NUR 445 Final Exam: Acute & Chronic Health Disruptions
In Adults III V2 Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient in septic shock. Which intervention is the highest priority within the first
hour of care?
A. Obtaining blood cultures
B. Administering broad-spectrum antibiotics
C. Starting a vasopressor infusion
D. Initiating a large-bore IV fluid bolus
Ans: A
Explanation: The Surviving Sepsis Campaign guidelines emphasize that blood cultures must be obtained
before starting antibiotics. This allows for the identification of the specific pathogen while the antibiotics
target the infection. Although fluid resuscitation is critical, culture collection remains a primary
diagnostic step in the early bundle. Administering antibiotics before cultures can lead to false-negative
results and complicate treatment. Therefore, the nurse must prioritize diagnostic data collection to
ensure effective long-term therapy.
2. A patient is diagnosed with Acute Respiratory Distress Syndrome (ARDS). What is the primary
pathophysiology behind this condition?
A. Increased alveolar-capillary membrane permeability
B. Excessive mucus production in the bronchioles
C. Reduced cardiac output leading to pulmonary edema
D. Compression of the lungs by pleural effusion
,Ans: A
Explanation: ARDS is characterized by a systemic inflammatory response that damages the alveolar-
capillary membrane. This damage causes fluid to leak into the alveoli, resulting in severe hypoxemia.
Unlike cardiogenic pulmonary edema, ARDS is caused by inflammatory injury rather than hydrostatic
pressure. The resulting surfactant loss leads to alveolar collapse and decreased lung compliance.
Understanding this mechanism is vital for implementing lung-protective ventilation strategies.
3. Using the Parkland Formula, calculate the total fluid volume needed for a 70kg patient with 40% total
body surface area (TBSA) burns in the first 24 hours.
A. 5,600 mL
B. 11,200 mL
C. 14,000 mL
D. 28,000 mL
Ans: B
Explanation: The Parkland formula calculates fluid requirements as 4 mL x weight in kg x % TBSA
burned. For this patient, the calculation is 4 times 70 times 40, which equals 11,200 mL. Half of this total
volume must be administered within the first 8 hours post-injury. The remaining half is given over the
subsequent 16 hours to maintain organ perfusion. Proper fluid resuscitation is essential to prevent
hypovolemic shock in major burn victims.
4. A patient with a head injury presents with a Widening Pulse Pressure, Bradycardia, and Irregular
Respirations. What does this signify?
A. Beck’s Triad
B. Virchow’s Triad
, C. Cushing’s Triad
D. Horner’s Syndrome
Ans: C
Explanation: Cushing’s Triad is a late sign of significantly increased intracranial pressure (ICP). It
consists of systolic hypertension with a widened pulse pressure, bradycardia, and irregular breathing
patterns. This clinical manifestation suggests that the brain is herniating or about to herniate. Immediate
medical intervention is required to lower the pressure and prevent permanent brain damage. Nurses
must recognize these signs promptly to initiate emergency protocols.
5. Which clinical finding is most indicative of a tension pneumothorax?
A. Dullness upon percussion of the chest
B. Increased breath sounds on the affected side
C. Hypertension and bradycardia
D. Tracheal deviation to the unaffected side
Ans: D
Explanation: Tension pneumothorax is a life-threatening emergency where air enters the pleural space
and cannot escape. This pressure buildup causes the mediastinum and trachea to shift toward the
opposite side of the injury. Patients typically exhibit respiratory distress, tachycardia, and signs of
obstructive shock. Immediate needle decompression is necessary to relieve the pressure before chest
tube insertion. Identifying tracheal deviation is a late but critical sign of this condition.
6. A patient in the ICU has a Swan-Ganz catheter. The nurse notes a Pulmonary Artery Wedge Pressure
(PAWP) of 22 mmHg. This likely indicates:
A. Left-sided heart failure
In Adults III V2 Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient in septic shock. Which intervention is the highest priority within the first
hour of care?
A. Obtaining blood cultures
B. Administering broad-spectrum antibiotics
C. Starting a vasopressor infusion
D. Initiating a large-bore IV fluid bolus
Ans: A
Explanation: The Surviving Sepsis Campaign guidelines emphasize that blood cultures must be obtained
before starting antibiotics. This allows for the identification of the specific pathogen while the antibiotics
target the infection. Although fluid resuscitation is critical, culture collection remains a primary
diagnostic step in the early bundle. Administering antibiotics before cultures can lead to false-negative
results and complicate treatment. Therefore, the nurse must prioritize diagnostic data collection to
ensure effective long-term therapy.
2. A patient is diagnosed with Acute Respiratory Distress Syndrome (ARDS). What is the primary
pathophysiology behind this condition?
A. Increased alveolar-capillary membrane permeability
B. Excessive mucus production in the bronchioles
C. Reduced cardiac output leading to pulmonary edema
D. Compression of the lungs by pleural effusion
,Ans: A
Explanation: ARDS is characterized by a systemic inflammatory response that damages the alveolar-
capillary membrane. This damage causes fluid to leak into the alveoli, resulting in severe hypoxemia.
Unlike cardiogenic pulmonary edema, ARDS is caused by inflammatory injury rather than hydrostatic
pressure. The resulting surfactant loss leads to alveolar collapse and decreased lung compliance.
Understanding this mechanism is vital for implementing lung-protective ventilation strategies.
3. Using the Parkland Formula, calculate the total fluid volume needed for a 70kg patient with 40% total
body surface area (TBSA) burns in the first 24 hours.
A. 5,600 mL
B. 11,200 mL
C. 14,000 mL
D. 28,000 mL
Ans: B
Explanation: The Parkland formula calculates fluid requirements as 4 mL x weight in kg x % TBSA
burned. For this patient, the calculation is 4 times 70 times 40, which equals 11,200 mL. Half of this total
volume must be administered within the first 8 hours post-injury. The remaining half is given over the
subsequent 16 hours to maintain organ perfusion. Proper fluid resuscitation is essential to prevent
hypovolemic shock in major burn victims.
4. A patient with a head injury presents with a Widening Pulse Pressure, Bradycardia, and Irregular
Respirations. What does this signify?
A. Beck’s Triad
B. Virchow’s Triad
, C. Cushing’s Triad
D. Horner’s Syndrome
Ans: C
Explanation: Cushing’s Triad is a late sign of significantly increased intracranial pressure (ICP). It
consists of systolic hypertension with a widened pulse pressure, bradycardia, and irregular breathing
patterns. This clinical manifestation suggests that the brain is herniating or about to herniate. Immediate
medical intervention is required to lower the pressure and prevent permanent brain damage. Nurses
must recognize these signs promptly to initiate emergency protocols.
5. Which clinical finding is most indicative of a tension pneumothorax?
A. Dullness upon percussion of the chest
B. Increased breath sounds on the affected side
C. Hypertension and bradycardia
D. Tracheal deviation to the unaffected side
Ans: D
Explanation: Tension pneumothorax is a life-threatening emergency where air enters the pleural space
and cannot escape. This pressure buildup causes the mediastinum and trachea to shift toward the
opposite side of the injury. Patients typically exhibit respiratory distress, tachycardia, and signs of
obstructive shock. Immediate needle decompression is necessary to relieve the pressure before chest
tube insertion. Identifying tracheal deviation is a late but critical sign of this condition.
6. A patient in the ICU has a Swan-Ganz catheter. The nurse notes a Pulmonary Artery Wedge Pressure
(PAWP) of 22 mmHg. This likely indicates:
A. Left-sided heart failure
