NUR104 | NUR104 Medsurg 2 Exam 1 Version 3 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient is admitted with early-stage septic shock. Which clinical manifestation
should the nurse anticipate finding during the assessment?
A. Cool, clammy skin
B. Bradycardia and hypertension
C. Warm, flushed skin and tachycardia
D. Decreased respiratory rate
Correct Answer: C
Expert Explanation: Early septic shock is characterized by a hyperdynamic state
where vasodilation occurs. This results in warm, flushed skin and a compensatory
increase in heart rate. The nurse must recognize these symptoms to initiate timely
fluid resuscitation. Monitoring for systemic inflammatory response syndrome is
vital for early intervention. This phase differs significantly from the late, cold phase
of shock.
2. Which assessment finding is considered the earliest indicator of hypoxia in a client
with respiratory distress?
A. Cyanosis of the lips
,B. Restlessness and agitation
C. Bradycardia
D. Oxygen saturation of 85%
A. Cyanosis of the lips
B. Bradycardia
C. Restlessness and agitation
D. Oxygen saturation of 85%
Correct Answer: C
Expert Explanation: The brain is highly sensitive to changes in oxygenation levels.
Restlessness and agitation are often the first behavioral signs of declining
respiratory status. Cyanosis is a late sign and indicates severe desaturation of
hemoglobin. Nurses should prioritize mental status checks when assessing for acute
hypoxia. Early detection allows for prompt oxygen delivery to prevent cellular
damage.
3. The nurse is monitoring a patient’s Central Venous Pressure (CVP). What does a CVP
reading of 1 mmHg primarily indicate?
A. Fluid volume overload
B. Right ventricular failure
,C. Normal cardiac function
D. Hypovolemia
Correct Answer: D
Expert Explanation: Central Venous Pressure reflects the filling pressure of the
right atrium. A low CVP reading typically suggests a state of hypovolemia or
dehydration. The normal range for CVP is generally 2 to 8 mmHg depending on the
source. Decreased preload leads to reduced cardiac output and impaired tissue
perfusion. The nurse should anticipate orders for intravenous fluid boluses for this
patient.
4. A patient experiencing a myocardial infarction presents with a blood pressure of
80/50 mmHg and crackles in the lungs. Which type of shock is most likely occurring?
A. Hypovolemic shock
B. Neurogenic shock
C. Cardiogenic shock
D. Anaphylactic shock
Correct Answer: C
Expert Explanation: Cardiogenic shock occurs when the heart’s pumping ability is
severely impaired. The presence of pulmonary crackles indicates left-sided heart
, failure and fluid backup. Low blood pressure reflects the heart’s inability to
maintain adequate systemic perfusion. This condition is a frequent complication of
extensive myocardial tissue damage. Management focuses on improving
contractility and reducing the workload of the heart.
5. Which intervention is a priority for a patient diagnosed with Acute Respiratory
Distress Syndrome (ARDS) who is on a ventilator?
A. Implementing Prone positioning
B. Administering high-dose antibiotics
C. Maintaining a low Positive End-Expiratory Pressure (PEEP)
D. Increasing fluid intake to thin secretions
Correct Answer: A
Expert Explanation: Prone positioning is used in ARDS to improve oxygenation by
redistributing blood flow. This technique recruits collapsed alveoli in the posterior
regions of the lungs. It helps reduce the pressure of the heart and abdomen on lung
tissue. Nurses must monitor for pressure ulcers and tube displacement during this
process. Improved ventilation-perfusion matching is the primary goal of this
intervention.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient is admitted with early-stage septic shock. Which clinical manifestation
should the nurse anticipate finding during the assessment?
A. Cool, clammy skin
B. Bradycardia and hypertension
C. Warm, flushed skin and tachycardia
D. Decreased respiratory rate
Correct Answer: C
Expert Explanation: Early septic shock is characterized by a hyperdynamic state
where vasodilation occurs. This results in warm, flushed skin and a compensatory
increase in heart rate. The nurse must recognize these symptoms to initiate timely
fluid resuscitation. Monitoring for systemic inflammatory response syndrome is
vital for early intervention. This phase differs significantly from the late, cold phase
of shock.
2. Which assessment finding is considered the earliest indicator of hypoxia in a client
with respiratory distress?
A. Cyanosis of the lips
,B. Restlessness and agitation
C. Bradycardia
D. Oxygen saturation of 85%
A. Cyanosis of the lips
B. Bradycardia
C. Restlessness and agitation
D. Oxygen saturation of 85%
Correct Answer: C
Expert Explanation: The brain is highly sensitive to changes in oxygenation levels.
Restlessness and agitation are often the first behavioral signs of declining
respiratory status. Cyanosis is a late sign and indicates severe desaturation of
hemoglobin. Nurses should prioritize mental status checks when assessing for acute
hypoxia. Early detection allows for prompt oxygen delivery to prevent cellular
damage.
3. The nurse is monitoring a patient’s Central Venous Pressure (CVP). What does a CVP
reading of 1 mmHg primarily indicate?
A. Fluid volume overload
B. Right ventricular failure
,C. Normal cardiac function
D. Hypovolemia
Correct Answer: D
Expert Explanation: Central Venous Pressure reflects the filling pressure of the
right atrium. A low CVP reading typically suggests a state of hypovolemia or
dehydration. The normal range for CVP is generally 2 to 8 mmHg depending on the
source. Decreased preload leads to reduced cardiac output and impaired tissue
perfusion. The nurse should anticipate orders for intravenous fluid boluses for this
patient.
4. A patient experiencing a myocardial infarction presents with a blood pressure of
80/50 mmHg and crackles in the lungs. Which type of shock is most likely occurring?
A. Hypovolemic shock
B. Neurogenic shock
C. Cardiogenic shock
D. Anaphylactic shock
Correct Answer: C
Expert Explanation: Cardiogenic shock occurs when the heart’s pumping ability is
severely impaired. The presence of pulmonary crackles indicates left-sided heart
, failure and fluid backup. Low blood pressure reflects the heart’s inability to
maintain adequate systemic perfusion. This condition is a frequent complication of
extensive myocardial tissue damage. Management focuses on improving
contractility and reducing the workload of the heart.
5. Which intervention is a priority for a patient diagnosed with Acute Respiratory
Distress Syndrome (ARDS) who is on a ventilator?
A. Implementing Prone positioning
B. Administering high-dose antibiotics
C. Maintaining a low Positive End-Expiratory Pressure (PEEP)
D. Increasing fluid intake to thin secretions
Correct Answer: A
Expert Explanation: Prone positioning is used in ARDS to improve oxygenation by
redistributing blood flow. This technique recruits collapsed alveoli in the posterior
regions of the lungs. It helps reduce the pressure of the heart and abdomen on lung
tissue. Nurses must monitor for pressure ulcers and tube displacement during this
process. Improved ventilation-perfusion matching is the primary goal of this
intervention.
