NSG4100 Nursing Practice - Adult Health III Exam
3 Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient with a 40% Total Body Surface Area (TBSA) burn is in the emergent phase.
Which laboratory value should the nurse expect to find?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Decreased Hematocrit
Correct Answer: B
Expert Explanation: In the emergent phase of a burn, massive cell destruction
occurs which releases intracellular potassium into the extracellular space, leading to
hyperkalemia. Sodium typically shifts into the interstitial space with fluid, causing
hyponatremia. Hematocrit levels are usually elevated due to hemoconcentration
from fluid loss out of the vascular space.
2. The nurse is caring for a patient in septic shock. Which of the following is the
priority intervention within the first hour of recognition?
A. Initiating enteral nutrition
B. Starting a low-dose dopamine infusion
,C. Administration of broad-spectrum antibiotics
D. Obtaining a chest X-ray
Correct Answer: C
Expert Explanation: Early administration of broad-spectrum antibiotics is a critical
component of the 1-hour sepsis bundle to reduce mortality. Antibiotics should be
started as soon as possible after blood cultures are obtained. Other interventions
like nutrition and imaging are important but secondary to immediate infection
control and fluid resuscitation.
3. A patient with ARDS is being placed in the prone position. What is the primary
physiological benefit of this intervention?
A. To improve drainage of oral secretions
B. To recruit collapsed alveoli in the posterior lung segments
C. To decrease the patient’s work of breathing
D. To facilitate easier suctioning of the endotracheal tube
Correct Answer: B
Expert Explanation: Prone positioning helps redistribute pulmonary edema and
improves oxygenation by recruiting alveoli in the posterior lung regions that are
often collapsed in the supine position. It allows for better ventilation-perfusion
,matching across the lungs. This maneuver is typically reserved for patients with
severe ARDS who remain hypoxic despite high levels of PEEP.
4. A patient’s hemodynamic monitor shows a Central Venous Pressure (CVP) of 1
mmHg. Which action should the nurse anticipate?
A. Administration of a loop diuretic
B. Administering a dose of morphine sulfate
C. Decreasing the titration of norepinephrine
D. Increasing the rate of IV fluid administration
Correct Answer: D
Expert Explanation: A normal CVP ranges from 2 to 8 mmHg, and a value of 1
mmHg indicates hypovolemia or low preload. The nurse should anticipate fluid
resuscitation with isotonic crystalloids to increase the circulating volume. Diuretics
would further decrease the CVP and worsen the patient’s condition.
5. Which clinical manifestation is most characteristic of the ‘cold’ phase of septic
shock?
A. Tachycardia and flushed skin
B. Bounding pulses and high cardiac output
C. Increased urine output and bradypnea
, D. Hypotension and cool, clammy skin
Correct Answer: D
Expert Explanation: The ‘cold’ or late phase of septic shock is characterized by low
cardiac output and high systemic vascular resistance as the body attempts to
compensate. This results in poor peripheral perfusion, manifesting as cool, clammy
skin and worsening hypotension. In contrast, the ‘warm’ phase involves vasodilation
and increased cardiac output.
6. A patient with a burn injury develops a high-pitched inspiratory sound (stridor).
What is the nurse’s priority action?
A. Administering nebulized albuterol
B. Preparing for immediate endotracheal intubation
C. Elevating the head of the bed to 90 degrees
D. Encouraging the patient to cough and deep breathe
Correct Answer: B
Expert Explanation: Stridor is a medical emergency indicating significant upper
airway obstruction, often due to inhalation injury and edema. The nurse must act
quickly to secure the airway via intubation before the edema makes it impossible.
Waiting for nebulizer treatments or positioning changes could lead to complete
respiratory arrest.
3 Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient with a 40% Total Body Surface Area (TBSA) burn is in the emergent phase.
Which laboratory value should the nurse expect to find?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Decreased Hematocrit
Correct Answer: B
Expert Explanation: In the emergent phase of a burn, massive cell destruction
occurs which releases intracellular potassium into the extracellular space, leading to
hyperkalemia. Sodium typically shifts into the interstitial space with fluid, causing
hyponatremia. Hematocrit levels are usually elevated due to hemoconcentration
from fluid loss out of the vascular space.
2. The nurse is caring for a patient in septic shock. Which of the following is the
priority intervention within the first hour of recognition?
A. Initiating enteral nutrition
B. Starting a low-dose dopamine infusion
,C. Administration of broad-spectrum antibiotics
D. Obtaining a chest X-ray
Correct Answer: C
Expert Explanation: Early administration of broad-spectrum antibiotics is a critical
component of the 1-hour sepsis bundle to reduce mortality. Antibiotics should be
started as soon as possible after blood cultures are obtained. Other interventions
like nutrition and imaging are important but secondary to immediate infection
control and fluid resuscitation.
3. A patient with ARDS is being placed in the prone position. What is the primary
physiological benefit of this intervention?
A. To improve drainage of oral secretions
B. To recruit collapsed alveoli in the posterior lung segments
C. To decrease the patient’s work of breathing
D. To facilitate easier suctioning of the endotracheal tube
Correct Answer: B
Expert Explanation: Prone positioning helps redistribute pulmonary edema and
improves oxygenation by recruiting alveoli in the posterior lung regions that are
often collapsed in the supine position. It allows for better ventilation-perfusion
,matching across the lungs. This maneuver is typically reserved for patients with
severe ARDS who remain hypoxic despite high levels of PEEP.
4. A patient’s hemodynamic monitor shows a Central Venous Pressure (CVP) of 1
mmHg. Which action should the nurse anticipate?
A. Administration of a loop diuretic
B. Administering a dose of morphine sulfate
C. Decreasing the titration of norepinephrine
D. Increasing the rate of IV fluid administration
Correct Answer: D
Expert Explanation: A normal CVP ranges from 2 to 8 mmHg, and a value of 1
mmHg indicates hypovolemia or low preload. The nurse should anticipate fluid
resuscitation with isotonic crystalloids to increase the circulating volume. Diuretics
would further decrease the CVP and worsen the patient’s condition.
5. Which clinical manifestation is most characteristic of the ‘cold’ phase of septic
shock?
A. Tachycardia and flushed skin
B. Bounding pulses and high cardiac output
C. Increased urine output and bradypnea
, D. Hypotension and cool, clammy skin
Correct Answer: D
Expert Explanation: The ‘cold’ or late phase of septic shock is characterized by low
cardiac output and high systemic vascular resistance as the body attempts to
compensate. This results in poor peripheral perfusion, manifesting as cool, clammy
skin and worsening hypotension. In contrast, the ‘warm’ phase involves vasodilation
and increased cardiac output.
6. A patient with a burn injury develops a high-pitched inspiratory sound (stridor).
What is the nurse’s priority action?
A. Administering nebulized albuterol
B. Preparing for immediate endotracheal intubation
C. Elevating the head of the bed to 90 degrees
D. Encouraging the patient to cough and deep breathe
Correct Answer: B
Expert Explanation: Stridor is a medical emergency indicating significant upper
airway obstruction, often due to inhalation injury and edema. The nurse must act
quickly to secure the airway via intubation before the edema makes it impossible.
Waiting for nebulizer treatments or positioning changes could lead to complete
respiratory arrest.
