NUR2790/NUR 2790 Exam 1 V3 |
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a client with a pH of 7.28, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L.
Which acid-base imbalance does this represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH is below the normal range of 7.35-7.45, indicating acidosis.
The PaCO2 is elevated above 45 mmHg, while the bicarbonate remains normal, which
characterizes respiratory acidosis. This condition is often caused by hypoventilation or
impaired gas exchange in the lungs.
2. Which clinical finding is most characteristic of the compensatory stage of shock?
A. Absent bowel sounds
B. Increased heart rate
,C. Profound hypotension
D. Anuria (no urine output)
Correct Answer: B
Expert Explanation: During the compensatory stage, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. An increased heart
rate helps maintain cardiac output despite a decrease in stroke volume. This stage is also
characterized by peripheral vasoconstriction and cool, clammy skin.
3. In a mass casualty event, which color tag would the nurse assign to a client with a sucking
chest wound who is gasping for air?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
Expert Explanation: The red tag is used for immediate life-threatening injuries that
require rapid intervention to survive. A sucking chest wound compromises respiratory
function and represents a priority ‘A’ (Airway) or ‘B’ (Breathing) issue. Assigning this tag
ensures the patient receives stabilization during the primary triage phase.
, 4. A patient has sustained deep partial-thickness burns to both entire legs. Using the Rule of
Nines, what is the estimated total body surface area (TBSA) burned?
A. 36%
B. 27%
C. 18%
D. 45%
Correct Answer: A
Expert Explanation: According to the Rule of Nines, each entire leg (front and back)
accounts for 18% of the total body surface area. Therefore, two entire legs equate to 36%
(18% + 18%). Accurate TBSA calculation is critical for determining fluid resuscitation
needs during the first 24 hours.
5. The nurse hears the high-pressure alarm sounding on a client’s mechanical ventilator.
Which action should the nurse take first?
A. Assess the patient’s respiratory status
B. Manually ventilate the patient
C. Suction the patient’s airway
D. Check for kinks in the ventilator tubing
Correct Answer: A
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a client with a pH of 7.28, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L.
Which acid-base imbalance does this represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH is below the normal range of 7.35-7.45, indicating acidosis.
The PaCO2 is elevated above 45 mmHg, while the bicarbonate remains normal, which
characterizes respiratory acidosis. This condition is often caused by hypoventilation or
impaired gas exchange in the lungs.
2. Which clinical finding is most characteristic of the compensatory stage of shock?
A. Absent bowel sounds
B. Increased heart rate
,C. Profound hypotension
D. Anuria (no urine output)
Correct Answer: B
Expert Explanation: During the compensatory stage, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. An increased heart
rate helps maintain cardiac output despite a decrease in stroke volume. This stage is also
characterized by peripheral vasoconstriction and cool, clammy skin.
3. In a mass casualty event, which color tag would the nurse assign to a client with a sucking
chest wound who is gasping for air?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
Expert Explanation: The red tag is used for immediate life-threatening injuries that
require rapid intervention to survive. A sucking chest wound compromises respiratory
function and represents a priority ‘A’ (Airway) or ‘B’ (Breathing) issue. Assigning this tag
ensures the patient receives stabilization during the primary triage phase.
, 4. A patient has sustained deep partial-thickness burns to both entire legs. Using the Rule of
Nines, what is the estimated total body surface area (TBSA) burned?
A. 36%
B. 27%
C. 18%
D. 45%
Correct Answer: A
Expert Explanation: According to the Rule of Nines, each entire leg (front and back)
accounts for 18% of the total body surface area. Therefore, two entire legs equate to 36%
(18% + 18%). Accurate TBSA calculation is critical for determining fluid resuscitation
needs during the first 24 hours.
5. The nurse hears the high-pressure alarm sounding on a client’s mechanical ventilator.
Which action should the nurse take first?
A. Assess the patient’s respiratory status
B. Manually ventilate the patient
C. Suction the patient’s airway
D. Check for kinks in the ventilator tubing
Correct Answer: A
