NR-341/NR341 Exam 1 V3 | Complex Adult
Health Q&A with Rationale | Chamberlain
University
1. A patient in the ICU has a pulmonary artery catheter. The nurse notes a Pulmonary
Capillary Wedge Pressure (PCWP) of 22 mmHg. Which clinical manifestation is most likely?
A. Jugular vein distention
B. Decreased urine output
C. Crackles in the lungs
D. Poor skin turgor
Correct Answer: C
Expert Explanation: A PCWP of 22 mmHg is significantly elevated above the normal range
of 6 to 12 mmHg. This elevation indicates high left ventricular end-diastolic pressure,
which leads to fluid backing up into the pulmonary vasculature. The resulting pulmonary
congestion typically manifests as crackles upon auscultation.
2. A nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm sounds.
Which action should the nurse take first?
A. Check for kinks in the tubing
B. Increase the oxygen concentration
C. Suction the patient’s airway
,D. Auscultate breath sounds
Correct Answer: D
Expert Explanation: The nurse should first assess the patient to determine the cause of
the alarm. Auscultating breath sounds helps identify if the patient has a pneumothorax,
displacement of the tube, or secretional obstruction. Assessment of the patient’s
physiological status always precedes mechanical troubleshooting in critical care nursing.
3. An arterial blood gas (ABG) report shows pH 7.30, PaCO2 50, and HCO3 24. How should the
nurse interpret these results?
A. Uncompensated metabolic acidosis
B. Compensated respiratory acidosis
C. Uncompensated respiratory acidosis
D. Compensated metabolic alkalosis
Correct Answer: C
Expert Explanation: The pH is low, indicating acidosis, and the PaCO2 is high, which
points to a respiratory cause. Since the HCO3 is within the normal range, the body has not
yet begun to compensate for the imbalance. Therefore, this represents uncompensated
respiratory acidosis, often seen in hypoventilation.
4. A patient presents to the ED with a suspected spinal cord injury. The blood pressure is
82/40 mmHg and the pulse is 54 bpm. The nurse recognizes these findings as:
A. Hypovolemic shock
, B. Septic shock
C. Cardiogenic shock
D. Neurogenic shock
Correct Answer: D
Expert Explanation: Neurogenic shock is characterized by hypotension and bradycardia
due to the loss of sympathetic nervous system tone. This occurs typically in cervical or high
thoracic spinal cord injuries. Unlike other forms of shock where the heart rate increases to
compensate for low blood pressure, the heart rate remains low in neurogenic shock.
5. Which intervention is the priority for a patient in the compensatory stage of shock?
A. Administering broad-spectrum antibiotics
B. Starting dopamine infusion
C. Administering IV fluid boluses
D. Obtaining a type and cross-match
Correct Answer: C
Expert Explanation: The primary goal in early or compensatory shock is to restore tissue
perfusion by increasing intravascular volume. IV fluid boluses are the first-line treatment
to stabilize blood pressure and ensure adequate cardiac output. Early intervention
prevents progression to the progressive and irreversible stages of shock.
Health Q&A with Rationale | Chamberlain
University
1. A patient in the ICU has a pulmonary artery catheter. The nurse notes a Pulmonary
Capillary Wedge Pressure (PCWP) of 22 mmHg. Which clinical manifestation is most likely?
A. Jugular vein distention
B. Decreased urine output
C. Crackles in the lungs
D. Poor skin turgor
Correct Answer: C
Expert Explanation: A PCWP of 22 mmHg is significantly elevated above the normal range
of 6 to 12 mmHg. This elevation indicates high left ventricular end-diastolic pressure,
which leads to fluid backing up into the pulmonary vasculature. The resulting pulmonary
congestion typically manifests as crackles upon auscultation.
2. A nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm sounds.
Which action should the nurse take first?
A. Check for kinks in the tubing
B. Increase the oxygen concentration
C. Suction the patient’s airway
,D. Auscultate breath sounds
Correct Answer: D
Expert Explanation: The nurse should first assess the patient to determine the cause of
the alarm. Auscultating breath sounds helps identify if the patient has a pneumothorax,
displacement of the tube, or secretional obstruction. Assessment of the patient’s
physiological status always precedes mechanical troubleshooting in critical care nursing.
3. An arterial blood gas (ABG) report shows pH 7.30, PaCO2 50, and HCO3 24. How should the
nurse interpret these results?
A. Uncompensated metabolic acidosis
B. Compensated respiratory acidosis
C. Uncompensated respiratory acidosis
D. Compensated metabolic alkalosis
Correct Answer: C
Expert Explanation: The pH is low, indicating acidosis, and the PaCO2 is high, which
points to a respiratory cause. Since the HCO3 is within the normal range, the body has not
yet begun to compensate for the imbalance. Therefore, this represents uncompensated
respiratory acidosis, often seen in hypoventilation.
4. A patient presents to the ED with a suspected spinal cord injury. The blood pressure is
82/40 mmHg and the pulse is 54 bpm. The nurse recognizes these findings as:
A. Hypovolemic shock
, B. Septic shock
C. Cardiogenic shock
D. Neurogenic shock
Correct Answer: D
Expert Explanation: Neurogenic shock is characterized by hypotension and bradycardia
due to the loss of sympathetic nervous system tone. This occurs typically in cervical or high
thoracic spinal cord injuries. Unlike other forms of shock where the heart rate increases to
compensate for low blood pressure, the heart rate remains low in neurogenic shock.
5. Which intervention is the priority for a patient in the compensatory stage of shock?
A. Administering broad-spectrum antibiotics
B. Starting dopamine infusion
C. Administering IV fluid boluses
D. Obtaining a type and cross-match
Correct Answer: C
Expert Explanation: The primary goal in early or compensatory shock is to restore tissue
perfusion by increasing intravascular volume. IV fluid boluses are the first-line treatment
to stabilize blood pressure and ensure adequate cardiac output. Early intervention
prevents progression to the progressive and irreversible stages of shock.
