NUR 445 Final Exam: Acute & Chronic Health Disruptions
In Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with ARDS is being mechanically ventilated with high PEEP. Which assessment finding most
concerns the nurse?
A. Yellow-tinged tracheal secretions
B. SpO2 92% on 60% FiO2
C. Respiratory rate of 22 breaths per minute
D. Blood pressure 88/46 mmHg
Ans: D
Explanation: High Positive End-Expiratory Pressure can cause increased intrathoracic pressure which
significantly reduces venous return. This reduction in preload leads to decreased cardiac output and
subsequent hypotension. The nurse must monitor for hemodynamic instability when PEEP levels are
titrated upward. A blood pressure of 88/46 indicates a potential compromise in organ perfusion that
requires immediate intervention. Other findings like SpO2 or secretions are important but less acute than
cardiovascular collapse.
2. Which hemodynamic parameter should the nurse expect to find in a patient with early septic shock?
A. Decreased heart rate
B. Increased cardiac output (CO)
C. Increased systemic vascular resistance (SVR)
D. Increased central venous pressure (CVP)
Ans: B
,Explanation: Early septic shock is characterized by a hyperdynamic state known as the ‘warm phase.’
During this period, massive vasodilation occurs, which results in a low systemic vascular resistance. To
compensate for the vasodilation and maintain perfusion, the heart rate and stroke volume increase,
leading to a high cardiac output. Patients typically present with warm, flushed skin and a bounding pulse
during this initial stage. Recognition of these hyperdynamic signs is vital for initiating prompt fluid
resuscitation and antibiotic therapy.
3. A patient with a T3 spinal cord injury becomes suddenly diaphoretic, hypertensive (190/110), and reports
a pounding headache. What is the priority nursing action?
A. Administer PRN hydralazine
B. Elevate the head of the bed to 90 degrees
C. Perform a bladder scan
D. Notify the healthcare provider immediately
Ans: B
Explanation: These symptoms are classic indicators of autonomic dysreflexia, a life-threatening
emergency in spinal cord injury patients. The first priority is to sit the patient upright to induce
orthostatic hypotension and lower the blood pressure. Once the patient is positioned, the nurse should
then assess for the noxious stimulus, such as a full bladder or impacted bowel. Quick intervention is
required to prevent complications like stroke or seizures from the extreme hypertension. Only after
positioning and assessment should pharmacological interventions or notifications be prioritized.
4. The nurse is caring for a patient who sustained full-thickness burns to 40% of their body 4 hours ago.
Which laboratory result is most expected during this phase?
A. Hematocrit 32%
B. Serum potassium 6.2 mEq/L
, C. Serum sodium 152 mEq/L
D. BUN 10 mg/dL
Ans: B
Explanation: During the emergent phase of a burn injury, massive cell destruction occurs, releasing
intracellular components into the bloodstream. This leads to hyperkalemia as potassium moves from the
intracellular space to the extracellular fluid. Additionally, fluid shifts out of the vascular space, causing
hemoconcentration and an elevated hematocrit. Sodium levels typically decrease because sodium follows
fluid into the interstitial space (third-spacing). Monitoring for cardiac dysrhythmias associated with high
potassium levels is a critical nursing responsibility during this time.
5. A patient is admitted with a traumatic brain injury and has an ICP of 22 mmHg. Which intervention is
contraindicated?
A. Administering Mannitol 20%
B. Maintaining neck alignment
C. Maintaining a quiet environment
D. Clustering nursing care activities
Ans: D
Explanation: Clustering nursing activities can cause sustained increases in intracranial pressure, which
may lead to brain herniation. For patients with elevated ICP, care should be spaced out to allow the ICP to
return to baseline between tasks. Mannitol is an osmotic diuretic used frequently to decrease cerebral
edema and lower ICP. Maintaining neck alignment ensures optimal venous drainage from the brain to
prevent further pressure buildup. A quiet environment helps minimize stimuli that could trigger spikes in
intracranial pressure.
In Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with ARDS is being mechanically ventilated with high PEEP. Which assessment finding most
concerns the nurse?
A. Yellow-tinged tracheal secretions
B. SpO2 92% on 60% FiO2
C. Respiratory rate of 22 breaths per minute
D. Blood pressure 88/46 mmHg
Ans: D
Explanation: High Positive End-Expiratory Pressure can cause increased intrathoracic pressure which
significantly reduces venous return. This reduction in preload leads to decreased cardiac output and
subsequent hypotension. The nurse must monitor for hemodynamic instability when PEEP levels are
titrated upward. A blood pressure of 88/46 indicates a potential compromise in organ perfusion that
requires immediate intervention. Other findings like SpO2 or secretions are important but less acute than
cardiovascular collapse.
2. Which hemodynamic parameter should the nurse expect to find in a patient with early septic shock?
A. Decreased heart rate
B. Increased cardiac output (CO)
C. Increased systemic vascular resistance (SVR)
D. Increased central venous pressure (CVP)
Ans: B
,Explanation: Early septic shock is characterized by a hyperdynamic state known as the ‘warm phase.’
During this period, massive vasodilation occurs, which results in a low systemic vascular resistance. To
compensate for the vasodilation and maintain perfusion, the heart rate and stroke volume increase,
leading to a high cardiac output. Patients typically present with warm, flushed skin and a bounding pulse
during this initial stage. Recognition of these hyperdynamic signs is vital for initiating prompt fluid
resuscitation and antibiotic therapy.
3. A patient with a T3 spinal cord injury becomes suddenly diaphoretic, hypertensive (190/110), and reports
a pounding headache. What is the priority nursing action?
A. Administer PRN hydralazine
B. Elevate the head of the bed to 90 degrees
C. Perform a bladder scan
D. Notify the healthcare provider immediately
Ans: B
Explanation: These symptoms are classic indicators of autonomic dysreflexia, a life-threatening
emergency in spinal cord injury patients. The first priority is to sit the patient upright to induce
orthostatic hypotension and lower the blood pressure. Once the patient is positioned, the nurse should
then assess for the noxious stimulus, such as a full bladder or impacted bowel. Quick intervention is
required to prevent complications like stroke or seizures from the extreme hypertension. Only after
positioning and assessment should pharmacological interventions or notifications be prioritized.
4. The nurse is caring for a patient who sustained full-thickness burns to 40% of their body 4 hours ago.
Which laboratory result is most expected during this phase?
A. Hematocrit 32%
B. Serum potassium 6.2 mEq/L
, C. Serum sodium 152 mEq/L
D. BUN 10 mg/dL
Ans: B
Explanation: During the emergent phase of a burn injury, massive cell destruction occurs, releasing
intracellular components into the bloodstream. This leads to hyperkalemia as potassium moves from the
intracellular space to the extracellular fluid. Additionally, fluid shifts out of the vascular space, causing
hemoconcentration and an elevated hematocrit. Sodium levels typically decrease because sodium follows
fluid into the interstitial space (third-spacing). Monitoring for cardiac dysrhythmias associated with high
potassium levels is a critical nursing responsibility during this time.
5. A patient is admitted with a traumatic brain injury and has an ICP of 22 mmHg. Which intervention is
contraindicated?
A. Administering Mannitol 20%
B. Maintaining neck alignment
C. Maintaining a quiet environment
D. Clustering nursing care activities
Ans: D
Explanation: Clustering nursing activities can cause sustained increases in intracranial pressure, which
may lead to brain herniation. For patients with elevated ICP, care should be spaced out to allow the ICP to
return to baseline between tasks. Mannitol is an osmotic diuretic used frequently to decrease cerebral
edema and lower ICP. Maintaining neck alignment ensures optimal venous drainage from the brain to
prevent further pressure buildup. A quiet environment helps minimize stimuli that could trigger spikes in
intracranial pressure.
