NUR 417 Exam 3 V3 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 3) | Concordia
1. A patient is admitted to the ICU with a diagnosis of Septic Shock. The nurse notes the
patient’s blood pressure is 82/46 mmHg, heart rate 128 bpm, and lactate level 4.2 mmol/L.
Which of the following interventions should the nurse prioritize during the first hour of
treatment? (Select all that apply)
A. Administer a 30 mL/kg isotonic fluid bolus.
B. Obtain blood cultures before starting antibiotics.
C. Initiate broad-spectrum antibiotics.
D. Start vasopressors if MAP remains below 65 mmHg after fluid resuscitation.
E. Administer high-dose corticosteroids immediately.
Correct Answer: ABCD
Explanation: According to the Surviving Sepsis Campaign, the 1-hour bundle includes
measuring lactate levels, obtaining blood cultures, administering broad-spectrum
antibiotics, and beginning fluid resuscitation with crystalloids for hypotension or lactate
≥4. Vasopressors should be applied if the patient is hypotensive during or after fluid
resuscitation to maintain a MAP ≥65 mmHg. Corticosteroids are typically reserved for
patients who remain hemodynamically unstable despite fluid and vasopressor therapy, not
as a first-line 1-hour intervention.
,2. A 45-year-old male arrives at the emergency department with partial and full-thickness
burns to his entire right arm, the anterior trunk, and the anterior right leg. Using the Rule of
Nines, calculate the total body surface area (TBSA) affected.
A. 27%
B. 18%
C. 45%
D. 36%
Correct Answer: D
Explanation: The Rule of Nines assigns 9% to the entire right arm, 18% to the anterior
trunk, and 9% to the anterior right leg (the whole leg is 18%, so anterior only is 9%).
Adding these together: 9 + 18 + 9 = 36%. Accurate calculation is critical for determining
fluid resuscitation needs in the emergency phase.
3. A patient with Acute Kidney Injury (AKI) is in the diuretic phase. What is the priority
nursing assessment during this stage?
A. Monitoring for signs of hyperkalemia and metabolic acidosis.
B. Assessing for fluid volume deficit and electrolyte imbalances like hypokalemia.
C. Restricting fluid intake to 500 mL plus the previous day’s output.
D. Assessing for weight gain and peripheral edema.
Correct Answer: B
,Explanation: During the diuretic phase of AKI, the kidneys begin to recover their ability to
excrete waste but cannot yet concentrate urine, leading to massive fluid loss. The nurse
must monitor for dehydration, hypovolemia, and electrolyte depletion, especially
hypokalemia and hyponatremia. This phase is the opposite of the oliguric phase where
fluid restriction and monitoring for hyperkalemia would be prioritized.
4. A patient is admitted with Diabetic Ketoacidosis (DKA). The nurse identifies which of the
following as clinical manifestations characteristic of DKA? (Select all that apply)
A. Kussmaul respirations
B. Fruity breath odor
C. Blood glucose of 1,200 mg/dL
D. Serum bicarbonate level of 12 mEq/L
E. Presence of ketones in the urine
Correct Answer: ABDE
Explanation: DKA is characterized by metabolic acidosis (low bicarbonate), ketosis
(ketones in urine/breath), and compensatory Kussmaul respirations to blow off CO2. While
hyperglycemia is present, levels of 1,200 mg/dL are more commonly associated with
Hyperosmolar Hyperglycemic State (HHS) rather than DKA, which usually presents with
glucose between 250-600 mg/dL. The fruity breath odor is a direct result of acetone
production during ketosis.
, 5. A patient is receiving treatment for Syndrome of Inappropriate Antidiuretic Hormone
(SIADH). Which order should the nurse question?
A. Fluid restriction of 800 mL per 24 hours.
B. Frequent oral intake of ice chips and water.
C. Administration of 3% Hypertonic Saline via a central line.
D. Seizure precautions.
Correct Answer: B
Explanation: SIADH involves excessive water retention and dilutional hyponatremia, so
fluid restriction is a primary intervention. Encouraging oral intake of water or ice chips
would worsen the condition and potentially lead to cerebral edema or seizures. The use of
3% hypertonic saline is appropriate for severe hyponatremia but must be administered
carefully.
6. Which assessment finding in a patient with a T4 spinal cord injury indicates the
development of neurogenic shock?
