| Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A patient with severe burns is in the emergent phase of injury. Which electrolyte
imbalance should the nurse most expect to find?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypocalcemia
Correct Answer: A
Expert Explanation: During the emergent phase of a burn injury, massive cellular
destruction occurs, causing potassium to leak out of the cells into the extracellular fluid.
This process leads to hyperkalemia, which can result in life-threatening cardiac
dysrhythmias. The nurse must monitor the patient’s ECG and serum potassium levels
closely during the first 24 to 48 hours.
2. A patient is admitted with a diagnosis of Diabetes Insipidus (DI). Which clinical
manifestation is most characteristic of this condition?
A. High urine specific gravity
,B. Excessive thirst and polyuria
C. Fluid volume overload
D. Elevated blood glucose levels
Correct Answer: B
Expert Explanation: Diabetes Insipidus is characterized by a deficiency of Antidiuretic
Hormone (ADH), which leads to the kidneys’ inability to concentrate urine. This results in
the excretion of massive amounts of dilute urine and intense thirst, known as polydipsia.
Patients often have a very low urine specific gravity, typically less than 1.005, due to the
high water content of the urine.
3. Which arterial blood gas (ABG) result indicates fully compensated respiratory acidosis?
A. pH 7.25, PaCO2 55, HCO3 24
B. pH 7.36, PaCO2 50, HCO3 34
C. pH 7.48, PaCO2 30, HCO3 22
D. pH 7.35, PaCO2 40, HCO3 24
Correct Answer: B
Expert Explanation: In fully compensated respiratory acidosis, the pH returns to the
normal range (7.35-7.45) but remains on the acidic side. The PaCO2 is elevated, indicating
the primary respiratory problem, while the HCO3 is also elevated as the kidneys retain
bicarbonate to buffer the acid. Option A shows a normal pH with an elevated PaCO2 and a
high HCO3, confirming full compensation.
, 4. A patient is in septic shock. Which of the following is considered an early (warm phase)
sign?
A. Cool, clammy skin
B. Anuria and multi-organ failure
C. Severe hypotension and bradycardia
D. Hyperdynamic state with increased cardiac output
Correct Answer: D
Expert Explanation: In the early or ‘warm’ phase of septic shock, the body compensates
for vasodilation by increasing cardiac output. The patient often presents with flushed,
warm skin and a high heart rate, which is why it is termed hyperdynamic. As the shock
progresses to the ‘cold’ phase, the cardiac output drops, and the patient becomes cool and
pale.
5. What is the priority nursing intervention for a patient experiencing autonomic dysreflexia?
A. Administering a beta-blocker immediately
B. Sitting the patient upright and checking for bladder distension
C. Lowering the head of the bed
D. Performing a sterile dressing change
Correct Answer: B