NSG4100 | NSG4100 Nursing Practice - Adult
Health III Exam 2 Version 2 | Questions with
Correct Answers and Expert Explanation for Each
Question | Galen
1. A patient on mechanical ventilation is experiencing a high-pressure alarm. Which
action should the nurse take first?
A. Suction the patient’s airway.
B. Check for kinks in the ventilator tubing.
C. Increase the oxygen concentration.
D. Auscultate breath sounds for a tension pneumothorax.
Correct Answer: A
Expert Explanation: High-pressure alarms often indicate a blockage in the airway
such as secretions, biting on the tube, or kinks. The nurse should first assess the
patient and provide suctioning if secretions are present. If the alarm continues, then
check for tubing obstructions or mechanical issues.
2. Which arterial blood gas (ABG) result is most indicative of early Acute Respiratory
Distress Syndrome (ARDS)?
A. pH 7.35, PaCO2 48, HCO3 26, PaO2 80
B. pH 7.30, PaCO2 55, HCO3 28, PaO2 55
,C. pH 7.48, PaCO2 30, HCO3 22, PaO2 60
D. pH 7.40, PaCO2 40, HCO3 24, PaO2 95
Correct Answer: C
Expert Explanation: In the early stages of ARDS, patients typically hyperventilate
to compensate for hypoxemia, leading to respiratory alkalosis. This is characterized
by an increased pH, decreased PaCO2, and a low PaO2 despite oxygen therapy. As
the condition worsens, the patient may move into respiratory acidosis.
3. A patient with a chest tube has continuous bubbling in the water-seal chamber.
What does this finding suggest?
A. The lung has fully re-expanded.
B. This is a normal finding during expiration.
C. There is an air leak in the system.
D. The suction level is too high.
Correct Answer: C
Expert Explanation: Continuous bubbling in the water-seal chamber indicates that
air is leaking into the drainage system. Intermittent bubbling is normal when the
patient coughs or exhales, but constant bubbling requires investigation of the tubing
,and insertion site. If the leak is not found in the tubing, it may be coming from the
patient’s pleural space.
4. When using the Parkland Formula for burn resuscitation, which fluid is preferred for
the first 24 hours?
A. 0.45% Normal Saline
B. 5% Dextrose in Water
C. Lactated Ringer’s
D. Albumin
Correct Answer: C
Expert Explanation: Lactated Ringer’s is the isotonic crystalloid of choice because
it most closely mimics the composition of extracellular fluid and helps maintain
electrolyte balance. Using 0.9% NS can lead to hyperchloremic acidosis in large
volumes. The first half of the calculated volume is administered within the first 8
hours after the burn occurred.
5. An ICU patient with a head injury has an intracranial pressure (ICP) of 22 mmHg.
Which intervention is most appropriate?
A. Place the patient in Trendelenburg position.
B. Administer Mannitol as ordered.
, C. Encourage the patient to perform the Valsalva maneuver.
D. Suction the patient every hour to keep the airway clear.
Correct Answer: B
Expert Explanation: Normal ICP is 5 to 15 mmHg; 22 mmHg indicates intracranial
hypertension. Mannitol is an osmotic diuretic that pulls fluid from the brain tissue
into the vascular space to reduce swelling. Interventions like suctioning and the
Valsalva maneuver should be minimized as they increase ICP.
6. In a disaster triage situation, a victim with a sucking chest wound is tagged with
which color?
A. Red
B. Yellow
C. Green
D. Black
Correct Answer: A
Expert Explanation: A sucking chest wound represents an immediate threat to life
but is potentially survivable with rapid intervention. Red tags indicate ‘Immediate’
priority for those needing life-saving care within minutes. This category includes
airway obstructions, tension pneumothorax, and severe bleeding.
Health III Exam 2 Version 2 | Questions with
Correct Answers and Expert Explanation for Each
Question | Galen
1. A patient on mechanical ventilation is experiencing a high-pressure alarm. Which
action should the nurse take first?
A. Suction the patient’s airway.
B. Check for kinks in the ventilator tubing.
C. Increase the oxygen concentration.
D. Auscultate breath sounds for a tension pneumothorax.
Correct Answer: A
Expert Explanation: High-pressure alarms often indicate a blockage in the airway
such as secretions, biting on the tube, or kinks. The nurse should first assess the
patient and provide suctioning if secretions are present. If the alarm continues, then
check for tubing obstructions or mechanical issues.
2. Which arterial blood gas (ABG) result is most indicative of early Acute Respiratory
Distress Syndrome (ARDS)?
A. pH 7.35, PaCO2 48, HCO3 26, PaO2 80
B. pH 7.30, PaCO2 55, HCO3 28, PaO2 55
,C. pH 7.48, PaCO2 30, HCO3 22, PaO2 60
D. pH 7.40, PaCO2 40, HCO3 24, PaO2 95
Correct Answer: C
Expert Explanation: In the early stages of ARDS, patients typically hyperventilate
to compensate for hypoxemia, leading to respiratory alkalosis. This is characterized
by an increased pH, decreased PaCO2, and a low PaO2 despite oxygen therapy. As
the condition worsens, the patient may move into respiratory acidosis.
3. A patient with a chest tube has continuous bubbling in the water-seal chamber.
What does this finding suggest?
A. The lung has fully re-expanded.
B. This is a normal finding during expiration.
C. There is an air leak in the system.
D. The suction level is too high.
Correct Answer: C
Expert Explanation: Continuous bubbling in the water-seal chamber indicates that
air is leaking into the drainage system. Intermittent bubbling is normal when the
patient coughs or exhales, but constant bubbling requires investigation of the tubing
,and insertion site. If the leak is not found in the tubing, it may be coming from the
patient’s pleural space.
4. When using the Parkland Formula for burn resuscitation, which fluid is preferred for
the first 24 hours?
A. 0.45% Normal Saline
B. 5% Dextrose in Water
C. Lactated Ringer’s
D. Albumin
Correct Answer: C
Expert Explanation: Lactated Ringer’s is the isotonic crystalloid of choice because
it most closely mimics the composition of extracellular fluid and helps maintain
electrolyte balance. Using 0.9% NS can lead to hyperchloremic acidosis in large
volumes. The first half of the calculated volume is administered within the first 8
hours after the burn occurred.
5. An ICU patient with a head injury has an intracranial pressure (ICP) of 22 mmHg.
Which intervention is most appropriate?
A. Place the patient in Trendelenburg position.
B. Administer Mannitol as ordered.
, C. Encourage the patient to perform the Valsalva maneuver.
D. Suction the patient every hour to keep the airway clear.
Correct Answer: B
Expert Explanation: Normal ICP is 5 to 15 mmHg; 22 mmHg indicates intracranial
hypertension. Mannitol is an osmotic diuretic that pulls fluid from the brain tissue
into the vascular space to reduce swelling. Interventions like suctioning and the
Valsalva maneuver should be minimized as they increase ICP.
6. In a disaster triage situation, a victim with a sucking chest wound is tagged with
which color?
A. Red
B. Yellow
C. Green
D. Black
Correct Answer: A
Expert Explanation: A sucking chest wound represents an immediate threat to life
but is potentially survivable with rapid intervention. Red tags indicate ‘Immediate’
priority for those needing life-saving care within minutes. This category includes
airway obstructions, tension pneumothorax, and severe bleeding.
