NR341/NR 341 Exam 2 V1 | Complex Adult Health
Q&A with Rationale | Chamberlain University
1. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position.
Which finding best indicates that this intervention is effective?
A. Reduced airway peak pressures
B. Decrease in heart rate from 110 to 90 bpm
C. Increased PaO2/FiO2 ratio
D. Increase in central venous pressure (CVP)
Correct Answer: C
Explanation: The primary goal of prone positioning in ARDS is to improve oxygenation by
recruiting dorsal lung segments and improving ventilation-perfusion matching. An increase
in the PaO2/FiO2 ratio indicates that gas exchange has improved significantly. The nurse
should continue to monitor arterial blood gases to evaluate the sustained effectiveness of
the position change.
2. A client is admitted with full-thickness burns to 30% of the body. Which assessment finding
is most critical to report to the healthcare provider during the emergent phase?
A. Pain level of 8 on a 10-point scale
B. Potassium level of 5.1 mEq/L
C. Urinary output of 20 mL/hr
,D. Blood pressure of 100/60 mmHg
Correct Answer: C
Explanation: During the emergent phase of a burn, fluid shift leads to hypovolemia, and
low urine output is a direct indicator of inadequate renal perfusion. The target urine output
for a burn patient is typically 0.5 to 1 mL/kg/hr or at least 30-50 mL/hr. A rate of 20 mL/hr
suggests the client is at risk for acute kidney injury and requires immediate fluid
adjustment.
3. The nurse is caring for a patient on a mechanical ventilator who is exhibiting signs of
respiratory distress. The high-pressure alarm is sounding. What is the priority nursing action?
A. Suction the patient’s endotracheal tube
B. Manually ventilate the patient with a bag-valve mask
C. Increase the oxygen concentration to 100%
D. Auscultate the patient’s breath sounds
Correct Answer: D
Explanation: The nurse should first assess the patient to determine the cause of the high-
pressure alarm, such as secretions, bronchospasm, or the patient biting the tube.
Auscultating breath sounds provides immediate information about lung expansion and
potential obstructions. If the cause is not immediately reversible and the patient is in
distress, manual ventilation would be the next step.
, 4. A patient’s ECG monitor shows a rapid, irregular rhythm with no discernible P waves. The
heart rate is 140 beats per minute. Which medication does the nurse anticipate
administering?
A. Diltiazem
B. Atropine
C. Epinephrine
D. Lidocaine
Correct Answer: A
Explanation: The description of no P waves and an irregular rhythm is consistent with
atrial fibrillation with a rapid ventricular response. Diltiazem is a calcium channel blocker
used to control the heart rate in patients with atrial fibrillation. Controlling the rate is
essential to improve cardiac output and prevent myocardial ischemia.
5. A client in the ICU has the following ABG results: pH 7.30, PaCO2 52, HCO3 24. How should
the nurse interpret these results?
A. Compensated respiratory alkalosis
B. Partially compensated metabolic acidosis
C. Uncompensated respiratory acidosis
D. Uncompensated metabolic alkalosis
Correct Answer: C
Q&A with Rationale | Chamberlain University
1. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position.
Which finding best indicates that this intervention is effective?
A. Reduced airway peak pressures
B. Decrease in heart rate from 110 to 90 bpm
C. Increased PaO2/FiO2 ratio
D. Increase in central venous pressure (CVP)
Correct Answer: C
Explanation: The primary goal of prone positioning in ARDS is to improve oxygenation by
recruiting dorsal lung segments and improving ventilation-perfusion matching. An increase
in the PaO2/FiO2 ratio indicates that gas exchange has improved significantly. The nurse
should continue to monitor arterial blood gases to evaluate the sustained effectiveness of
the position change.
2. A client is admitted with full-thickness burns to 30% of the body. Which assessment finding
is most critical to report to the healthcare provider during the emergent phase?
A. Pain level of 8 on a 10-point scale
B. Potassium level of 5.1 mEq/L
C. Urinary output of 20 mL/hr
,D. Blood pressure of 100/60 mmHg
Correct Answer: C
Explanation: During the emergent phase of a burn, fluid shift leads to hypovolemia, and
low urine output is a direct indicator of inadequate renal perfusion. The target urine output
for a burn patient is typically 0.5 to 1 mL/kg/hr or at least 30-50 mL/hr. A rate of 20 mL/hr
suggests the client is at risk for acute kidney injury and requires immediate fluid
adjustment.
3. The nurse is caring for a patient on a mechanical ventilator who is exhibiting signs of
respiratory distress. The high-pressure alarm is sounding. What is the priority nursing action?
A. Suction the patient’s endotracheal tube
B. Manually ventilate the patient with a bag-valve mask
C. Increase the oxygen concentration to 100%
D. Auscultate the patient’s breath sounds
Correct Answer: D
Explanation: The nurse should first assess the patient to determine the cause of the high-
pressure alarm, such as secretions, bronchospasm, or the patient biting the tube.
Auscultating breath sounds provides immediate information about lung expansion and
potential obstructions. If the cause is not immediately reversible and the patient is in
distress, manual ventilation would be the next step.
, 4. A patient’s ECG monitor shows a rapid, irregular rhythm with no discernible P waves. The
heart rate is 140 beats per minute. Which medication does the nurse anticipate
administering?
A. Diltiazem
B. Atropine
C. Epinephrine
D. Lidocaine
Correct Answer: A
Explanation: The description of no P waves and an irregular rhythm is consistent with
atrial fibrillation with a rapid ventricular response. Diltiazem is a calcium channel blocker
used to control the heart rate in patients with atrial fibrillation. Controlling the rate is
essential to improve cardiac output and prevent myocardial ischemia.
5. A client in the ICU has the following ABG results: pH 7.30, PaCO2 52, HCO3 24. How should
the nurse interpret these results?
A. Compensated respiratory alkalosis
B. Partially compensated metabolic acidosis
C. Uncompensated respiratory acidosis
D. Uncompensated metabolic alkalosis
Correct Answer: C
