NUR 425 Exam 1: Acute & Chronic Health Disruptions In
Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with left-sided heart failure is being assessed by a nurse. Which finding is the most indicative of
acute pulmonary edema?
A. Expectoration of pink, frothy sputum
B. Significant dependent pitting edema
C. Increased jugular venous distension
D. Frequent dry, non-productive cough
Ans: A
Explanation: The correct choice is B because pink frothy sputum is a definitive sign of fluid entering the
alveoli in pulmonary edema. This occurs when high capillary pressure in the lungs forces plasma and red
blood cells out. Dependent edema and jugular distension are more commonly associated with right-sided
heart failure rather than acute left-sided distress. A dry cough may occur in early heart failure but does
not indicate the severity of pulmonary edema. Nurses must recognize this as an emergency requiring
immediate oxygen and diuretic therapy.
2. A nurse is evaluating a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 52, HCO3 26. What is the
correct interpretation?
A. Uncompensated respiratory acidosis
B. Compensated metabolic acidosis
C. Partially compensated respiratory alkalosis
D. Uncompensated metabolic alkalosis
,Ans: A
Explanation: Interpretation B is correct because the pH is below 7.35 and the PaCO2 is elevated above
45 mmHg. The normal bicarbonate level indicates that the kidneys have not yet begun to compensate for
the respiratory imbalance. Metabolic acidosis would require a low bicarbonate level rather than an
elevated PaCO2 level. Respiratory alkalosis would present with a high pH and a low PaCO2 value.
Respiratory acidosis is frequently caused by hypoventilation in patients with conditions like COPD or
pneumonia.
3. Which clinical manifestation should a nurse prioritize when assessing a patient for a suspected pulmonary
embolism (PE)?
A. Gradual onset of productive cough
B. Warm, flushed skin and hypertension
C. Bradypnea and decreased heart rate
D. Sudden onset of pleuritic chest pain
Ans: D
Explanation: Choice B is the priority finding because sudden pleuritic chest pain is a hallmark sign of a
pulmonary embolism. This pain results from local ischemia and inflammation of the pleura due to
blocked blood flow. A productive cough is typically associated with infections like pneumonia rather than
a vascular blockage. Patients with PE usually exhibit tachycardia and tachypnea rather than bradycardia
or slow breathing. Early recognition of these symptoms is vital to prevent right ventricular failure and
sudden cardiac death.
4. A client is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which laboratory
result is the nurse most likely to find?
A. Urine specific gravity of 1.002
, B. Serum osmolality of 310 mOsm/kg
C. Serum sodium of 124 mEq/L
D. Increased hematocrit and hemoglobin
Ans: C
Explanation: Answer A is correct as SIADH causes excessive water retention leading to dilutional
hyponatremia. The serum osmolality would be low, not high, because the blood is excessively diluted by
retained water. A low urine specific gravity is characteristic of Diabetes Insipidus rather than the
concentrated urine found in SIADH. Hematocrit would typically decrease due to hemodilution rather than
increase in this specific pathology. Nursing management includes strict fluid restriction and monitoring
of neurologic status due to the risk of seizures.
5. When monitoring a patient with increased intracranial pressure (ICP), which set of vital signs represents
Cushing’s Triad?
A. Bradycardia, hypertension with widening pulse pressure, and irregular respirations
B. Tachycardia, hypotension, and tachypnea
C. Bradycardia, hypotension, and Cheyne-Stokes breathing
D. Tachycardia, hypertension, and hyperventilation
Ans: A
Explanation: Option B correctly identifies the components of Cushing’s Triad, which is a late sign of
brainstem herniation. Bradycardia occurs as a compensatory response to the significant increase in mean
arterial pressure. Widening pulse pressure reflects the body’s attempt to maintain cerebral perfusion
despite high resistance. Irregular breathing patterns like Cheyne-Stokes indicate significant neurological
Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with left-sided heart failure is being assessed by a nurse. Which finding is the most indicative of
acute pulmonary edema?
A. Expectoration of pink, frothy sputum
B. Significant dependent pitting edema
C. Increased jugular venous distension
D. Frequent dry, non-productive cough
Ans: A
Explanation: The correct choice is B because pink frothy sputum is a definitive sign of fluid entering the
alveoli in pulmonary edema. This occurs when high capillary pressure in the lungs forces plasma and red
blood cells out. Dependent edema and jugular distension are more commonly associated with right-sided
heart failure rather than acute left-sided distress. A dry cough may occur in early heart failure but does
not indicate the severity of pulmonary edema. Nurses must recognize this as an emergency requiring
immediate oxygen and diuretic therapy.
2. A nurse is evaluating a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 52, HCO3 26. What is the
correct interpretation?
A. Uncompensated respiratory acidosis
B. Compensated metabolic acidosis
C. Partially compensated respiratory alkalosis
D. Uncompensated metabolic alkalosis
,Ans: A
Explanation: Interpretation B is correct because the pH is below 7.35 and the PaCO2 is elevated above
45 mmHg. The normal bicarbonate level indicates that the kidneys have not yet begun to compensate for
the respiratory imbalance. Metabolic acidosis would require a low bicarbonate level rather than an
elevated PaCO2 level. Respiratory alkalosis would present with a high pH and a low PaCO2 value.
Respiratory acidosis is frequently caused by hypoventilation in patients with conditions like COPD or
pneumonia.
3. Which clinical manifestation should a nurse prioritize when assessing a patient for a suspected pulmonary
embolism (PE)?
A. Gradual onset of productive cough
B. Warm, flushed skin and hypertension
C. Bradypnea and decreased heart rate
D. Sudden onset of pleuritic chest pain
Ans: D
Explanation: Choice B is the priority finding because sudden pleuritic chest pain is a hallmark sign of a
pulmonary embolism. This pain results from local ischemia and inflammation of the pleura due to
blocked blood flow. A productive cough is typically associated with infections like pneumonia rather than
a vascular blockage. Patients with PE usually exhibit tachycardia and tachypnea rather than bradycardia
or slow breathing. Early recognition of these symptoms is vital to prevent right ventricular failure and
sudden cardiac death.
4. A client is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which laboratory
result is the nurse most likely to find?
A. Urine specific gravity of 1.002
, B. Serum osmolality of 310 mOsm/kg
C. Serum sodium of 124 mEq/L
D. Increased hematocrit and hemoglobin
Ans: C
Explanation: Answer A is correct as SIADH causes excessive water retention leading to dilutional
hyponatremia. The serum osmolality would be low, not high, because the blood is excessively diluted by
retained water. A low urine specific gravity is characteristic of Diabetes Insipidus rather than the
concentrated urine found in SIADH. Hematocrit would typically decrease due to hemodilution rather than
increase in this specific pathology. Nursing management includes strict fluid restriction and monitoring
of neurologic status due to the risk of seizures.
5. When monitoring a patient with increased intracranial pressure (ICP), which set of vital signs represents
Cushing’s Triad?
A. Bradycardia, hypertension with widening pulse pressure, and irregular respirations
B. Tachycardia, hypotension, and tachypnea
C. Bradycardia, hypotension, and Cheyne-Stokes breathing
D. Tachycardia, hypertension, and hyperventilation
Ans: A
Explanation: Option B correctly identifies the components of Cushing’s Triad, which is a late sign of
brainstem herniation. Bradycardia occurs as a compensatory response to the significant increase in mean
arterial pressure. Widening pulse pressure reflects the body’s attempt to maintain cerebral perfusion
despite high resistance. Irregular breathing patterns like Cheyne-Stokes indicate significant neurological
