NUR 417 Exam 3 V2 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 3) | Concordia
1. A patient with ARDS is receiving mechanical ventilation with high levels of PEEP. Which
assessment finding should the nurse prioritize as a potential complication of PEEP?
A. Subcutaneous emphysema and pneumothorax
B. Increased cardiac output
C. Decreased intracranial pressure
D. Increased urine output
Correct Answer: A
Explanation: High levels of PEEP can lead to barotrauma, which may manifest as
subcutaneous emphysema or a tension pneumothorax. This occurs because the increased
intrathoracic pressure can cause alveolar rupture. The nurse must monitor for decreased
breath sounds and tracheal deviation to ensure patient safety.
2. The nurse is caring for a patient in the early stages of septic shock. Which clinical
manifestation is most characteristic of the ‘warm’ phase of sepsis?
A. Cool, clammy skin
B. Decreased heart rate
C. Increased cardiac output and flushed skin
,D. Severely low blood pressure requiring vasopressors
Correct Answer: C
Explanation: In the early hyperdynamic phase of septic shock, the body compensates by
increasing cardiac output and decreasing systemic vascular resistance. This results in
warm, flushed skin and a bounding pulse. Recognizing this stage is critical for initiating
early fluid resuscitation and antibiotic therapy to prevent progression to the ‘cold’ phase.
3. A patient is admitted with 40% total body surface area (TBSA) burns. Using the Parkland
formula (4mL x kg x %TBSA), how much fluid should the 70kg patient receive in the first 8
hours?
A. 11,200 mL
B. 5,600 mL
C. 2,800 mL
D. 8,400 mL
Correct Answer: B
Explanation: The Parkland formula calculates total fluid for 24 hours: 4mL x 70kg x 40% =
11,200 mL. Half of this total volume must be administered in the first 8 hours following the
injury, which equals 5,600 mL. Accurate fluid resuscitation is vital to prevent hypovolemic
shock and maintain organ perfusion in burn patients.
, 4. Which electrolyte imbalance is the primary concern during the initial resuscitative phase of
a major burn injury?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B
Explanation: During the initial burn injury, massive cell destruction causes potassium to
leak out of the intracellular compartment into the extracellular space. This leads to
hyperkalemia, which can cause life-threatening cardiac arrhythmias. The nurse must
monitor the ECG closely and prepare for interventions to lower serum potassium if
necessary.
5. A patient’s ventilator alarm sounds, indicating ‘High Pressure.’ What is the most
appropriate initial action by the nurse?
A. Silence the alarm and check the settings
B. Disconnect the patient and use a manual resuscitation bag
C. Call the respiratory therapist immediately
D. Suction the patient’s airway
Correct Answer: D
Adult II | Actual Q&A with Rationale (NUR417
Exam 3) | Concordia
1. A patient with ARDS is receiving mechanical ventilation with high levels of PEEP. Which
assessment finding should the nurse prioritize as a potential complication of PEEP?
A. Subcutaneous emphysema and pneumothorax
B. Increased cardiac output
C. Decreased intracranial pressure
D. Increased urine output
Correct Answer: A
Explanation: High levels of PEEP can lead to barotrauma, which may manifest as
subcutaneous emphysema or a tension pneumothorax. This occurs because the increased
intrathoracic pressure can cause alveolar rupture. The nurse must monitor for decreased
breath sounds and tracheal deviation to ensure patient safety.
2. The nurse is caring for a patient in the early stages of septic shock. Which clinical
manifestation is most characteristic of the ‘warm’ phase of sepsis?
A. Cool, clammy skin
B. Decreased heart rate
C. Increased cardiac output and flushed skin
,D. Severely low blood pressure requiring vasopressors
Correct Answer: C
Explanation: In the early hyperdynamic phase of septic shock, the body compensates by
increasing cardiac output and decreasing systemic vascular resistance. This results in
warm, flushed skin and a bounding pulse. Recognizing this stage is critical for initiating
early fluid resuscitation and antibiotic therapy to prevent progression to the ‘cold’ phase.
3. A patient is admitted with 40% total body surface area (TBSA) burns. Using the Parkland
formula (4mL x kg x %TBSA), how much fluid should the 70kg patient receive in the first 8
hours?
A. 11,200 mL
B. 5,600 mL
C. 2,800 mL
D. 8,400 mL
Correct Answer: B
Explanation: The Parkland formula calculates total fluid for 24 hours: 4mL x 70kg x 40% =
11,200 mL. Half of this total volume must be administered in the first 8 hours following the
injury, which equals 5,600 mL. Accurate fluid resuscitation is vital to prevent hypovolemic
shock and maintain organ perfusion in burn patients.
, 4. Which electrolyte imbalance is the primary concern during the initial resuscitative phase of
a major burn injury?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B
Explanation: During the initial burn injury, massive cell destruction causes potassium to
leak out of the intracellular compartment into the extracellular space. This leads to
hyperkalemia, which can cause life-threatening cardiac arrhythmias. The nurse must
monitor the ECG closely and prepare for interventions to lower serum potassium if
necessary.
5. A patient’s ventilator alarm sounds, indicating ‘High Pressure.’ What is the most
appropriate initial action by the nurse?
A. Silence the alarm and check the settings
B. Disconnect the patient and use a manual resuscitation bag
C. Call the respiratory therapist immediately
D. Suction the patient’s airway
Correct Answer: D
