NUR2790 Exam 3 V1 | NUR 2790
Professional Nursing III / PN3 Exam Q&A |
Rasmussen University
1. A patient presents with a suspected tension pneumothorax. Which clinical finding should
the nurse prioritize during the emergency assessment?
A. Tracheal deviation toward the unaffected side
B. Increased breath sounds on the affected side
C. Bradycardia and hypertension
D. Subcutaneous emphysema at the base of the neck
Answer: A
Rationale: Tracheal deviation is a late sign of tension pneumothorax indicating significant
pressure buildup that shifts mediastinal structures. This condition requires immediate
needle decompression to prevent cardiovascular collapse. The nurse must recognize that
air trapped in the pleural space cannot escape, leading to increased intrathoracic pressure
and decreased venous return.
2. A nurse is caring for a patient in the early stage of septic shock. Which hemodynamic
finding is most consistent with this phase?
A. Decreased cardiac output and high systemic vascular resistance
B. Normal blood pressure and elevated central venous pressure
,C. Increased cardiac output and low systemic vascular resistance
D. Decreased heart rate and increased urine output
Answer: C
Rationale: Early septic shock, also known as the hyperdynamic or warm phase, is
characterized by vasodilation and decreased systemic vascular resistance. To compensate
for the low resistance, the heart increases its rate and stroke volume, leading to an elevated
cardiac output. This physiological response attempts to maintain tissue perfusion despite
widespread inflammatory mediators causing vascular leakage.
3. A patient is admitted with severe burns over 40% of their body. Using the Parkland
formula, what is the priority nursing intervention during the first 24 hours?
A. Initiating rapid fluid resuscitation with lactated Ringer’s
B. Administering high-dose prophylactic antibiotics
C. Preparing the patient for immediate skin grafting
D. Maintaining a strict NPO status for 48 hours
Answer: A
Rationale: Fluid resuscitation is the cornerstone of initial burn management to prevent
hypovolemic shock due to massive capillary leaking. The Parkland formula guides the
volume of lactated Ringer’s to be administered, with half the total volume given in the first
8 hours post-injury. Failure to provide adequate fluid can lead to acute kidney injury and
multisystem organ failure.
, 4. During a primary survey of a trauma victim, which assessment finding requires the nurse’s
immediate action first?
A. An open fracture of the femur
B. Absent breath sounds on the left side
C. A Glascow Coma Scale score of 12
D. Inability to speak and gurgling sounds
Answer: D
Rationale: The primary survey follows the ABCDE priority (Airway, Breathing, Circulation,
Disability, Exposure). Inability to speak and gurgling sounds indicate a compromised
airway, which is the highest priority. Immediate intervention is required to secure the
airway before addressing breathing or circulation issues.
5. Which lab value is the most sensitive indicator of tissue hypoxia and the severity of shock
in a critical care patient?
A. Serum Potassium level
B. White blood cell count
C. Serum Lactate level
D. Hemoglobin level
Answer: C
Professional Nursing III / PN3 Exam Q&A |
Rasmussen University
1. A patient presents with a suspected tension pneumothorax. Which clinical finding should
the nurse prioritize during the emergency assessment?
A. Tracheal deviation toward the unaffected side
B. Increased breath sounds on the affected side
C. Bradycardia and hypertension
D. Subcutaneous emphysema at the base of the neck
Answer: A
Rationale: Tracheal deviation is a late sign of tension pneumothorax indicating significant
pressure buildup that shifts mediastinal structures. This condition requires immediate
needle decompression to prevent cardiovascular collapse. The nurse must recognize that
air trapped in the pleural space cannot escape, leading to increased intrathoracic pressure
and decreased venous return.
2. A nurse is caring for a patient in the early stage of septic shock. Which hemodynamic
finding is most consistent with this phase?
A. Decreased cardiac output and high systemic vascular resistance
B. Normal blood pressure and elevated central venous pressure
,C. Increased cardiac output and low systemic vascular resistance
D. Decreased heart rate and increased urine output
Answer: C
Rationale: Early septic shock, also known as the hyperdynamic or warm phase, is
characterized by vasodilation and decreased systemic vascular resistance. To compensate
for the low resistance, the heart increases its rate and stroke volume, leading to an elevated
cardiac output. This physiological response attempts to maintain tissue perfusion despite
widespread inflammatory mediators causing vascular leakage.
3. A patient is admitted with severe burns over 40% of their body. Using the Parkland
formula, what is the priority nursing intervention during the first 24 hours?
A. Initiating rapid fluid resuscitation with lactated Ringer’s
B. Administering high-dose prophylactic antibiotics
C. Preparing the patient for immediate skin grafting
D. Maintaining a strict NPO status for 48 hours
Answer: A
Rationale: Fluid resuscitation is the cornerstone of initial burn management to prevent
hypovolemic shock due to massive capillary leaking. The Parkland formula guides the
volume of lactated Ringer’s to be administered, with half the total volume given in the first
8 hours post-injury. Failure to provide adequate fluid can lead to acute kidney injury and
multisystem organ failure.
, 4. During a primary survey of a trauma victim, which assessment finding requires the nurse’s
immediate action first?
A. An open fracture of the femur
B. Absent breath sounds on the left side
C. A Glascow Coma Scale score of 12
D. Inability to speak and gurgling sounds
Answer: D
Rationale: The primary survey follows the ABCDE priority (Airway, Breathing, Circulation,
Disability, Exposure). Inability to speak and gurgling sounds indicate a compromised
airway, which is the highest priority. Immediate intervention is required to secure the
airway before addressing breathing or circulation issues.
5. Which lab value is the most sensitive indicator of tissue hypoxia and the severity of shock
in a critical care patient?
A. Serum Potassium level
B. White blood cell count
C. Serum Lactate level
D. Hemoglobin level
Answer: C
