NUR 425 Exam 1: Acute & Chronic Health Disruptions In
Adults II V2 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient’s ABG results are: pH 7.28, PaCO2 55 mm Hg, and HCO3 26 mEq/L. Which acid-base imbalance
does the nurse identify?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Ans: B
Explanation: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mm Hg indicates a respiratory
cause. The bicarbonate level is within the normal range, suggesting no compensation has occurred yet.
This condition often results from hypoventilation or impaired gas exchange. The nurse should focus on
improving the patient’s ventilation and oxygenation status. Monitoring for signs of respiratory distress is
a priority intervention.
2. A patient with a history of heart failure presents with a heart rate of 38 bpm and is complaining of
dizziness. Which medication should the nurse anticipate administering?
A. Amiodarone
B. Adenosine
C. Atropine
D. Diltiazem
Ans: C
,Explanation: The patient is experiencing symptomatic bradycardia, which requires immediate
intervention to increase heart rate. Atropine is the first-line medication for hemodynamically unstable
bradycardia because it blocks vagal effects on the SA node. Adenosine is used for supraventricular
tachycardia, which would be inappropriate here. Diltiazem and amiodarone are used to slow the heart
rate or manage arrhythmias. The goal of atropine is to restore adequate cardiac output and tissue
perfusion.
3. A nurse is caring for a patient in the early stages of septic shock. Which clinical manifestation is most
common during this ‘warm’ phase?
A. Hypothermia and bradycardia
B. Cool, clammy skin and hypotension
C. Hyperthermia and warm, flushed skin
D. Oliguria and peripheral edema
Ans: C
Explanation: In the early or hyperdynamic phase of septic shock, the body exhibits a high cardiac output
state. This results in vasodilation, causing the skin to feel warm and appear flushed. The patient typically
has a fever as part of the systemic inflammatory response. In contrast, the ‘cold’ phase involves
vasoconstriction and cool, clammy skin. Early identification allows for rapid fluid resuscitation and
antibiotic administration.
4. Which electrolyte imbalance is a patient at risk for when experiencing Acute Kidney Injury (AKI) during
the oliguric phase?
A. Hypokalemia
B. Hyperkalemia
, C. Hypercalcemia
D. Hypophosphatemia
Ans: B
Explanation: The oliguric phase of AKI is characterized by a significant decrease in urine output,
preventing the excretion of potassium. This leads to hyperkalemia, which is a life-threatening condition
due to the risk of cardiac dysrhythmias. Patients often exhibit peaked T-waves on an electrocardiogram
as an early sign of elevation. Management includes restricting dietary potassium and potentially using
medications like Kayexalate or insulin with glucose. Continuous cardiac monitoring is essential for safety
during this phase.
5. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which IV fluid should the nurse
expect to initiate first?
A. Dextrose 5% in Water (D5W)
B. 0.9% Normal Saline
C. 0.45% Normal Saline
D. Dextrose 5% in 0.9% Normal Saline
Ans: B
Explanation: Initial management of DKA focuses on rehydrating the patient and restoring extracellular
fluid volume. Isotonic saline, such as 0.9% Normal Saline, is the fluid of choice for initial resuscitation.
Once blood glucose levels drop to around 250 mg/dL, dextrose is added to prevent hypoglycemia. Rapid
fluid replacement helps improve renal perfusion and clear ketones. The nurse must carefully monitor for
signs of fluid volume overload during this process.
Adults II V2 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient’s ABG results are: pH 7.28, PaCO2 55 mm Hg, and HCO3 26 mEq/L. Which acid-base imbalance
does the nurse identify?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Ans: B
Explanation: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mm Hg indicates a respiratory
cause. The bicarbonate level is within the normal range, suggesting no compensation has occurred yet.
This condition often results from hypoventilation or impaired gas exchange. The nurse should focus on
improving the patient’s ventilation and oxygenation status. Monitoring for signs of respiratory distress is
a priority intervention.
2. A patient with a history of heart failure presents with a heart rate of 38 bpm and is complaining of
dizziness. Which medication should the nurse anticipate administering?
A. Amiodarone
B. Adenosine
C. Atropine
D. Diltiazem
Ans: C
,Explanation: The patient is experiencing symptomatic bradycardia, which requires immediate
intervention to increase heart rate. Atropine is the first-line medication for hemodynamically unstable
bradycardia because it blocks vagal effects on the SA node. Adenosine is used for supraventricular
tachycardia, which would be inappropriate here. Diltiazem and amiodarone are used to slow the heart
rate or manage arrhythmias. The goal of atropine is to restore adequate cardiac output and tissue
perfusion.
3. A nurse is caring for a patient in the early stages of septic shock. Which clinical manifestation is most
common during this ‘warm’ phase?
A. Hypothermia and bradycardia
B. Cool, clammy skin and hypotension
C. Hyperthermia and warm, flushed skin
D. Oliguria and peripheral edema
Ans: C
Explanation: In the early or hyperdynamic phase of septic shock, the body exhibits a high cardiac output
state. This results in vasodilation, causing the skin to feel warm and appear flushed. The patient typically
has a fever as part of the systemic inflammatory response. In contrast, the ‘cold’ phase involves
vasoconstriction and cool, clammy skin. Early identification allows for rapid fluid resuscitation and
antibiotic administration.
4. Which electrolyte imbalance is a patient at risk for when experiencing Acute Kidney Injury (AKI) during
the oliguric phase?
A. Hypokalemia
B. Hyperkalemia
, C. Hypercalcemia
D. Hypophosphatemia
Ans: B
Explanation: The oliguric phase of AKI is characterized by a significant decrease in urine output,
preventing the excretion of potassium. This leads to hyperkalemia, which is a life-threatening condition
due to the risk of cardiac dysrhythmias. Patients often exhibit peaked T-waves on an electrocardiogram
as an early sign of elevation. Management includes restricting dietary potassium and potentially using
medications like Kayexalate or insulin with glucose. Continuous cardiac monitoring is essential for safety
during this phase.
5. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which IV fluid should the nurse
expect to initiate first?
A. Dextrose 5% in Water (D5W)
B. 0.9% Normal Saline
C. 0.45% Normal Saline
D. Dextrose 5% in 0.9% Normal Saline
Ans: B
Explanation: Initial management of DKA focuses on rehydrating the patient and restoring extracellular
fluid volume. Isotonic saline, such as 0.9% Normal Saline, is the fluid of choice for initial resuscitation.
Once blood glucose levels drop to around 250 mg/dL, dextrose is added to prevent hypoglycemia. Rapid
fluid replacement helps improve renal perfusion and clear ketones. The nurse must carefully monitor for
signs of fluid volume overload during this process.
