NR341/NR 341 Exam 2 V2 | Complex Adult
Health Q&A with Rationale | Chamberlain
University
1. A nurse identifies ventricular fibrillation on the cardiac monitor of a patient. After
confirming the patient is unresponsive and pulseless, which action should the nurse take
first?
A. Administer 1 mg of Epinephrine IV push.
B. Initiate an Amiodarone infusion at 150 mg.
C. Prepare the patient for synchronized cardioversion.
D. Perform immediate unsynchronized defibrillation.
Correct Answer: D
Expert Explanation: Ventricular fibrillation is a pulseless, lethal rhythm that requires
immediate defibrillation to stop the chaotic electrical activity and allow the SA node to take
over. Delaying defibrillation reduces the likelihood of successful resuscitation and return of
spontaneous circulation. While medications like epinephrine are used later in the ACLS
protocol, the priority in ‘shockable’ rhythms is electricity.
,2. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). The nurse notes
the ventilator is set to include Positive End-Expiratory Pressure (PEEP). What is the primary
purpose of PEEP in this patient?
A. To prevent the patient from breathing against the ventilator.
B. To decrease the risk of barotrauma by lowering peak pressures.
C. To keep the alveoli open at the end of expiration and improve oxygenation.
D. To increase the fraction of inspired oxygen (FiO2) delivered.
Correct Answer: C
Expert Explanation: PEEP maintains a certain level of pressure in the lungs at the end of
expiration to prevent alveolar collapse, which is common in ARDS. This increases the
surface area available for gas exchange and allows for lower levels of FiO2 to be used,
reducing oxygen toxicity. By recruiting more alveoli, the nurse helps improve the patient’s
overall arterial oxygenation.
3. A nurse is caring for a patient in the compensatory stage of shock. Which clinical
manifestation is most consistent with this stage?
A. Cool, clammy skin and increased heart rate.
B. Mean Arterial Pressure (MAP) less than 60 mmHg.
C. Anuria and metabolic acidosis.
D. Comatose state with fixed, dilated pupils.
,Correct Answer: A
Expert Explanation: During the compensatory stage of shock, the body activates the
sympathetic nervous system to maintain cardiac output and blood pressure. This leads to
peripheral vasoconstriction, causing the skin to feel cool and clammy, and an increased
heart rate to move blood to vital organs. If the underlying cause is not treated, the patient
will eventually move into the progressive stage where MAP significantly drops.
4. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. Which
medication should the nurse expect to administer first to protect the heart from
arrhythmias?
A. Calcium Gluconate IV.
B. Furosemide (Lasix).
C. Sodium Polystyrene Sulfonate (Kayexalate).
D. Regular Insulin and D50W.
Correct Answer: A
Expert Explanation: Calcium gluconate does not lower the potassium level, but it
stabilizes the myocardial cell membrane to prevent lethal dysrhythmias associated with
hyperkalemia. It is the immediate priority for patients showing cardiac sensitivity to high
potassium levels. After stabilization, other medications like insulin or Kayexalate are used
to actually shift or remove potassium from the body.
, 5. The nurse notes that a patient’s ventilator high-pressure alarm is sounding. Which action
should the nurse perform first?
A. Increase the oxygen concentration to 100%.
B. Call the respiratory therapist to adjust the settings.
C. Silence the alarm and document the event.
D. Check the patient for the need for suctioning.
Correct Answer: D
Expert Explanation: A high-pressure alarm indicates that the ventilator is meeting
resistance when delivering a breath, which can be caused by secretions, kinking of the tube,
or the patient biting the tube. The nurse should immediately assess the patient’s airway
and suction if necessary to clear obstructions. If the cause is not immediately found and
fixed, the nurse must manually ventilate the patient with an Ambu bag.
6. A patient presents with a heart rate of 38 bpm, blood pressure of 82/50 mmHg, and
reports feeling dizzy. What is the first-line medication recommended by ACLS guidelines for
this symptomatic bradycardia?
