NURS 480 Exam 1 V1 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 1) | West Coast University
1. A nurse is caring for a patient with ARDS who is being mechanically ventilated. Which
positioning technique is most likely to improve oxygenation by recruiting more alveoli?
A. Supine
B. High-Fowler’s
C. Trendelenburg
D. Prone
Answer: D
Rationale: Prone positioning is a common intervention used in severe ARDS to improve
oxygenation and ventilation-perfusion matching. It works by shifting the weight of the
heart and abdominal contents away from the dorsal lung regions, allowing those alveoli to
re-expand. This technique is often used as a rescue therapy when other ventilation
strategies fail to maintain adequate PaO2 levels.
2. When assessing a patient’s hemodynamic profile, the nurse notes a CVP of 1 mmHg. What
is the most appropriate initial nursing action?
A. Administer a diuretic as ordered
,B. Perform a 12-lead EKG
C. Prepare for immediate intubation
D. Administer a fluid bolus of normal saline
Answer: D
Rationale: A Central Venous Pressure (CVP) of 1 mmHg is significantly below the normal
range of 2 to 8 mmHg, indicating hypovolemia. The nurse should prioritize fluid
resuscitation to restore intravascular volume and improve preload. Failing to address a low
CVP can lead to decreased cardiac output and inadequate tissue perfusion.
3. A patient in the ICU is on a ventilator with a high-pressure alarm sounding. After checking
the patient, what is the most likely cause of this alarm?
A. The patient’s cuff has a slow leak
B. A leak in the ventilator circuit
C. The endotracheal tube has become disconnected
D. Patient is biting the endotracheal tube
Answer: D
Rationale: High-pressure alarms are triggered when the ventilator meets resistance while
attempting to deliver the set tidal volume. Biting the endotracheal tube, secretions in the
airway, or kinking of the tubing are common causes of this alarm. In contrast, leaks or
,disconnections would typically trigger a low-pressure alarm due to the loss of pressure in
the circuit.
4. The nurse is caring for a patient with septic shock. Which laboratory value is the most
critical indicator of tissue hypoxia and hypoperfusion?
A. Hemoglobin
B. Blood Urea Nitrogen (BUN)
C. White Blood Cell (WBC) count
D. Serum Lactate
Answer: D
Rationale: Serum lactate levels are a hallmark indicator of anaerobic metabolism
occurring at the cellular level during shock states. Elevated lactate levels above 2 mmol/L
suggest that the cells are not receiving enough oxygen, leading to metabolic acidosis.
Monitoring lactate is essential for evaluating the effectiveness of resuscitation and the
severity of the shock.
5. In the emergent phase of burn care, which electrolyte imbalance is most commonly
expected by the nurse?
A. Hypokalemia
B. Hypoglycemia
C. Hypercalcemia
, D. Hyperkalemia
Answer: D
Rationale: During the initial emergent phase of a major burn, cell destruction occurs,
leading to the release of intracellular potassium into the extracellular space. This results in
hyperkalemia, which must be monitored closely to prevent cardiac arrhythmias. Potassium
levels typically begin to normalize or even drop as the fluid shift resolves and diuresis
begins.
6. A nurse is evaluating ABG results: pH 7.25, PaCO2 55, HCO3 26. How should the nurse
interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH of 7.25 indicates acidosis, while the PaCO2 of 55 is elevated, suggesting
a respiratory cause for the pH imbalance. The HCO3 is within the normal range, indicating
that the kidneys have not yet significantly compensated for the imbalance. This profile is
consistent with acute respiratory acidosis, often seen in conditions that impair alveolar
ventilation.
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 1) | West Coast University
1. A nurse is caring for a patient with ARDS who is being mechanically ventilated. Which
positioning technique is most likely to improve oxygenation by recruiting more alveoli?
A. Supine
B. High-Fowler’s
C. Trendelenburg
D. Prone
Answer: D
Rationale: Prone positioning is a common intervention used in severe ARDS to improve
oxygenation and ventilation-perfusion matching. It works by shifting the weight of the
heart and abdominal contents away from the dorsal lung regions, allowing those alveoli to
re-expand. This technique is often used as a rescue therapy when other ventilation
strategies fail to maintain adequate PaO2 levels.
2. When assessing a patient’s hemodynamic profile, the nurse notes a CVP of 1 mmHg. What
is the most appropriate initial nursing action?
A. Administer a diuretic as ordered
,B. Perform a 12-lead EKG
C. Prepare for immediate intubation
D. Administer a fluid bolus of normal saline
Answer: D
Rationale: A Central Venous Pressure (CVP) of 1 mmHg is significantly below the normal
range of 2 to 8 mmHg, indicating hypovolemia. The nurse should prioritize fluid
resuscitation to restore intravascular volume and improve preload. Failing to address a low
CVP can lead to decreased cardiac output and inadequate tissue perfusion.
3. A patient in the ICU is on a ventilator with a high-pressure alarm sounding. After checking
the patient, what is the most likely cause of this alarm?
A. The patient’s cuff has a slow leak
B. A leak in the ventilator circuit
C. The endotracheal tube has become disconnected
D. Patient is biting the endotracheal tube
Answer: D
Rationale: High-pressure alarms are triggered when the ventilator meets resistance while
attempting to deliver the set tidal volume. Biting the endotracheal tube, secretions in the
airway, or kinking of the tubing are common causes of this alarm. In contrast, leaks or
,disconnections would typically trigger a low-pressure alarm due to the loss of pressure in
the circuit.
4. The nurse is caring for a patient with septic shock. Which laboratory value is the most
critical indicator of tissue hypoxia and hypoperfusion?
A. Hemoglobin
B. Blood Urea Nitrogen (BUN)
C. White Blood Cell (WBC) count
D. Serum Lactate
Answer: D
Rationale: Serum lactate levels are a hallmark indicator of anaerobic metabolism
occurring at the cellular level during shock states. Elevated lactate levels above 2 mmol/L
suggest that the cells are not receiving enough oxygen, leading to metabolic acidosis.
Monitoring lactate is essential for evaluating the effectiveness of resuscitation and the
severity of the shock.
5. In the emergent phase of burn care, which electrolyte imbalance is most commonly
expected by the nurse?
A. Hypokalemia
B. Hypoglycemia
C. Hypercalcemia
, D. Hyperkalemia
Answer: D
Rationale: During the initial emergent phase of a major burn, cell destruction occurs,
leading to the release of intracellular potassium into the extracellular space. This results in
hyperkalemia, which must be monitored closely to prevent cardiac arrhythmias. Potassium
levels typically begin to normalize or even drop as the fluid shift resolves and diuresis
begins.
6. A nurse is evaluating ABG results: pH 7.25, PaCO2 55, HCO3 26. How should the nurse
interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH of 7.25 indicates acidosis, while the PaCO2 of 55 is elevated, suggesting
a respiratory cause for the pH imbalance. The HCO3 is within the normal range, indicating
that the kidneys have not yet significantly compensated for the imbalance. This profile is
consistent with acute respiratory acidosis, often seen in conditions that impair alveolar
ventilation.
