NR 330 Exam 1: Adult Health II - Chamberlain University
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. The nurse
notes the peak inspiratory pressure is rising, and the patient has diminished breath sounds on the right side
with tracheal deviation. What is the priority nursing action?
A. Prepare for immediate needle decompression or chest tube insertion.
B. Suction the patient to clear possible secretions.
C. Increase the PEEP setting on the ventilator.
D. Obtain an arterial blood gas (ABG) sample immediately.
Correct Answer: A
Rationale: Tracheal deviation and diminished breath sounds in a ventilated patient are hallmark signs of
a tension pneumothorax. This condition is a life-threatening emergency as it compromises cardiac output
and oxygenation. Suctioning or increasing PEEP would likely worsen the pressure within the pleural
space. Immediate decompression is required to re-expand the lung and shift the mediastinum back to its
neutral position. Nursing management focuses on rapid identification and stabilization of the airway and
hemodynamics.
2. The nurse is monitoring a patient in the ICU with a pulmonary artery catheter. The central venous
pressure (CVP) is 15 mmHg, and the pulmonary artery wedge pressure (PAWP) is 18 mmHg. Which condition
does the nurse suspect?
A. Hypovolemic shock
B. Systemic vasodilation
C. Left-sided heart failure
,D. Septic shock
Correct Answer: C
Rationale: Elevated CVP and PAWP readings indicate fluid volume overload or cardiac pump failure.
Normal CVP ranges from 2 to 6 mmHg, while normal PAWP is typically 4 to 12 mmHg. In left-sided heart
failure, the heart cannot effectively pump blood forward, causing pressure to back up into the lungs and
right side of the heart. Hypovolemic and septic shock would typically present with low hemodynamic
pressures due to fluid loss or vasodilation. Assessment of lung sounds and peripheral edema is essential
to correlate these findings with clinical status.
3. A patient with chronic kidney disease (CKD) presents with a potassium level of 7.2 mEq/L and tall, peaked
T-waves on the ECG. Which medication should the nurse expect to administer first to protect the heart?
A. Calcium gluconate
B. Furosemide (Lasix)
C. Sodium polystyrene sulfonate (Kayexalate)
D. Regular insulin and 50% dextrose
Correct Answer: A
Rationale: Severe hyperkalemia can lead to lethal cardiac dysrhythmias and cardiac arrest. Calcium
gluconate is administered first because it stabilizes the myocardial cell membrane to prevent
arrhythmias. While insulin and dextrose help shift potassium into the cells, they do not provide the
immediate cardiac protection that calcium does. Kayexalate and diuretics help remove potassium from
the body but work too slowly for an acute emergency. Continuous cardiac monitoring is mandatory
during the treatment of such high potassium levels.
,4. A patient admitted for acute pancreatitis develops a respiratory rate of 32 breaths/min and an oxygen
saturation of 88% on 6L oxygen via nasal cannula. Which complication should the nurse prioritize?
A. Pulmonary embolism
B. Atelectasis
C. Congestive heart failure
D. Acute respiratory distress syndrome (ARDS)
Correct Answer: D
Rationale: Acute pancreatitis is a major risk factor for the development of ARDS due to systemic
inflammation and enzyme release. The sudden onset of tachypnea and refractory hypoxemia are classic
early signs of this condition. ARDS involves non-cardiogenic pulmonary edema which leads to impaired
gas exchange. Treatment often requires high-flow oxygen or mechanical ventilation with positive end-
expiratory pressure. The nurse must monitor for worsening lung compliance and multi-organ
dysfunction syndrome.
5. The nurse is caring for a patient in septic shock. After receiving a fluid bolus of 30 mL/kg, the mean
arterial pressure (MAP) remains at 58 mmHg. What is the next priority intervention?
A. Start a norepinephrine (Levophed) infusion.
B. Administer a second fluid bolus of 500 mL.
C. Administer broad-spectrum antibiotics.
D. Obtain blood cultures from two different sites.
Correct Answer: A
Rationale: Septic shock is defined by persistent hypotension requiring vasopressors to maintain a MAP
of 65 mmHg or higher despite adequate fluid resuscitation. Norepinephrine is the first-line vasopressor
, used to increase systemic vascular resistance and improve blood pressure. Although antibiotics and
cultures are critical in the sepsis bundle, the immediate priority after fluid failure is hemodynamic
stabilization. Continuous monitoring of blood pressure via an arterial line is often preferred when
titrating vasopressors. Failure to maintain adequate perfusion can lead to rapid end-organ damage.
6. A patient with cirrhosis and esophageal varices is scheduled for an endoscopic variceal ligation (EVL).
Which laboratory result is most concerning to the nurse before the procedure?
A. Serum albumin of 2.8 g/dL
B. Prothrombin time (PT) of 22 seconds
C. Ammonia level of 60 mcg/dL
D. Hemoglobin of 10.5 g/dL
Correct Answer: B
Rationale: Cirrhosis severely impacts the liver’s ability to synthesize clotting factors, leading to a
prolonged prothrombin time. An elevated PT or INR significantly increases the risk of uncontrollable
bleeding during invasive procedures like EVL. While low albumin and elevated ammonia are typical
findings in cirrhosis, they are not as immediately life-threatening during a surgical procedure as
coagulopathy. The nurse must notify the provider and may need to administer Vitamin K or fresh frozen
plasma. Ensuring the patient is hemodynamically stable before the procedure is a safety priority.
7. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which of the following initial orders
should the nurse question?