A. Dopamine infusion.
B. Atropine 1 mg IV.
C. Epinephrine IV.
D. Adenosine 6 mg rapid IV push.
Health Q&A with Rationale | Chamberlain
University
1. A nurse identifies ventricular fibrillation on the cardiac monitor of a patient. After
confirming the patient is unresponsive and pulseless, which action should the nurse take
first?
A. Administer 1 mg of Epinephrine IV push.
B. Initiate an Amiodarone infusion at 150 mg.
C. Prepare the patient for synchronized cardioversion.
D. Perform immediate unsynchronized defibrillation.
Correct Answer: D
Expert Explanation: Ventricular fibrillation is a pulseless, lethal rhythm that requires
immediate defibrillation to stop the chaotic electrical activity and allow the SA node to take
over. Delaying defibrillation reduces the likelihood of successful resuscitation and return of
spontaneous circulation. While medications like epinephrine are used later in the ACLS
protocol, the priority in ‘shockable’ rhythms is electricity.
,2. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). The nurse notes
the ventilator is set to include Positive End-Expiratory Pressure (PEEP). What is the primary
purpose of PEEP in this patient?
A. To prevent the patient from breathing against the ventilator.
B. To decrease the risk of barotrauma by lowering peak pressures.
C. To keep the alveoli open at the end of expiration and improve oxygenation.
D. To increase the fraction of inspired oxygen (FiO2) delivered.
Correct Answer: C
Expert Explanation: PEEP maintains a certain level of pressure in the lungs at the end of
expiration to prevent alveolar collapse, which is common in ARDS. This increases the
surface area available for gas exchange and allows for lower levels of FiO2 to be used,
reducing oxygen toxicity. By recruiting more alveoli, the nurse helps improve the patient’s
overall arterial oxygenation.
3. A nurse is caring for a patient in the compensatory stage of shock. Which clinical
manifestation is most consistent with this stage?
A. Cool, clammy skin and increased heart rate.
B. Mean Arterial Pressure (MAP) less than 60 mmHg.
C. Anuria and metabolic acidosis.
D. Comatose state with fixed, dilated pupils.
,Correct Answer: A
Expert Explanation: During the compensatory stage of shock, the body activates the
sympathetic nervous system to maintain cardiac output and blood pressure. This leads to
peripheral vasoconstriction, causing the skin to feel cool and clammy, and an increased
heart rate to move blood to vital organs. If the underlying cause is not treated, the patient
will eventually move into the progressive stage where MAP significantly drops.
4. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. Which
medication should the nurse expect to administer first to protect the heart from
arrhythmias?
A. Calcium Gluconate IV.
B. Furosemide (Lasix).
C. Sodium Polystyrene Sulfonate (Kayexalate).
D. Regular Insulin and D50W.
Correct Answer: A
Expert Explanation: Calcium gluconate does not lower the potassium level, but it
stabilizes the myocardial cell membrane to prevent lethal dysrhythmias associated with
hyperkalemia. It is the immediate priority for patients showing cardiac sensitivity to high
potassium levels. After stabilization, other medications like insulin or Kayexalate are used
to actually shift or remove potassium from the body.
, 5. The nurse notes that a patient’s ventilator high-pressure alarm is sounding. Which action
should the nurse perform first?
A. Increase the oxygen concentration to 100%.
B. Call the respiratory therapist to adjust the settings.
C. Silence the alarm and document the event.
D. Check the patient for the need for suctioning.
Correct Answer: D
Expert Explanation: A high-pressure alarm indicates that the ventilator is meeting
resistance when delivering a breath, which can be caused by secretions, kinking of the tube,
or the patient biting the tube. The nurse should immediately assess the patient’s airway
and suction if necessary to clear obstructions. If the cause is not immediately found and
fixed, the nurse must manually ventilate the patient with an Ambu bag.
6. A patient presents with a heart rate of 38 bpm, blood pressure of 82/50 mmHg, and
reports feeling dizzy. What is the first-line medication recommended by ACLS guidelines for
this symptomatic bradycardia?
A. Dopamine infusion.
B. Atropine 1 mg IV.
C. Epinephrine IV.
D. Adenosine 6 mg rapid IV push.
