NSG4100 | NSG4100 Nursing Practice - Adult
Health III Exam 2 Version 3 | Questions with
Correct Answers and Expert Explanation for Each
Question | Galen
1. A patient in the ICU is being treated for septic shock. Which of the following
assessment findings would indicate the patient is entering the progressive stage of
shock?
A. Mean arterial pressure (MAP) of 75 mmHg
B. Heart rate of 95 beats per minute
C. Urine output of 20 mL/hour for the past 2 hours
D. Hyperactive bowel sounds in all quadrants
Correct Answer: C
Expert Explanation: In the progressive stage of shock, compensatory mechanisms
begin to fail, leading to decreased organ perfusion. A urine output of less than 0.5
mL/kg/hr or 30 mL/hr is a significant indicator of acute kidney injury due to
hypoperfusion. This stage requires immediate intervention to prevent multiple
organ dysfunction syndrome.
,2. A nurse is caring for a patient on a mechanical ventilator with Positive End-
Expiratory Pressure (PEEP) set at 15 cm H2O. Which complication should the nurse
monitor for most closely?
A. Increased cardiac output
B. Respiratory alkalosis
C. Decreased intracranial pressure
D. Pneumothorax
Correct Answer: D
Expert Explanation: High levels of PEEP increase the risk of barotrauma, which can
lead to a pneumothorax or subcutaneous emphysema. The increased intrathoracic
pressure can also cause a decrease in venous return and subsequently lower cardiac
output. Nurses must frequently assess lung sounds and hemodynamic stability in
patients receiving high PEEP.
3. An adult patient was admitted with 40% total body surface area (TBSA) burns. Using
the Parkland formula (4mL x kg x %TBSA), calculate the total fluid resuscitation
needed for the first 24 hours for a patient weighing 70 kg.
A. 5,600 mL
B. 11,200 mL
,C. 8,400 mL
D. 14,000 mL
Correct Answer: B
Expert Explanation: The Parkland formula calculates total fluid for the first 24
hours as 4 mL multiplied by the patient’s weight in kg multiplied by the percentage
of TBSA burned. For this patient, the calculation is 4 x 70 x 40, which equals 11,200
mL. Half of this total volume is administered in the first 8 hours, and the remainder
over the next 16 hours.
4. Which clinical manifestation is a hallmark sign of the compensatory stage of shock?
A. Tachycardia and tachypnea
B. Decreased level of consciousness
C. Cold, clammy skin
D. Metabolic acidosis with high lactate
Correct Answer: A
Expert Explanation: During the compensatory stage of shock, the body activates
the sympathetic nervous system to maintain cardiac output and oxygen delivery.
This results in an increased heart rate and respiratory rate to compensate for
, decreased tissue perfusion. Blood pressure may remain within normal limits during
this initial phase due to vasoconstriction.
5. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone
position. What is the primary rationale for this intervention?
A. To improve oxygenation by recruiting collapsed alveoli
B. To reduce the risk of pressure ulcers on the sacrum
C. To decrease the patient’s work of breathing
D. To facilitate easier suctioning of secretions
Correct Answer: A
Expert Explanation: Prone positioning in ARDS helps to improve oxygenation by
redistributing pulmonary blood flow and improving ventilation-perfusion matching.
It allows for the recruitment of alveoli in the dorsal regions of the lungs that are
often collapsed in the supine position. This intervention is typically used for patients
with severe ARDS who remain hypoxemic despite optimal ventilator settings.
6. A nurse observes a patient’s cardiac monitor and notes a saw-tooth pattern of P
waves with a regular QRS rhythm. Which rhythm is the patient experiencing?
A. Atrial flutter
B. Ventricular tachycardia
Health III Exam 2 Version 3 | Questions with
Correct Answers and Expert Explanation for Each
Question | Galen
1. A patient in the ICU is being treated for septic shock. Which of the following
assessment findings would indicate the patient is entering the progressive stage of
shock?
A. Mean arterial pressure (MAP) of 75 mmHg
B. Heart rate of 95 beats per minute
C. Urine output of 20 mL/hour for the past 2 hours
D. Hyperactive bowel sounds in all quadrants
Correct Answer: C
Expert Explanation: In the progressive stage of shock, compensatory mechanisms
begin to fail, leading to decreased organ perfusion. A urine output of less than 0.5
mL/kg/hr or 30 mL/hr is a significant indicator of acute kidney injury due to
hypoperfusion. This stage requires immediate intervention to prevent multiple
organ dysfunction syndrome.
,2. A nurse is caring for a patient on a mechanical ventilator with Positive End-
Expiratory Pressure (PEEP) set at 15 cm H2O. Which complication should the nurse
monitor for most closely?
A. Increased cardiac output
B. Respiratory alkalosis
C. Decreased intracranial pressure
D. Pneumothorax
Correct Answer: D
Expert Explanation: High levels of PEEP increase the risk of barotrauma, which can
lead to a pneumothorax or subcutaneous emphysema. The increased intrathoracic
pressure can also cause a decrease in venous return and subsequently lower cardiac
output. Nurses must frequently assess lung sounds and hemodynamic stability in
patients receiving high PEEP.
3. An adult patient was admitted with 40% total body surface area (TBSA) burns. Using
the Parkland formula (4mL x kg x %TBSA), calculate the total fluid resuscitation
needed for the first 24 hours for a patient weighing 70 kg.
A. 5,600 mL
B. 11,200 mL
,C. 8,400 mL
D. 14,000 mL
Correct Answer: B
Expert Explanation: The Parkland formula calculates total fluid for the first 24
hours as 4 mL multiplied by the patient’s weight in kg multiplied by the percentage
of TBSA burned. For this patient, the calculation is 4 x 70 x 40, which equals 11,200
mL. Half of this total volume is administered in the first 8 hours, and the remainder
over the next 16 hours.
4. Which clinical manifestation is a hallmark sign of the compensatory stage of shock?
A. Tachycardia and tachypnea
B. Decreased level of consciousness
C. Cold, clammy skin
D. Metabolic acidosis with high lactate
Correct Answer: A
Expert Explanation: During the compensatory stage of shock, the body activates
the sympathetic nervous system to maintain cardiac output and oxygen delivery.
This results in an increased heart rate and respiratory rate to compensate for
, decreased tissue perfusion. Blood pressure may remain within normal limits during
this initial phase due to vasoconstriction.
5. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone
position. What is the primary rationale for this intervention?
A. To improve oxygenation by recruiting collapsed alveoli
B. To reduce the risk of pressure ulcers on the sacrum
C. To decrease the patient’s work of breathing
D. To facilitate easier suctioning of secretions
Correct Answer: A
Expert Explanation: Prone positioning in ARDS helps to improve oxygenation by
redistributing pulmonary blood flow and improving ventilation-perfusion matching.
It allows for the recruitment of alveoli in the dorsal regions of the lungs that are
often collapsed in the supine position. This intervention is typically used for patients
with severe ARDS who remain hypoxemic despite optimal ventilator settings.
6. A nurse observes a patient’s cardiac monitor and notes a saw-tooth pattern of P
waves with a regular QRS rhythm. Which rhythm is the patient experiencing?
A. Atrial flutter
B. Ventricular tachycardia
