NUR2790/NUR 2790 Final Exam V1 |
Professional Nursing III / PN3 Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client in the resuscitative phase of burn injury. Which of the
following findings should the nurse expect?
A. Increased urinary output
B. Decreased serum potassium
C. Decreased heart rate
D. Increased hematocrit
Answer: D
Rationale: During the resuscitative phase, fluid shifts from the intravascular space to the
interstitial space, leading to hemoconcentration. This process results in an elevated
hematocrit level due to the loss of plasma volume. Monitoring these levels is crucial for
guiding fluid resuscitation efforts in burn patients.
2. A client is admitted with suspected ARDS. Which arterial blood gas (ABG) result would the
nurse most likely observe in the early stages?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
,D. Metabolic alkalosis
Answer: C
Rationale: In the early stages of ARDS, the client often experiences tachypnea as they
attempt to compensate for hypoxia. This rapid breathing leads to the excessive blowing off
of carbon dioxide, which causes respiratory alkalosis. As the condition worsens and the
client tires, they may eventually transition into respiratory acidosis.
3. A nurse is assessing a client with a high-level spinal cord injury (C4). Which of the following
is the priority assessment?
A. Skin integrity
B. Bladder distension
C. Muscle strength in lower extremities
D. Respiratory effort
Answer: D
Rationale: Injuries at or above the C4 level affect the phrenic nerve, which controls the
diaphragm. This puts the client at high risk for respiratory failure or insufficiency. Ensuring
adequate ventilation and oxygenation is the most critical priority in the immediate care of
these patients.
4. Which of the following interventions should a nurse implement for a client experiencing
autonomic dysreflexia?
A. Place the client in a supine position
, B. Administer a beta-blocker immediately
C. Check the client for bladder distension
D. Increase the rate of IV fluid administration
Answer: C
Rationale: Autonomic dysreflexia is often triggered by a noxious stimulus such as a full
bladder or impacted bowel. The first nursing action should be to sit the patient up to lower
blood pressure and then identify/remove the stimulus. Checking for a kinked catheter or
bladder distension is a standard part of this assessment.
5. A patient with liver cirrhosis has a high ammonia level and is confused. Which medication
should the nurse anticipate administering?
A. Lactulose
B. Spironolactone
C. Propranolol
D. Vitamin K
Answer: A
Rationale: Lactulose is used to lower ammonia levels by promoting its excretion through
the stool. It works by acidifying the colon, which converts ammonia into ammonium, a non-
absorbable form. The reduction in ammonia helps alleviate the symptoms of hepatic
encephalopathy.
Professional Nursing III / PN3 Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client in the resuscitative phase of burn injury. Which of the
following findings should the nurse expect?
A. Increased urinary output
B. Decreased serum potassium
C. Decreased heart rate
D. Increased hematocrit
Answer: D
Rationale: During the resuscitative phase, fluid shifts from the intravascular space to the
interstitial space, leading to hemoconcentration. This process results in an elevated
hematocrit level due to the loss of plasma volume. Monitoring these levels is crucial for
guiding fluid resuscitation efforts in burn patients.
2. A client is admitted with suspected ARDS. Which arterial blood gas (ABG) result would the
nurse most likely observe in the early stages?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
,D. Metabolic alkalosis
Answer: C
Rationale: In the early stages of ARDS, the client often experiences tachypnea as they
attempt to compensate for hypoxia. This rapid breathing leads to the excessive blowing off
of carbon dioxide, which causes respiratory alkalosis. As the condition worsens and the
client tires, they may eventually transition into respiratory acidosis.
3. A nurse is assessing a client with a high-level spinal cord injury (C4). Which of the following
is the priority assessment?
A. Skin integrity
B. Bladder distension
C. Muscle strength in lower extremities
D. Respiratory effort
Answer: D
Rationale: Injuries at or above the C4 level affect the phrenic nerve, which controls the
diaphragm. This puts the client at high risk for respiratory failure or insufficiency. Ensuring
adequate ventilation and oxygenation is the most critical priority in the immediate care of
these patients.
4. Which of the following interventions should a nurse implement for a client experiencing
autonomic dysreflexia?
A. Place the client in a supine position
, B. Administer a beta-blocker immediately
C. Check the client for bladder distension
D. Increase the rate of IV fluid administration
Answer: C
Rationale: Autonomic dysreflexia is often triggered by a noxious stimulus such as a full
bladder or impacted bowel. The first nursing action should be to sit the patient up to lower
blood pressure and then identify/remove the stimulus. Checking for a kinked catheter or
bladder distension is a standard part of this assessment.
5. A patient with liver cirrhosis has a high ammonia level and is confused. Which medication
should the nurse anticipate administering?
A. Lactulose
B. Spironolactone
C. Propranolol
D. Vitamin K
Answer: A
Rationale: Lactulose is used to lower ammonia levels by promoting its excretion through
the stool. It works by acidifying the colon, which converts ammonia into ammonium, a non-
absorbable form. The reduction in ammonia helps alleviate the symptoms of hepatic
encephalopathy.
