NUR2790/NUR 2790 Exam 3 V3 |
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a patient in the emergent phase of a major burn. Which physiological
change should the nurse expect to observe?
A. Increased blood viscosity and hematocrit
B. Decreased capillary permeability
C. Decreased heart rate due to fluid overload
D. Increased urine output and clear sensorium
Correct Answer: A
Expert Explanation: In the emergent phase of a burn, fluid shifts from the vascular space
to the interstitial space. This leads to hemoconcentration, which results in an increased
hematocrit and increased blood viscosity. The nurse must monitor for hypovolemia and
initiate aggressive fluid resuscitation immediately.
2. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) for a patient with
burns on the entire left arm and the entire chest.
A. 18%
,B. 36%
C. 27%
D. 45%
Correct Answer: C
Expert Explanation: The entire left arm represents 9% of the TBSA. The entire chest
(anterior trunk) represents 18% of the TBSA. Adding 9% and 18% results in a total of 27%
for the calculation.
3. Which assessment finding is most indicative of the hyperdynamic (early) phase of septic
shock?
A. Cool, clammy skin
B. Decreased cardiac output
C. Severe hypotension and oliguria
D. Warm, flushed skin
Correct Answer: D
Expert Explanation: In the early or ‘warm’ phase of septic shock, vasodilation causes the
skin to feel warm and flushed. This phase is characterized by a high cardiac output and low
systemic vascular resistance. Recognizing these early signs allows for prompt intervention
to prevent progression to the cold phase.
, 4. A patient with a traumatic brain injury has a blood pressure of 160/60 mmHg and a heart
rate of 50 bpm. What condition does the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Cushing’s triad
D. Septic shock
Correct Answer: C
Expert Explanation: Cushing’s triad consists of bradycardia, hypertension with a widening
pulse pressure, and irregular respirations. It is a late sign of increased intracranial pressure
(ICP) and indicates potential brain herniation. The nurse should notify the provider
immediately as this is a medical emergency.
5. A patient is receiving mechanical ventilation and the high-pressure alarm sounds. Which
action should the nurse take first?
A. Check for a disconnection in the circuit
B. Assess the patient’s airway and suction if needed
C. Silence the alarm and increase the oxygen level
D. Wait 5 minutes to see if the alarm resolves
Correct Answer: B
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a patient in the emergent phase of a major burn. Which physiological
change should the nurse expect to observe?
A. Increased blood viscosity and hematocrit
B. Decreased capillary permeability
C. Decreased heart rate due to fluid overload
D. Increased urine output and clear sensorium
Correct Answer: A
Expert Explanation: In the emergent phase of a burn, fluid shifts from the vascular space
to the interstitial space. This leads to hemoconcentration, which results in an increased
hematocrit and increased blood viscosity. The nurse must monitor for hypovolemia and
initiate aggressive fluid resuscitation immediately.
2. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) for a patient with
burns on the entire left arm and the entire chest.
A. 18%
,B. 36%
C. 27%
D. 45%
Correct Answer: C
Expert Explanation: The entire left arm represents 9% of the TBSA. The entire chest
(anterior trunk) represents 18% of the TBSA. Adding 9% and 18% results in a total of 27%
for the calculation.
3. Which assessment finding is most indicative of the hyperdynamic (early) phase of septic
shock?
A. Cool, clammy skin
B. Decreased cardiac output
C. Severe hypotension and oliguria
D. Warm, flushed skin
Correct Answer: D
Expert Explanation: In the early or ‘warm’ phase of septic shock, vasodilation causes the
skin to feel warm and flushed. This phase is characterized by a high cardiac output and low
systemic vascular resistance. Recognizing these early signs allows for prompt intervention
to prevent progression to the cold phase.
, 4. A patient with a traumatic brain injury has a blood pressure of 160/60 mmHg and a heart
rate of 50 bpm. What condition does the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Cushing’s triad
D. Septic shock
Correct Answer: C
Expert Explanation: Cushing’s triad consists of bradycardia, hypertension with a widening
pulse pressure, and irregular respirations. It is a late sign of increased intracranial pressure
(ICP) and indicates potential brain herniation. The nurse should notify the provider
immediately as this is a medical emergency.
5. A patient is receiving mechanical ventilation and the high-pressure alarm sounds. Which
action should the nurse take first?
A. Check for a disconnection in the circuit
B. Assess the patient’s airway and suction if needed
C. Silence the alarm and increase the oxygen level
D. Wait 5 minutes to see if the alarm resolves
Correct Answer: B
