NUR612/NUR 612 Exam 4 V3 | Advanced
Nursing II Q&A with Rationale | William
Paterson University
1. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation. Which of the following PEEP settings is most appropriate to improve oxygenation
while preventing alveolar collapse?
A. 5 cm H2O
B. 25 cm H2O
C. 0 cm H2O
D. 10-15 cm H2O
Correct Answer: D
Expert Explanation: Positive End-Expiratory Pressure (PEEP) is essential in ARDS
management to maintain alveolar recruitment. Higher levels, often between 10-15 cm H2O,
are typically required to counteract the shunt and improve gas exchange. Excessive PEEP
above 20 cm H2O should be monitored closely for risk of barotrauma and decreased
cardiac output.
2. In the early stages of septic shock, which hemodynamic finding is most characteristic?
A. High Systemic Vascular Resistance (SVR)
B. Low Cardiac Output (CO)
,C. High Cardiac Output (CO)
D. Decreased Central Venous Pressure (CVP)
Correct Answer: C
Expert Explanation: Early septic shock, also known as the warm phase, is characterized by
vasodilation and a hyperdynamic state. This leads to a compensatory increase in cardiac
output and a decrease in systemic vascular resistance. As the shock progresses to the cold
phase, the cardiac output will eventually drop due to myocardial depression.
3. A patient with a head injury presents with a widened pulse pressure, bradycardia, and
irregular respirations. What does the nurse identify this as?
A. Virchow’s Triad
B. Horner’s Syndrome
C. Beck’s Triad
D. Cushing’s Triad
Correct Answer: D
Expert Explanation: Cushing’s Triad is a late sign of increased intracranial pressure and
impending brain herniation. It consists of hypertension with a widening pulse pressure,
bradycardia, and abnormal breathing patterns. Prompt recognition is vital to initiate life-
saving interventions like osmotic diuretics or hyperventilation.
, 4. Which laboratory value is the priority for the nurse to monitor in a patient diagnosed with
Diabetic Ketoacidosis (DKA) receiving an insulin infusion?
A. Potassium level
B. Sodium level
C. Magnesium level
D. Calcium level
Correct Answer: A
Expert Explanation: Insulin therapy causes potassium to shift from the extracellular fluid
into the intracellular space, which can lead to severe hypokalemia. Nurses must monitor
potassium levels hourly to prevent life-threatening cardiac arrhythmias. Replacement
therapy is often started even when potassium levels are within the normal range to
anticipate this shift.
5. A patient with a T6 spinal cord injury reports a sudden severe headache and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer PRN antihypertensives
B. Check for bladder distention or fecal impaction
C. Lower the head of the bed to the flat position
D. Prepare for an emergency CT scan of the head
Correct Answer: B
Nursing II Q&A with Rationale | William
Paterson University
1. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation. Which of the following PEEP settings is most appropriate to improve oxygenation
while preventing alveolar collapse?
A. 5 cm H2O
B. 25 cm H2O
C. 0 cm H2O
D. 10-15 cm H2O
Correct Answer: D
Expert Explanation: Positive End-Expiratory Pressure (PEEP) is essential in ARDS
management to maintain alveolar recruitment. Higher levels, often between 10-15 cm H2O,
are typically required to counteract the shunt and improve gas exchange. Excessive PEEP
above 20 cm H2O should be monitored closely for risk of barotrauma and decreased
cardiac output.
2. In the early stages of septic shock, which hemodynamic finding is most characteristic?
A. High Systemic Vascular Resistance (SVR)
B. Low Cardiac Output (CO)
,C. High Cardiac Output (CO)
D. Decreased Central Venous Pressure (CVP)
Correct Answer: C
Expert Explanation: Early septic shock, also known as the warm phase, is characterized by
vasodilation and a hyperdynamic state. This leads to a compensatory increase in cardiac
output and a decrease in systemic vascular resistance. As the shock progresses to the cold
phase, the cardiac output will eventually drop due to myocardial depression.
3. A patient with a head injury presents with a widened pulse pressure, bradycardia, and
irregular respirations. What does the nurse identify this as?
A. Virchow’s Triad
B. Horner’s Syndrome
C. Beck’s Triad
D. Cushing’s Triad
Correct Answer: D
Expert Explanation: Cushing’s Triad is a late sign of increased intracranial pressure and
impending brain herniation. It consists of hypertension with a widening pulse pressure,
bradycardia, and abnormal breathing patterns. Prompt recognition is vital to initiate life-
saving interventions like osmotic diuretics or hyperventilation.
, 4. Which laboratory value is the priority for the nurse to monitor in a patient diagnosed with
Diabetic Ketoacidosis (DKA) receiving an insulin infusion?
A. Potassium level
B. Sodium level
C. Magnesium level
D. Calcium level
Correct Answer: A
Expert Explanation: Insulin therapy causes potassium to shift from the extracellular fluid
into the intracellular space, which can lead to severe hypokalemia. Nurses must monitor
potassium levels hourly to prevent life-threatening cardiac arrhythmias. Replacement
therapy is often started even when potassium levels are within the normal range to
anticipate this shift.
5. A patient with a T6 spinal cord injury reports a sudden severe headache and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer PRN antihypertensives
B. Check for bladder distention or fecal impaction
C. Lower the head of the bed to the flat position
D. Prepare for an emergency CT scan of the head
Correct Answer: B
