulin and Dextrose
C. Calcium Gluconate
D. Furosemide
Ans: C
Explanation: Calcium gluconate is administered in severe hyperkalemia to stabilize the myocardial cell
membrane and prevent lethal dysrhythmias. It does not lower the serum potassium level but protects the
heart while other treatments are initiated. After calcium administration, insulin and dextrose are
typically given to shift potassium into the cells. Sodium polystyrene sulfonate works more slowly by
