Adult Health II (D446) New OA 2 Exam 2
V2 | Adult Health II (D446) New OA 2 Exam
Q&A | WGU
1. A patient on a mechanical ventilator triggers the high-pressure alarm. Which action should
the nurse take first?
A. Suction the patient’s airway immediately.
B. Increase the oxygen concentration.
C. Check the tubing for kinks or obstruction.
D. Call the respiratory therapist for assistance.
Answer: C
Rationale: The high-pressure alarm is triggered when the ventilator encounters resistance.
Checking for kinks in the tubing is a quick, non-invasive first step to identify a common
mechanical issue. If no kinks are found, the nurse should then assess for secretions or
patient biting on the tube.
2. Which clinical manifestation is most indicative of the ‘ebb phase’ of a major burn injury?
A. Hyperglycemia and increased metabolic rate.
B. Increased body temperature and tachycardia.
C. Massive diuresis and fluid volume excess.
D. Decreased cardiac output and reduced oxygen consumption.
,Answer: D
Rationale: The ebb phase occurs in the first 24 to 48 hours post-burn and is characterized
by hypovolemic shock. During this time, cardiac output decreases and oxygen consumption
slows down to preserve energy. This phase is followed by the flow phase, which is marked
by hypermetabolism and increased cardiac output.
3. A patient with a T6 spinal cord injury reports a severe, pounding headache and nasal
congestion. Their blood pressure is 190/100 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication.
B. Place the patient in a flat, supine position.
C. Raise the head of the bed to a high-Fowler’s position.
D. Perform a digital rectal exam to check for impaction.
Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, a life-threatening emergency
in spinal cord injuries. Elevating the head of the bed to 90 degrees helps utilize orthostatic
pressure to lower the blood pressure. After positioning, the nurse must then identify and
remove the triggering stimulus, such as a full bladder or bowel.
4. Which arterial blood gas (ABG) result is consistent with a patient in early septic shock
experiencing hyperventilation?
A. pH 7.32, PaCO2 50, HCO3 24
B. pH 7.35, PaCO2 40, HCO3 24
, C. pH 7.48, PaCO2 30, HCO3 22
D. pH 7.28, PaCO2 38, HCO3 18
Answer: C
Rationale: In the early stages of septic shock, patients often breathe rapidly, leading to
respiratory alkalosis. A pH above 7.45 and a PaCO2 below 35 reflect this condition. As the
shock progresses and tissue perfusion worsens, the patient will likely shift into metabolic
acidosis.
5. The nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) on a
ventilator. What is the primary purpose of applying Positive End-Expiratory Pressure (PEEP)?
A. To keep the alveoli open and improve oxygenation.
B. To prevent barotrauma from high tidal volumes.
C. To decrease the work of breathing for the patient.
D. To increase the patient’s respiratory rate.
Answer: A
Rationale: PEEP maintains a set amount of pressure in the lungs at the end of expiration to
prevent alveolar collapse. This improves functional residual capacity and allows for better
gas exchange across the alveolar-capillary membrane. It is a cornerstone treatment for
managing the refractory hypoxemia seen in ARDS.
V2 | Adult Health II (D446) New OA 2 Exam
Q&A | WGU
1. A patient on a mechanical ventilator triggers the high-pressure alarm. Which action should
the nurse take first?
A. Suction the patient’s airway immediately.
B. Increase the oxygen concentration.
C. Check the tubing for kinks or obstruction.
D. Call the respiratory therapist for assistance.
Answer: C
Rationale: The high-pressure alarm is triggered when the ventilator encounters resistance.
Checking for kinks in the tubing is a quick, non-invasive first step to identify a common
mechanical issue. If no kinks are found, the nurse should then assess for secretions or
patient biting on the tube.
2. Which clinical manifestation is most indicative of the ‘ebb phase’ of a major burn injury?
A. Hyperglycemia and increased metabolic rate.
B. Increased body temperature and tachycardia.
C. Massive diuresis and fluid volume excess.
D. Decreased cardiac output and reduced oxygen consumption.
,Answer: D
Rationale: The ebb phase occurs in the first 24 to 48 hours post-burn and is characterized
by hypovolemic shock. During this time, cardiac output decreases and oxygen consumption
slows down to preserve energy. This phase is followed by the flow phase, which is marked
by hypermetabolism and increased cardiac output.
3. A patient with a T6 spinal cord injury reports a severe, pounding headache and nasal
congestion. Their blood pressure is 190/100 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication.
B. Place the patient in a flat, supine position.
C. Raise the head of the bed to a high-Fowler’s position.
D. Perform a digital rectal exam to check for impaction.
Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, a life-threatening emergency
in spinal cord injuries. Elevating the head of the bed to 90 degrees helps utilize orthostatic
pressure to lower the blood pressure. After positioning, the nurse must then identify and
remove the triggering stimulus, such as a full bladder or bowel.
4. Which arterial blood gas (ABG) result is consistent with a patient in early septic shock
experiencing hyperventilation?
A. pH 7.32, PaCO2 50, HCO3 24
B. pH 7.35, PaCO2 40, HCO3 24
, C. pH 7.48, PaCO2 30, HCO3 22
D. pH 7.28, PaCO2 38, HCO3 18
Answer: C
Rationale: In the early stages of septic shock, patients often breathe rapidly, leading to
respiratory alkalosis. A pH above 7.45 and a PaCO2 below 35 reflect this condition. As the
shock progresses and tissue perfusion worsens, the patient will likely shift into metabolic
acidosis.
5. The nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) on a
ventilator. What is the primary purpose of applying Positive End-Expiratory Pressure (PEEP)?
A. To keep the alveoli open and improve oxygenation.
B. To prevent barotrauma from high tidal volumes.
C. To decrease the work of breathing for the patient.
D. To increase the patient’s respiratory rate.
Answer: A
Rationale: PEEP maintains a set amount of pressure in the lungs at the end of expiration to
prevent alveolar collapse. This improves functional residual capacity and allows for better
gas exchange across the alveolar-capillary membrane. It is a cornerstone treatment for
managing the refractory hypoxemia seen in ARDS.
