NUR2790/NUR 2790 Final Exam V3 |
Professional Nursing III / PN3 Q&A with
Rationale | Rasmussen University
1. A patient with a spinal cord injury at T4 reports a sudden, severe headache and is found to
have a blood pressure of 190/110 mmHg. What should be the nurse’s first action?
A. Place the patient in a sitting position or elevate the head of the bed to 45 degrees.
B. Administer the prescribed PRN antihypertensive medication.
C. Perform a digital rectal exam to check for fecal impaction.
D. Check the urinary catheter for kinks or obstruction.
Answer: A
Rationale: The patient is exhibiting signs of autonomic dysreflexia, which is a life-
threatening emergency in spinal cord injury patients. The immediate nursing priority is to
elevate the head of the bed to help lower blood pressure through orthostatic changes. After
positioning, the nurse should then identify and remove the triggering stimulus, such as a
full bladder or impacted bowel.
2. The nurse is caring for a patient in the compensatory stage of shock. Which clinical finding
is expected?
A. Metabolic acidosis and cold, clammy skin.
B. Anuria and multi-system organ failure.
,C. Lethargy and decreased responsiveness to painful stimuli.
D. Increased heart rate and narrowed pulse pressure.
Answer: D
Rationale: During the compensatory stage of shock, the body uses homeostatic
mechanisms like the sympathetic nervous system to maintain cardiac output. This results
in an increased heart rate and vasoconstriction, which may present as a narrowed pulse
pressure. Recognizing these early signs is crucial for initiating timely fluid resuscitation
and preventing progression to the progressive stage.
3. A patient with acute respiratory distress syndrome (ARDS) is on mechanical ventilation
with High-Frequency Oscillatory Ventilation. What is the primary goal of this therapy?
A. To maximize tidal volume to clear carbon dioxide.
B. To allow the patient to breathe spontaneously between machine breaths.
C. To provide high pressure to keep the alveoli open while using low volumes to prevent
trauma.
D. To decrease the need for sedation and neuromuscular blocking agents.
Answer: C
Rationale: High-Frequency Oscillatory Ventilation (HFOV) uses very small tidal volumes at
rapid rates to maintain lung recruitment. This strategy is designed to prevent ventilator-
induced lung injury (VILI) by avoiding the over-distension of alveoli. It is typically used as a
rescue therapy for patients with severe ARDS who are failing traditional ventilation modes.
, 4. Which lab value is the most sensitive indicator of acute kidney injury (AKI) in a critically ill
patient?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium
C. Glomerular Filtration Rate (GFR)
D. Serum Creatinine
Answer: D
Rationale: Serum creatinine is the most reliable indicator of renal function because it is a
waste product of muscle metabolism excreted solely by the kidneys. While BUN can be
affected by protein intake or hydration status, creatinine remains relatively stable unless
kidney function is impaired. A sudden rise in creatinine typically signals a significant
decrease in the glomerular filtration rate.
5. A patient in the Intensive Care Unit (ICU) has a MAP (Mean Arterial Pressure) of 55 mmHg.
How should the nurse interpret this finding?
A. The MAP is too low to adequately perfuse vital organs like the kidneys and brain.
B. The MAP is high, indicating a risk for a hypertensive crisis.
C. The MAP is within the normal range for a resting adult.
D. The MAP is slightly low but is acceptable if the patient is sleeping.
Answer: A
Professional Nursing III / PN3 Q&A with
Rationale | Rasmussen University
1. A patient with a spinal cord injury at T4 reports a sudden, severe headache and is found to
have a blood pressure of 190/110 mmHg. What should be the nurse’s first action?
A. Place the patient in a sitting position or elevate the head of the bed to 45 degrees.
B. Administer the prescribed PRN antihypertensive medication.
C. Perform a digital rectal exam to check for fecal impaction.
D. Check the urinary catheter for kinks or obstruction.
Answer: A
Rationale: The patient is exhibiting signs of autonomic dysreflexia, which is a life-
threatening emergency in spinal cord injury patients. The immediate nursing priority is to
elevate the head of the bed to help lower blood pressure through orthostatic changes. After
positioning, the nurse should then identify and remove the triggering stimulus, such as a
full bladder or impacted bowel.
2. The nurse is caring for a patient in the compensatory stage of shock. Which clinical finding
is expected?
A. Metabolic acidosis and cold, clammy skin.
B. Anuria and multi-system organ failure.
,C. Lethargy and decreased responsiveness to painful stimuli.
D. Increased heart rate and narrowed pulse pressure.
Answer: D
Rationale: During the compensatory stage of shock, the body uses homeostatic
mechanisms like the sympathetic nervous system to maintain cardiac output. This results
in an increased heart rate and vasoconstriction, which may present as a narrowed pulse
pressure. Recognizing these early signs is crucial for initiating timely fluid resuscitation
and preventing progression to the progressive stage.
3. A patient with acute respiratory distress syndrome (ARDS) is on mechanical ventilation
with High-Frequency Oscillatory Ventilation. What is the primary goal of this therapy?
A. To maximize tidal volume to clear carbon dioxide.
B. To allow the patient to breathe spontaneously between machine breaths.
C. To provide high pressure to keep the alveoli open while using low volumes to prevent
trauma.
D. To decrease the need for sedation and neuromuscular blocking agents.
Answer: C
Rationale: High-Frequency Oscillatory Ventilation (HFOV) uses very small tidal volumes at
rapid rates to maintain lung recruitment. This strategy is designed to prevent ventilator-
induced lung injury (VILI) by avoiding the over-distension of alveoli. It is typically used as a
rescue therapy for patients with severe ARDS who are failing traditional ventilation modes.
, 4. Which lab value is the most sensitive indicator of acute kidney injury (AKI) in a critically ill
patient?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium
C. Glomerular Filtration Rate (GFR)
D. Serum Creatinine
Answer: D
Rationale: Serum creatinine is the most reliable indicator of renal function because it is a
waste product of muscle metabolism excreted solely by the kidneys. While BUN can be
affected by protein intake or hydration status, creatinine remains relatively stable unless
kidney function is impaired. A sudden rise in creatinine typically signals a significant
decrease in the glomerular filtration rate.
5. A patient in the Intensive Care Unit (ICU) has a MAP (Mean Arterial Pressure) of 55 mmHg.
How should the nurse interpret this finding?
A. The MAP is too low to adequately perfuse vital organs like the kidneys and brain.
B. The MAP is high, indicating a risk for a hypertensive crisis.
C. The MAP is within the normal range for a resting adult.
D. The MAP is slightly low but is acceptable if the patient is sleeping.
Answer: A
