NUR 445 Final Exam: Acute & Chronic Health Disruptions
In Adults III V1 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is caring for a patient in the early compensatory stage of hypovolemic shock. Which clinical
manifestation should the nurse expect to observe?
A. Increased respiratory rate
B. Decreased heart rate
C. Profound hypotension
D. Decreased urinary output
Ans: A
Explanation: The correct answer is B because the body increases the respiratory rate to improve
oxygenation and compensate for metabolic acidosis. In the compensatory stage, the sympathetic nervous
system is activated to maintain cardiac output. A decreased heart rate would not occur as the body tries
to compensate. Profound hypotension is a sign of the progressive stage, not the early compensatory
stage. Monitoring the respiratory status is vital to assess the progression of shock.
2. When calculating fluid resuscitation for a burn patient using the Parkland Formula, which fluid is most
commonly used in the first 24 hours?
A. Lactated Ringer’s
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. 3% Hypertonic Saline
Ans: A
,Explanation: Lactated Ringer’s is the fluid of choice because its composition most closely matches
extracellular fluid. This isotonic solution helps maintain volume without causing significant electrolyte
shifts in the initial phase. Normal saline is avoided in large volumes to prevent hyperchloremic acidosis.
Dextrose is not used initially because it can lead to osmotic diuresis. Administering the correct fluid is
critical for preventing hypovolemic shock in burn victims.
3. A patient with a head injury has an intracranial pressure (ICP) of 18 mmHg. What is the most appropriate
nursing intervention?
A. Place the patient in Trendelenburg position
B. Perform frequent suctioning to clear the airway
C. Encourage the patient to cough and deep breathe
D. Keep the head of the bed elevated at 30 degrees
Ans: D
Explanation: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain and
helps reduce ICP. Trendelenburg position is contraindicated as it increases intracranial pressure
significantly. Coughing and deep breathing can increase intra-abdominal and intrathoracic pressure,
leading to higher ICP. Frequent suctioning should be avoided as it triggers spikes in intracranial pressure.
Maintaining a neutral neck alignment is also essential for optimal drainage.
4. Which assessment finding is most characteristic of a patient in the oliguric phase of acute kidney injury
(AKI)?
A. Urinary output of 1500 mL/day
B. Serum creatinine level of 0.8 mg/dL
C. Metabolic alkalosis
, D. Fluid volume overload
Ans: D
Explanation: Fluid volume overload occurs during the oliguric phase because the kidneys are unable to
excrete sufficient urine. The urinary output in this phase is typically less than 400 mL per day, not 1500
mL. Serum creatinine levels would be elevated rather than normal or low. Patients in AKI typically
experience metabolic acidosis rather than alkalosis due to the inability to excrete hydrogen ions. Careful
monitoring of weight and lung sounds is necessary to manage fluid status.
5. The nurse is monitoring a patient with acute respiratory distress syndrome (ARDS) on mechanical
ventilation. What is the primary purpose of Positive End-Expiratory Pressure (PEEP)?
A. To decrease the risk of barotrauma
B. To increase the patient’s respiratory rate
C. To decrease the fraction of inspired oxygen (FiO2)
D. To prevent alveolar collapse at the end of expiration
Ans: D
Explanation: PEEP is used to keep the alveoli open at the end of expiration, which improves gas
exchange and oxygenation. It increases the functional residual capacity of the lungs in patients with
ARDS. While it can help lower FiO2 requirements, its primary physiological goal is alveolar recruitment.
Excessively high PEEP can actually increase the risk of barotrauma or pneumothorax. Nursing care
involves monitoring for decreased cardiac output associated with high PEEP levels.
6. A patient with liver cirrhosis and hepatic encephalopathy is prescribed lactulose. What is the primary goal
of this medication?
A. To reduce blood pressure in the portal vein
In Adults III V1 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is caring for a patient in the early compensatory stage of hypovolemic shock. Which clinical
manifestation should the nurse expect to observe?
A. Increased respiratory rate
B. Decreased heart rate
C. Profound hypotension
D. Decreased urinary output
Ans: A
Explanation: The correct answer is B because the body increases the respiratory rate to improve
oxygenation and compensate for metabolic acidosis. In the compensatory stage, the sympathetic nervous
system is activated to maintain cardiac output. A decreased heart rate would not occur as the body tries
to compensate. Profound hypotension is a sign of the progressive stage, not the early compensatory
stage. Monitoring the respiratory status is vital to assess the progression of shock.
2. When calculating fluid resuscitation for a burn patient using the Parkland Formula, which fluid is most
commonly used in the first 24 hours?
A. Lactated Ringer’s
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. 3% Hypertonic Saline
Ans: A
,Explanation: Lactated Ringer’s is the fluid of choice because its composition most closely matches
extracellular fluid. This isotonic solution helps maintain volume without causing significant electrolyte
shifts in the initial phase. Normal saline is avoided in large volumes to prevent hyperchloremic acidosis.
Dextrose is not used initially because it can lead to osmotic diuresis. Administering the correct fluid is
critical for preventing hypovolemic shock in burn victims.
3. A patient with a head injury has an intracranial pressure (ICP) of 18 mmHg. What is the most appropriate
nursing intervention?
A. Place the patient in Trendelenburg position
B. Perform frequent suctioning to clear the airway
C. Encourage the patient to cough and deep breathe
D. Keep the head of the bed elevated at 30 degrees
Ans: D
Explanation: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain and
helps reduce ICP. Trendelenburg position is contraindicated as it increases intracranial pressure
significantly. Coughing and deep breathing can increase intra-abdominal and intrathoracic pressure,
leading to higher ICP. Frequent suctioning should be avoided as it triggers spikes in intracranial pressure.
Maintaining a neutral neck alignment is also essential for optimal drainage.
4. Which assessment finding is most characteristic of a patient in the oliguric phase of acute kidney injury
(AKI)?
A. Urinary output of 1500 mL/day
B. Serum creatinine level of 0.8 mg/dL
C. Metabolic alkalosis
, D. Fluid volume overload
Ans: D
Explanation: Fluid volume overload occurs during the oliguric phase because the kidneys are unable to
excrete sufficient urine. The urinary output in this phase is typically less than 400 mL per day, not 1500
mL. Serum creatinine levels would be elevated rather than normal or low. Patients in AKI typically
experience metabolic acidosis rather than alkalosis due to the inability to excrete hydrogen ions. Careful
monitoring of weight and lung sounds is necessary to manage fluid status.
5. The nurse is monitoring a patient with acute respiratory distress syndrome (ARDS) on mechanical
ventilation. What is the primary purpose of Positive End-Expiratory Pressure (PEEP)?
A. To decrease the risk of barotrauma
B. To increase the patient’s respiratory rate
C. To decrease the fraction of inspired oxygen (FiO2)
D. To prevent alveolar collapse at the end of expiration
Ans: D
Explanation: PEEP is used to keep the alveoli open at the end of expiration, which improves gas
exchange and oxygenation. It increases the functional residual capacity of the lungs in patients with
ARDS. While it can help lower FiO2 requirements, its primary physiological goal is alveolar recruitment.
Excessively high PEEP can actually increase the risk of barotrauma or pneumothorax. Nursing care
involves monitoring for decreased cardiac output associated with high PEEP levels.
6. A patient with liver cirrhosis and hepatic encephalopathy is prescribed lactulose. What is the primary goal
of this medication?
A. To reduce blood pressure in the portal vein
