NUR2790/NUR 2790 Exam 2 V1 |
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A patient with a head injury exhibits a blood pressure of 180/60 mmHg, a heart rate of 50
bpm, and irregular respirations. What does the nurse identify this as?
A. Beck’s Triad
B. Cushing’s Triad
C. Virchow’s Triad
D. Horner’s Syndrome
Correct Answer: B
Expert Explanation: Cushing’s triad is a late sign of increased intracranial pressure. It
consists of bradycardia, widening pulse pressure (hypertension), and respiratory
irregularity. The nurse must recognize this as a medical emergency requiring immediate
intervention.
2. Which assessment finding in a patient with a spinal cord injury at T4 suggests autonomic
dysreflexia?
A. Loss of deep tendon reflexes
,B. Hypotension and tachycardia
C. Flaccid paralysis below the level of injury
D. Severe headache and flushed skin above the injury
Correct Answer: D
Expert Explanation: Autonomic dysreflexia is a life-threatening condition typically
occurring in patients with injuries at or above T6. It is characterized by extreme
hypertension, a pounding headache, and profuse sweating above the level of the lesion.
This is often triggered by a noxious stimulus such as a distended bladder or bowel.
3. The ventilator high-pressure alarm is sounding for a patient on mechanical ventilation.
What is the nurse’s priority action?
A. Check for a leak in the ventilator circuit
B. Increase the oxygen concentration (FiO2)
C. Auscultate lung sounds for potential obstruction or pneumothorax
D. Disconnect the patient and manually ventilate
Correct Answer: C
Expert Explanation: High-pressure alarms are triggered by increased resistance in the
system, such as secretions, biting the tube, or a pneumothorax. The nurse should first
assess the patient’s airway and lung sounds to identify the cause. Checking for leaks is
appropriate for low-pressure alarms, not high-pressure ones.
, 4. A patient in the oliguric phase of acute kidney injury (AKI) has a potassium level of 6.8
mEq/L. Which medication should the nurse anticipate administering first?
A. Epoetin alfa
B. Sodium polystyrene sulfonate
C. Calcium gluconate
D. Furosemide
Correct Answer: C
Expert Explanation: While other medications help lower potassium over time, calcium
gluconate is administered first to stabilize the myocardial cell membrane. This prevents
life-threatening arrhythmias associated with severe hyperkalemia. It does not lower the
potassium level itself but protects the heart while other treatments work.
5. Which laboratory value is most indicative of the ‘ebb’ phase in a patient who has suffered a
major burn?
A. Decreased hematocrit
B. Increased cardiac output
C. Increased hematocrit
D. Hypoglycemia
Correct Answer: C
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A patient with a head injury exhibits a blood pressure of 180/60 mmHg, a heart rate of 50
bpm, and irregular respirations. What does the nurse identify this as?
A. Beck’s Triad
B. Cushing’s Triad
C. Virchow’s Triad
D. Horner’s Syndrome
Correct Answer: B
Expert Explanation: Cushing’s triad is a late sign of increased intracranial pressure. It
consists of bradycardia, widening pulse pressure (hypertension), and respiratory
irregularity. The nurse must recognize this as a medical emergency requiring immediate
intervention.
2. Which assessment finding in a patient with a spinal cord injury at T4 suggests autonomic
dysreflexia?
A. Loss of deep tendon reflexes
,B. Hypotension and tachycardia
C. Flaccid paralysis below the level of injury
D. Severe headache and flushed skin above the injury
Correct Answer: D
Expert Explanation: Autonomic dysreflexia is a life-threatening condition typically
occurring in patients with injuries at or above T6. It is characterized by extreme
hypertension, a pounding headache, and profuse sweating above the level of the lesion.
This is often triggered by a noxious stimulus such as a distended bladder or bowel.
3. The ventilator high-pressure alarm is sounding for a patient on mechanical ventilation.
What is the nurse’s priority action?
A. Check for a leak in the ventilator circuit
B. Increase the oxygen concentration (FiO2)
C. Auscultate lung sounds for potential obstruction or pneumothorax
D. Disconnect the patient and manually ventilate
Correct Answer: C
Expert Explanation: High-pressure alarms are triggered by increased resistance in the
system, such as secretions, biting the tube, or a pneumothorax. The nurse should first
assess the patient’s airway and lung sounds to identify the cause. Checking for leaks is
appropriate for low-pressure alarms, not high-pressure ones.
, 4. A patient in the oliguric phase of acute kidney injury (AKI) has a potassium level of 6.8
mEq/L. Which medication should the nurse anticipate administering first?
A. Epoetin alfa
B. Sodium polystyrene sulfonate
C. Calcium gluconate
D. Furosemide
Correct Answer: C
Expert Explanation: While other medications help lower potassium over time, calcium
gluconate is administered first to stabilize the myocardial cell membrane. This prevents
life-threatening arrhythmias associated with severe hyperkalemia. It does not lower the
potassium level itself but protects the heart while other treatments work.
5. Which laboratory value is most indicative of the ‘ebb’ phase in a patient who has suffered a
major burn?
A. Decreased hematocrit
B. Increased cardiac output
C. Increased hematocrit
D. Hypoglycemia
Correct Answer: C
