NURS 480 Exam 2 V3 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 2) | West Coast University
1. A nurse is caring for a client in the ICU with a Mean Arterial Pressure (MAP) of 58 mmHg.
Which action should the nurse prioritize?
A. Place the client in a high-Fowler’s position.
B. Decrease the rate of the current vasopressor infusion.
C. Administer a prescribed IV fluid bolus to increase volume.
D. Continue to monitor the client’s vital signs every hour.
Answer: C
Rationale: A MAP below 65 mmHg indicates inadequate organ perfusion and requires
immediate intervention. Administering a fluid bolus is the initial step to increase preload
and improve cardiac output. The nurse must act quickly to prevent acute kidney injury or
other end-organ damage caused by hypotension.
2. When interpreting a client’s hemodynamic parameters, the nurse notes a Central Venous
Pressure (CVP) of 1 mmHg. What does this finding likely indicate?
A. Hypervolemia due to renal failure.
B. Hypovolemia requiring fluid resuscitation.
,C. Right-sided heart failure causing congestion.
D. Adequate fluid balance and tissue perfusion.
Answer: B
Rationale: The normal range for Central Venous Pressure is typically 2 to 8 mmHg. A value
of 1 mmHg indicates a low preload, which is most commonly caused by hypovolemia. The
nurse should anticipate orders for IV fluids or blood products depending on the underlying
cause.
3. A client is diagnosed with ARDS and is placed on mechanical ventilation with High PEEP.
Which complication should the nurse monitor for?
A. Increased cardiac output.
B. Decreased venous return and hypotension.
C. Improved renal perfusion.
D. Decreased intracranial pressure.
Answer: B
Rationale: High levels of Positive End-Expiratory Pressure (PEEP) increase intrathoracic
pressure, which can compress the vena cava. This leads to decreased venous return to the
heart, subsequently lowering cardiac output and blood pressure. The nurse must monitor
the client’s hemodynamics closely when PEEP is titrated upward.
, 4. A nurse assesses a client in the early stages of septic shock. Which clinical finding is
characteristic of this ‘warm’ phase?
A. Bradycardia and hypertension.
B. Increased cardiac output and vasodilation.
C. Cool, clammy skin and oliguria.
D. Decreased peripheral pulses and cyanosis.
Answer: B
Rationale: In the early or hyperdynamic phase of septic shock, the body compensates for
infection with a high cardiac output. Vasodilation occurs due to inflammatory mediators,
making the skin feel warm and flushed. This stage is transient and will lead to the cold
phase if not treated effectively.
5. The nurse is caring for a client with a Pulmonary Artery Wedge Pressure (PAWP) of 22
mmHg. Which assessment finding is most likely?
A. Flat neck veins and dry mucous membranes.
B. Elevated urine output.
C. Strong, bounding peripheral pulses.
D. Crackles in the lungs and dyspnea.
Answer: D
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 2) | West Coast University
1. A nurse is caring for a client in the ICU with a Mean Arterial Pressure (MAP) of 58 mmHg.
Which action should the nurse prioritize?
A. Place the client in a high-Fowler’s position.
B. Decrease the rate of the current vasopressor infusion.
C. Administer a prescribed IV fluid bolus to increase volume.
D. Continue to monitor the client’s vital signs every hour.
Answer: C
Rationale: A MAP below 65 mmHg indicates inadequate organ perfusion and requires
immediate intervention. Administering a fluid bolus is the initial step to increase preload
and improve cardiac output. The nurse must act quickly to prevent acute kidney injury or
other end-organ damage caused by hypotension.
2. When interpreting a client’s hemodynamic parameters, the nurse notes a Central Venous
Pressure (CVP) of 1 mmHg. What does this finding likely indicate?
A. Hypervolemia due to renal failure.
B. Hypovolemia requiring fluid resuscitation.
,C. Right-sided heart failure causing congestion.
D. Adequate fluid balance and tissue perfusion.
Answer: B
Rationale: The normal range for Central Venous Pressure is typically 2 to 8 mmHg. A value
of 1 mmHg indicates a low preload, which is most commonly caused by hypovolemia. The
nurse should anticipate orders for IV fluids or blood products depending on the underlying
cause.
3. A client is diagnosed with ARDS and is placed on mechanical ventilation with High PEEP.
Which complication should the nurse monitor for?
A. Increased cardiac output.
B. Decreased venous return and hypotension.
C. Improved renal perfusion.
D. Decreased intracranial pressure.
Answer: B
Rationale: High levels of Positive End-Expiratory Pressure (PEEP) increase intrathoracic
pressure, which can compress the vena cava. This leads to decreased venous return to the
heart, subsequently lowering cardiac output and blood pressure. The nurse must monitor
the client’s hemodynamics closely when PEEP is titrated upward.
, 4. A nurse assesses a client in the early stages of septic shock. Which clinical finding is
characteristic of this ‘warm’ phase?
A. Bradycardia and hypertension.
B. Increased cardiac output and vasodilation.
C. Cool, clammy skin and oliguria.
D. Decreased peripheral pulses and cyanosis.
Answer: B
Rationale: In the early or hyperdynamic phase of septic shock, the body compensates for
infection with a high cardiac output. Vasodilation occurs due to inflammatory mediators,
making the skin feel warm and flushed. This stage is transient and will lead to the cold
phase if not treated effectively.
5. The nurse is caring for a client with a Pulmonary Artery Wedge Pressure (PAWP) of 22
mmHg. Which assessment finding is most likely?
A. Flat neck veins and dry mucous membranes.
B. Elevated urine output.
C. Strong, bounding peripheral pulses.
D. Crackles in the lungs and dyspnea.
Answer: D
