NUR2790 Exam 3 V3 | NUR 2790
Professional Nursing III / PN3 Exam Q&A |
Rasmussen University
1. A nurse is caring for a patient who has been involved in a motor vehicle accident and is
suspected of having a tension pneumothorax. Which assessment finding should the nurse
report to the provider immediately?
A. Tracheal deviation to the unaffected side
B. Bilateral breath sounds present
C. Oxygen saturation of 94% on room air
D. Localized chest pain upon inspiration
Answer: A
Rationale: Tracheal deviation is a late and life-threatening sign of a tension pneumothorax
where pressure shifts the mediastinum. This condition requires immediate decompression
to prevent cardiovascular collapse and respiratory failure. The nurse must prioritize this
finding over localized pain as it indicates a critical obstructive shock state.
2. During a mass casualty incident, a nurse is performing triage. Which patient should be
assigned a ‘Red Tag’?
A. A patient with a sucking chest wound and respiratory distress
B. A patient with a compound fracture of the forearm
,C. A patient with a minor abrasion and walking independently
D. A patient who is pulseless and non-breathing
Answer: A
Rationale: A Red Tag indicates an immediate threat to life that is treatable with rapid
intervention. A sucking chest wound causes severe respiratory distress but is survivable if
treated quickly, unlike a black tag patient who is already deceased or pulseless. Following
the START triage system, this patient represents the highest priority for transport and care.
3. A patient in the ICU is receiving mechanical ventilation. The low-pressure alarm sounds.
Which action should the nurse take first?
A. Check for a disconnection in the ventilator tubing
B. Administer a sedative to the patient
C. Increase the fraction of inspired oxygen (FiO2)
D. Suction the patient’s endotracheal tube
Answer: A
Rationale: A low-pressure alarm typically indicates a leak or a disconnection in the circuit,
which prevents the delivery of prescribed tidal volumes. The nurse must immediately
verify the integrity of the system to ensure the patient is receiving ventilation. If the cause
is not found quickly, the nurse should manually ventilate the patient with a bag-valve mask.
, 4. A nurse is caring for a patient in septic shock. Which hemodynamic parameter is most
indicative of the ‘warm’ or early phase of septic shock?
A. High cardiac output and low SVR
B. Increased systemic vascular resistance (SVR)
C. Decreased cardiac output
D. Decreased central venous pressure (CVP)
Answer: A
Rationale: In early septic shock, massive vasodilation leads to a decrease in systemic
vascular resistance (SVR) and a compensatory increase in cardiac output. This
hyperdynamic state creates warm, flushed skin, which is characteristic of the ‘warm’ shock
phase. Monitoring these parameters is essential for identifying the progression of the
inflammatory response before the patient enters the cold, hypodynamic phase.
5. A patient with ARDS is being placed in the prone position. What is the primary rationale for
this nursing intervention?
A. To decrease the patient’s work of breathing
B. To improve oxygenation by recruiting dorsal alveoli
C. To prevent ventilator-associated pneumonia
D. To make it easier for the nurse to suction the patient
Answer: B
Professional Nursing III / PN3 Exam Q&A |
Rasmussen University
1. A nurse is caring for a patient who has been involved in a motor vehicle accident and is
suspected of having a tension pneumothorax. Which assessment finding should the nurse
report to the provider immediately?
A. Tracheal deviation to the unaffected side
B. Bilateral breath sounds present
C. Oxygen saturation of 94% on room air
D. Localized chest pain upon inspiration
Answer: A
Rationale: Tracheal deviation is a late and life-threatening sign of a tension pneumothorax
where pressure shifts the mediastinum. This condition requires immediate decompression
to prevent cardiovascular collapse and respiratory failure. The nurse must prioritize this
finding over localized pain as it indicates a critical obstructive shock state.
2. During a mass casualty incident, a nurse is performing triage. Which patient should be
assigned a ‘Red Tag’?
A. A patient with a sucking chest wound and respiratory distress
B. A patient with a compound fracture of the forearm
,C. A patient with a minor abrasion and walking independently
D. A patient who is pulseless and non-breathing
Answer: A
Rationale: A Red Tag indicates an immediate threat to life that is treatable with rapid
intervention. A sucking chest wound causes severe respiratory distress but is survivable if
treated quickly, unlike a black tag patient who is already deceased or pulseless. Following
the START triage system, this patient represents the highest priority for transport and care.
3. A patient in the ICU is receiving mechanical ventilation. The low-pressure alarm sounds.
Which action should the nurse take first?
A. Check for a disconnection in the ventilator tubing
B. Administer a sedative to the patient
C. Increase the fraction of inspired oxygen (FiO2)
D. Suction the patient’s endotracheal tube
Answer: A
Rationale: A low-pressure alarm typically indicates a leak or a disconnection in the circuit,
which prevents the delivery of prescribed tidal volumes. The nurse must immediately
verify the integrity of the system to ensure the patient is receiving ventilation. If the cause
is not found quickly, the nurse should manually ventilate the patient with a bag-valve mask.
, 4. A nurse is caring for a patient in septic shock. Which hemodynamic parameter is most
indicative of the ‘warm’ or early phase of septic shock?
A. High cardiac output and low SVR
B. Increased systemic vascular resistance (SVR)
C. Decreased cardiac output
D. Decreased central venous pressure (CVP)
Answer: A
Rationale: In early septic shock, massive vasodilation leads to a decrease in systemic
vascular resistance (SVR) and a compensatory increase in cardiac output. This
hyperdynamic state creates warm, flushed skin, which is characteristic of the ‘warm’ shock
phase. Monitoring these parameters is essential for identifying the progression of the
inflammatory response before the patient enters the cold, hypodynamic phase.
5. A patient with ARDS is being placed in the prone position. What is the primary rationale for
this nursing intervention?
A. To decrease the patient’s work of breathing
B. To improve oxygenation by recruiting dorsal alveoli
C. To prevent ventilator-associated pneumonia
D. To make it easier for the nurse to suction the patient
Answer: B