A. Normal saline (0.9% NaCl) at 1000 mL/hr
B. Regular insulin infusion at 0.1 units/kg/hr
C. Potassium chloride 20 mEq IV push
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. The nurse
notes the peak inspiratory pressure is rising, and the patient has diminished breath sounds on the right side
with tracheal deviation. What is the priority nursing action?
A. Prepare for immediate needle decompression or chest tube insertion.
B. Suction the patient to clear possible secretions.
C. Increase the PEEP setting on the ventilator.
D. Obtain an arterial blood gas (ABG) sample immediately.
Correct Answer: A
Rationale: Tracheal deviation and diminished breath sounds in a ventilated patient are hallmark signs of
a tension pneumothorax. This condition is a life-threatening emergency as it compromises cardiac output
and oxygenation. Suctioning or increasing PEEP would likely worsen the pressure within the pleural
space. Immediate decompression is required to re-expand the lung and shift the mediastinum back to its
neutral position. Nursing management focuses on rapid identification and stabilization of the airway and
hemodynamics.
2. The nurse is monitoring a patient in the ICU with a pulmonary artery catheter. The central venous
pressure (CVP) is 15 mmHg, and the pulmonary artery wedge pressure (PAWP) is 18 mmHg. Which condition
does the nurse suspect?
A. Hypovolemic shock
B. Systemic vasodilation
C. Left-sided heart failure
,D. Septic shock
Correct Answer: C
Rationale: Elevated CVP and PAWP readings indicate fluid volume overload or cardiac pump failure.
Normal CVP ranges from 2 to 6 mmHg, while normal PAWP is typically 4 to 12 mmHg. In left-sided heart
failure, the heart cannot effectively pump blood forward, causing pressure to back up into the lungs and
right side of the heart. Hypovolemic and septic shock would typically present with low hemodynamic
pressures due to fluid loss or vasodilation. Assessment of lung sounds and peripheral edema is essential
to correlate these findings with clinical status.
3. A patient with chronic kidney disease (CKD) presents with a potassium level of 7.2 mEq/L and tall, peaked
T-waves on the ECG. Which medication should the nurse expect to administer first to protect the heart?
A. Calcium gluconate
B. Furosemide (Lasix)
C. Sodium polystyrene sulfonate (Kayexalate)
D. Regular insulin and 50% dextrose
Correct Answer: A
Rationale: Severe hyperkalemia can lead to lethal cardiac dysrhythmias and cardiac arrest. Calcium
gluconate is administered first because it stabilizes the myocardial cell membrane to prevent
arrhythmias. While insulin and dextrose help shift potassium into the cells, they do not provide the
immediate cardiac protection that calcium does. Kayexalate and diuretics help remove potassium from
the body but work too slowly for an acute emergency. Continuous cardiac monitoring is mandatory
during the treatment of such high potassium levels.
,4. A patient admitted for acute pancreatitis develops a respiratory rate of 32 breaths/min and an oxygen
saturation of 88% on 6L oxygen via nasal cannula. Which complication should the nurse prioritize?
A. Pulmonary embolism
B. Atelectasis
C. Congestive heart failure
D. Acute respiratory distress syndrome (ARDS)
Correct Answer: D
Rationale: Acute pancreatitis is a major risk factor for the development of ARDS due to systemic
inflammation and enzyme release. The sudden onset of tachypnea and refractory hypoxemia are classic
early signs of this condition. ARDS involves non-cardiogenic pulmonary edema which leads to impaired
gas exchange. Treatment often requires high-flow oxygen or mechanical ventilation with positive end-
expiratory pressure. The nurse must monitor for worsening lung compliance and multi-organ
dysfunction syndrome.
5. The nurse is caring for a patient in septic shock. After receiving a fluid bolus of 30 mL/kg, the mean
arterial pressure (MAP) remains at 58 mmHg. What is the next priority intervention?
A. Start a norepinephrine (Levophed) infusion.
B. Administer a second fluid bolus of 500 mL.
C. Administer broad-spectrum antibiotics.
D. Obtain blood cultures from two different sites.
Correct Answer: A
Rationale: Septic shock is defined by persistent hypotension requiring vasopressors to maintain a MAP
of 65 mmHg or higher despite adequate fluid resuscitation. Norepinephrine is the first-line vasopressor
, used to increase systemic vascular resistance and improve blood pressure. Although antibiotics and
cultures are critical in the sepsis bundle, the immediate priority after fluid failure is hemodynamic
stabilization. Continuous monitoring of blood pressure via an arterial line is often preferred when
titrating vasopressors. Failure to maintain adequate perfusion can lead to rapid end-organ damage.
6. A patient with cirrhosis and esophageal varices is scheduled for an endoscopic variceal ligation (EVL).
Which laboratory result is most concerning to the nurse before the procedure?
A. Serum albumin of 2.8 g/dL
B. Prothrombin time (PT) of 22 seconds
C. Ammonia level of 60 mcg/dL
D. Hemoglobin of 10.5 g/dL
Correct Answer: B
Rationale: Cirrhosis severely impacts the liver’s ability to synthesize clotting factors, leading to a
prolonged prothrombin time. An elevated PT or INR significantly increases the risk of uncontrollable
bleeding during invasive procedures like EVL. While low albumin and elevated ammonia are typical
findings in cirrhosis, they are not as immediately life-threatening during a surgical procedure as
coagulopathy. The nurse must notify the provider and may need to administer Vitamin K or fresh frozen
plasma. Ensuring the patient is hemodynamically stable before the procedure is a safety priority.
7. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which of the following initial orders
should the nurse question?
A. Normal saline (0.9% NaCl) at 1000 mL/hr
B. Regular insulin infusion at 0.1 units/kg/hr
C. Potassium chloride 20 mEq IV push