A. Bradycardia and hypotension.
B. Tachycardia and hypertension.
C. Cool, clammy skin below the level of injury.
D. Increased systemic vascular resistance (SVR).
Correct Answer: A
Adult II | Actual Q&A with Rationale (NUR417
Exam 3) | Concordia
1. A patient is admitted to the ICU with a diagnosis of Septic Shock. The nurse notes the
patient’s blood pressure is 82/46 mmHg, heart rate 128 bpm, and lactate level 4.2 mmol/L.
Which of the following interventions should the nurse prioritize during the first hour of
treatment? (Select all that apply)
A. Administer a 30 mL/kg isotonic fluid bolus.
B. Obtain blood cultures before starting antibiotics.
C. Initiate broad-spectrum antibiotics.
D. Start vasopressors if MAP remains below 65 mmHg after fluid resuscitation.
E. Administer high-dose corticosteroids immediately.
Correct Answer: ABCD
Explanation: According to the Surviving Sepsis Campaign, the 1-hour bundle includes
measuring lactate levels, obtaining blood cultures, administering broad-spectrum
antibiotics, and beginning fluid resuscitation with crystalloids for hypotension or lactate
≥4. Vasopressors should be applied if the patient is hypotensive during or after fluid
resuscitation to maintain a MAP ≥65 mmHg. Corticosteroids are typically reserved for
patients who remain hemodynamically unstable despite fluid and vasopressor therapy, not
as a first-line 1-hour intervention.
,2. A 45-year-old male arrives at the emergency department with partial and full-thickness
burns to his entire right arm, the anterior trunk, and the anterior right leg. Using the Rule of
Nines, calculate the total body surface area (TBSA) affected.
A. 27%
B. 18%
C. 45%
D. 36%
Correct Answer: D
Explanation: The Rule of Nines assigns 9% to the entire right arm, 18% to the anterior
trunk, and 9% to the anterior right leg (the whole leg is 18%, so anterior only is 9%).
Adding these together: 9 + 18 + 9 = 36%. Accurate calculation is critical for determining
fluid resuscitation needs in the emergency phase.
3. A patient with Acute Kidney Injury (AKI) is in the diuretic phase. What is the priority
nursing assessment during this stage?
A. Monitoring for signs of hyperkalemia and metabolic acidosis.
B. Assessing for fluid volume deficit and electrolyte imbalances like hypokalemia.
C. Restricting fluid intake to 500 mL plus the previous day’s output.
D. Assessing for weight gain and peripheral edema.
Correct Answer: B
,Explanation: During the diuretic phase of AKI, the kidneys begin to recover their ability to
excrete waste but cannot yet concentrate urine, leading to massive fluid loss. The nurse
must monitor for dehydration, hypovolemia, and electrolyte depletion, especially
hypokalemia and hyponatremia. This phase is the opposite of the oliguric phase where
fluid restriction and monitoring for hyperkalemia would be prioritized.
4. A patient is admitted with Diabetic Ketoacidosis (DKA). The nurse identifies which of the
following as clinical manifestations characteristic of DKA? (Select all that apply)
A. Kussmaul respirations
B. Fruity breath odor
C. Blood glucose of 1,200 mg/dL
D. Serum bicarbonate level of 12 mEq/L
E. Presence of ketones in the urine
Correct Answer: ABDE
Explanation: DKA is characterized by metabolic acidosis (low bicarbonate), ketosis
(ketones in urine/breath), and compensatory Kussmaul respirations to blow off CO2. While
hyperglycemia is present, levels of 1,200 mg/dL are more commonly associated with
Hyperosmolar Hyperglycemic State (HHS) rather than DKA, which usually presents with
glucose between 250-600 mg/dL. The fruity breath odor is a direct result of acetone
production during ketosis.
, 5. A patient is receiving treatment for Syndrome of Inappropriate Antidiuretic Hormone
(SIADH). Which order should the nurse question?
A. Fluid restriction of 800 mL per 24 hours.
B. Frequent oral intake of ice chips and water.
C. Administration of 3% Hypertonic Saline via a central line.
D. Seizure precautions.
Correct Answer: B
Explanation: SIADH involves excessive water retention and dilutional hyponatremia, so
fluid restriction is a primary intervention. Encouraging oral intake of water or ice chips
would worsen the condition and potentially lead to cerebral edema or seizures. The use of
3% hypertonic saline is appropriate for severe hyponatremia but must be administered
carefully.
6. Which assessment finding in a patient with a T4 spinal cord injury indicates the
development of neurogenic shock?
A. Bradycardia and hypotension.
B. Tachycardia and hypertension.
C. Cool, clammy skin below the level of injury.
D. Increased systemic vascular resistance (SVR).
Correct Answer: A
