NUR2790/NUR 2790 Final Exam V3
| Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a patient in the compensatory stage of shock. Which clinical finding
should the nurse expect to observe?
A. Significant decrease in systolic blood pressure
B. Increased heart rate and narrowed pulse pressure
C. Cold, clammy skin and metabolic acidosis
D. Multi-organ dysfunction and lethargy
Correct Answer: B
Expert Explanation: In the compensatory stage of shock, the body initiates the fight-or-
flight response to maintain cardiac output. The nurse will typically see an increased heart
rate and a narrowed pulse pressure as the body attempts to compensate for decreased
volume or pump failure. This stage is characterized by the body’s successful attempt to
maintain a normal blood pressure despite the underlying issue.
,2. A patient presents with a burn injury involving the entire anterior torso and the entire right
arm. Using the Rule of Nines, what is the estimated Percentage of Total Body Surface Area
(TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Correct Answer: B
Expert Explanation: According to the Rule of Nines, the anterior torso accounts for 18% of
the TBSA. The entire right arm (both anterior and posterior) accounts for 9% of the TBSA.
Adding 18% and 9% results in a total of 27% for this patient’s burn calculation.
3. A patient with a traumatic brain injury (TBI) exhibits Cushing’s Triad. Which set of vital
signs is consistent with this finding?
A. BP 180/60, Pulse 50, Irregular respirations
B. BP 90/40, Pulse 120, Rapid respirations
C. BP 120/80, Pulse 72, Normal respirations
D. BP 200/100, Pulse 110, Cheyne-Stokes respirations
Correct Answer: A
, Expert Explanation: Cushing’s Triad is a late sign of increased intracranial pressure
consisting of bradycardia, hypertension with a widening pulse pressure, and irregular
respirations. The blood pressure of 180/60 shows a widening pulse pressure of 120 mmHg.
This constellation of symptoms indicates that the brain is nearing the point of herniation
and requires immediate intervention.
4. Which assessment finding in a patient with a chest tube should the nurse report to the
healthcare provider immediately?
A. Intermittent bubbling in the water seal chamber
B. Fluctuation of water level with inspiration and expiration
C. Continuous bubbling in the water seal chamber
D. Drainage of 50 mL of serosanguinous fluid over 4 hours
Correct Answer: C
Expert Explanation: Continuous bubbling in the water seal chamber typically indicates an
air leak within the drainage system or the patient’s pleural space. Intermittent bubbling is
expected if the patient has a pneumothorax and is coughing or exhaling. The nurse must
troubleshoot the system to locate the leak and notify the provider if it cannot be resolved.
5. A nurse is managing a patient on a mechanical ventilator. The high-pressure alarm sounds.
What is the most likely cause?
A. The patient has disconnected from the ventilator
B. There is a leak in the endotracheal tube cuff
| Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a patient in the compensatory stage of shock. Which clinical finding
should the nurse expect to observe?
A. Significant decrease in systolic blood pressure
B. Increased heart rate and narrowed pulse pressure
C. Cold, clammy skin and metabolic acidosis
D. Multi-organ dysfunction and lethargy
Correct Answer: B
Expert Explanation: In the compensatory stage of shock, the body initiates the fight-or-
flight response to maintain cardiac output. The nurse will typically see an increased heart
rate and a narrowed pulse pressure as the body attempts to compensate for decreased
volume or pump failure. This stage is characterized by the body’s successful attempt to
maintain a normal blood pressure despite the underlying issue.
,2. A patient presents with a burn injury involving the entire anterior torso and the entire right
arm. Using the Rule of Nines, what is the estimated Percentage of Total Body Surface Area
(TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Correct Answer: B
Expert Explanation: According to the Rule of Nines, the anterior torso accounts for 18% of
the TBSA. The entire right arm (both anterior and posterior) accounts for 9% of the TBSA.
Adding 18% and 9% results in a total of 27% for this patient’s burn calculation.
3. A patient with a traumatic brain injury (TBI) exhibits Cushing’s Triad. Which set of vital
signs is consistent with this finding?
A. BP 180/60, Pulse 50, Irregular respirations
B. BP 90/40, Pulse 120, Rapid respirations
C. BP 120/80, Pulse 72, Normal respirations
D. BP 200/100, Pulse 110, Cheyne-Stokes respirations
Correct Answer: A
, Expert Explanation: Cushing’s Triad is a late sign of increased intracranial pressure
consisting of bradycardia, hypertension with a widening pulse pressure, and irregular
respirations. The blood pressure of 180/60 shows a widening pulse pressure of 120 mmHg.
This constellation of symptoms indicates that the brain is nearing the point of herniation
and requires immediate intervention.
4. Which assessment finding in a patient with a chest tube should the nurse report to the
healthcare provider immediately?
A. Intermittent bubbling in the water seal chamber
B. Fluctuation of water level with inspiration and expiration
C. Continuous bubbling in the water seal chamber
D. Drainage of 50 mL of serosanguinous fluid over 4 hours
Correct Answer: C
Expert Explanation: Continuous bubbling in the water seal chamber typically indicates an
air leak within the drainage system or the patient’s pleural space. Intermittent bubbling is
expected if the patient has a pneumothorax and is coughing or exhaling. The nurse must
troubleshoot the system to locate the leak and notify the provider if it cannot be resolved.
5. A nurse is managing a patient on a mechanical ventilator. The high-pressure alarm sounds.
What is the most likely cause?
A. The patient has disconnected from the ventilator
B. There is a leak in the endotracheal tube cuff
