NR341/NR 341 Final Exam V3 | Complex Adult
Health Q&A with Rationale | Chamberlain
University
1. A patient with septic shock is receiving large volumes of crystalloid fluids. Which clinical
finding should the nurse prioritize as an indication of fluid volume overload?
A. Decreased Pulmonary Artery Wedge Pressure (PAWP).
B. Decreased Mean Arterial Pressure (MAP) and tachycardia.
C. Increased urine output and improved skin turgor.
D. Increased Central Venous Pressure (CVP) and crackles in lungs.
Correct Answer: D
Explanation: Increased Central Venous Pressure (CVP) reflects an increase in right-sided
heart pressure often caused by fluid excess. Crackles in the lung fields indicate that fluid is
shifting into the alveoli, which is a hallmark sign of pulmonary edema. The nurse must
monitor these parameters closely during aggressive fluid resuscitation to prevent
respiratory failure.
2. A patient is admitted to the ICU with a diagnosis of Acute Respiratory Distress Syndrome
(ARDS). The nurse notes the patient’s PaO2/FiO2 ratio is 150. How should the nurse interpret
this finding?
A. The patient has moderate ARDS.
B. The patient has mild ARDS.
,C. The patient has severe ARDS.
D. The patient’s lung function is within normal limits.
Correct Answer: A
Explanation: According to the Berlin definition, a PaO2/FiO2 ratio between 100 and 200
mmHg classifies the condition as moderate ARDS. A ratio of less than 100 mmHg would
indicate severe ARDS, while 200-300 mmHg is mild. This calculation is vital for
determining the level of hypoxemia and guiding the intensity of mechanical ventilation
settings.
3. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mmHg.
Which nursing intervention is most appropriate to help reduce the ICP?
A. Maintain the head of the bed (HOB) at 30 to 45 degrees.
B. Encourage the patient to perform frequent coughing and deep breathing.
C. Cluster nursing care to allow for longer periods of rest.
D. Keep the neck in a flexed position to promote comfort.
Correct Answer: A
Explanation: Elevating the head of the bed to 30-45 degrees facilitates venous drainage
from the brain through the jugular veins, thereby decreasing intracranial pressure.
Coughing and deep breathing can increase intra-thoracic pressure, which conversely
increases ICP. Nursing care should be spaced out rather than clustered to avoid sustained
elevations in pressure.
, 4. A patient is in the compensatory stage of shock. Which physiological response should the
nurse expect to observe?
A. Activation of the Renin-Angiotensin-Aldosterone System (RAAS).
B. Decreased heart rate to conserve energy.
C. Vasodilation to increase blood flow to the skin.
D. Increased urine output due to improved renal perfusion.
Correct Answer: A
Explanation: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the RAAS and the sympathetic nervous system. This
leads to sodium and water retention to increase blood volume and vasoconstriction to
maintain blood pressure. Observing a decrease in urine output and an increase in heart
rate are common clinical signs during this phase.
5. Which lab value is the most important for a nurse to monitor in a patient receiving a
continuous infusion of Heparin for a pulmonary embolism?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Correct Answer: C
Health Q&A with Rationale | Chamberlain
University
1. A patient with septic shock is receiving large volumes of crystalloid fluids. Which clinical
finding should the nurse prioritize as an indication of fluid volume overload?
A. Decreased Pulmonary Artery Wedge Pressure (PAWP).
B. Decreased Mean Arterial Pressure (MAP) and tachycardia.
C. Increased urine output and improved skin turgor.
D. Increased Central Venous Pressure (CVP) and crackles in lungs.
Correct Answer: D
Explanation: Increased Central Venous Pressure (CVP) reflects an increase in right-sided
heart pressure often caused by fluid excess. Crackles in the lung fields indicate that fluid is
shifting into the alveoli, which is a hallmark sign of pulmonary edema. The nurse must
monitor these parameters closely during aggressive fluid resuscitation to prevent
respiratory failure.
2. A patient is admitted to the ICU with a diagnosis of Acute Respiratory Distress Syndrome
(ARDS). The nurse notes the patient’s PaO2/FiO2 ratio is 150. How should the nurse interpret
this finding?
A. The patient has moderate ARDS.
B. The patient has mild ARDS.
,C. The patient has severe ARDS.
D. The patient’s lung function is within normal limits.
Correct Answer: A
Explanation: According to the Berlin definition, a PaO2/FiO2 ratio between 100 and 200
mmHg classifies the condition as moderate ARDS. A ratio of less than 100 mmHg would
indicate severe ARDS, while 200-300 mmHg is mild. This calculation is vital for
determining the level of hypoxemia and guiding the intensity of mechanical ventilation
settings.
3. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mmHg.
Which nursing intervention is most appropriate to help reduce the ICP?
A. Maintain the head of the bed (HOB) at 30 to 45 degrees.
B. Encourage the patient to perform frequent coughing and deep breathing.
C. Cluster nursing care to allow for longer periods of rest.
D. Keep the neck in a flexed position to promote comfort.
Correct Answer: A
Explanation: Elevating the head of the bed to 30-45 degrees facilitates venous drainage
from the brain through the jugular veins, thereby decreasing intracranial pressure.
Coughing and deep breathing can increase intra-thoracic pressure, which conversely
increases ICP. Nursing care should be spaced out rather than clustered to avoid sustained
elevations in pressure.
, 4. A patient is in the compensatory stage of shock. Which physiological response should the
nurse expect to observe?
A. Activation of the Renin-Angiotensin-Aldosterone System (RAAS).
B. Decreased heart rate to conserve energy.
C. Vasodilation to increase blood flow to the skin.
D. Increased urine output due to improved renal perfusion.
Correct Answer: A
Explanation: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the RAAS and the sympathetic nervous system. This
leads to sodium and water retention to increase blood volume and vasoconstriction to
maintain blood pressure. Observing a decrease in urine output and an increase in heart
rate are common clinical signs during this phase.
5. Which lab value is the most important for a nurse to monitor in a patient receiving a
continuous infusion of Heparin for a pulmonary embolism?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Correct Answer: C
