NUR 417 Exam 1 V1 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 1) | Concordia
1. A patient in the ICU is being monitored via a pulmonary artery catheter. The nurse notes a
Central Venous Pressure (CVP) of 1 mmHg. Which intervention should the nurse anticipate
first?
A. Infusion of a rapid intravenous fluid bolus
B. Administration of a loop diuretic
C. Preparation for immediate needle thoracostomy
D. Titration of a norepinephrine infusion
Correct Answer: A
Explanation: A Central Venous Pressure (CVP) of 1 mmHg is significantly below the
normal range of 2 to 8 mmHg, indicating hypovolemia or decreased preload. The primary
intervention for low CVP is fluid resuscitation to restore intravascular volume and improve
cardiac output. The nurse must monitor the patient closely for signs of fluid volume
overload during this process.
2. A patient with Diabetic Ketoacidosis (DKA) has a serum glucose of 240 mg/dL and the
insulin infusion is ongoing. Which action is most appropriate for the nurse to take next?
A. Discontinue the insulin infusion immediately
B. Increase the insulin infusion rate to clear ketones
,C. Switch the intravenous fluid to 5% dextrose in 0.45% normal saline
D. Administer subcutaneous glargine and stop the IV insulin
Correct Answer: C
Explanation: When blood glucose levels reach approximately 200-250 mg/dL in a DKA
patient, dextrose is added to the intravenous fluids to prevent hypoglycemia and allow for
the continued administration of insulin. The continued insulin is necessary to suppress
ketogenesis and resolve the underlying acidosis. Stopping the insulin prematurely can lead
to a rebound of ketoacidosis even if the blood sugar is lower.
3. The nurse is caring for a patient on mechanical ventilation. The high-pressure alarm begins
to sound. Which conditions could be the cause? (Select All That Apply)
A. Excessive secretions in the airway
B. The patient is biting the endotracheal tube
C. Disconnection of the ventilator circuit
D. Development of a tension pneumothorax
E. Extubation of the patient
F. Kinked ventilator tubing
Correct Answer: A, B, D, F
Explanation: High-pressure alarms are triggered by increased resistance in the system or
the patient’s lungs, such as secretions, biting the tube, kinks, or decreased lung compliance
,as seen in pneumothorax. Low-pressure alarms, conversely, are usually caused by
disconnections or leaks where the expected pressure is not met. The nurse must quickly
assess the patient’s respiratory status and check the equipment to identify the specific
cause.
4. Which clinical manifestation is a late sign of increased intracranial pressure (ICP)?
A. Restlessness and irritability
B. Slurred speech
C. Cushing’s triad
D. Constant headache
Correct Answer: C
Explanation: Cushing’s triad, which consists of bradycardia, hypertension with a widening
pulse pressure, and irregular respirations, is a late and ominous sign of brainstem
compression and increased ICP. Early signs of increased ICP are usually neurological
changes such as restlessness or a decreased level of consciousness. Once Cushing’s triad
appears, immediate intervention is required to prevent brain herniation.
5. A patient admitted with septic shock is receiving aggressive fluid resuscitation. Which
finding indicates the therapy is effective?
A. Heart rate of 115 beats per minute
B. Serum lactate level of 5.2 mmol/L
C. Mean Arterial Pressure (MAP) of 50 mmHg
, D. Urine output of 0.5 mL/kg/hr
Correct Answer: D
Explanation: Adequate urine output (minimum 0.5 mL/kg/hr) is a gold standard indicator
of end-organ perfusion during fluid resuscitation in shock. A MAP of at least 65 mmHg is
typically targeted; 50 mmHg is too low and indicates ongoing shock. A decrease in serum
lactate would be a positive sign, but a level of 5.2 mmol/L remains high and indicates
persistent tissue hypoxia.
6. A patient with Acute Respiratory Distress Syndrome (ARDS) is being placed in the prone
position. What is the primary physiological benefit of this intervention?
A. To increase the ease of suctioning secretions
B. To recruit alveoli and improve oxygenation in dorsal lung regions
C. To decrease the patient’s work of breathing
D. To prevent the development of ventilator-associated pneumonia
Correct Answer: B
Explanation: Prone positioning in ARDS helps to improve ventilation-perfusion (V/Q)
matching by recruiting collapsed alveoli in the dorsal lung fields, which are often the most
affected in ARDS. By shifting the weight of the heart and abdominal contents away from the
dorsal lungs, oxygenation is enhanced. This technique is often used as a rescue therapy for
patients with severe refractory hypoxemia.
Adult II | Actual Q&A with Rationale (NUR417
Exam 1) | Concordia
1. A patient in the ICU is being monitored via a pulmonary artery catheter. The nurse notes a
Central Venous Pressure (CVP) of 1 mmHg. Which intervention should the nurse anticipate
first?
A. Infusion of a rapid intravenous fluid bolus
B. Administration of a loop diuretic
C. Preparation for immediate needle thoracostomy
D. Titration of a norepinephrine infusion
Correct Answer: A
Explanation: A Central Venous Pressure (CVP) of 1 mmHg is significantly below the
normal range of 2 to 8 mmHg, indicating hypovolemia or decreased preload. The primary
intervention for low CVP is fluid resuscitation to restore intravascular volume and improve
cardiac output. The nurse must monitor the patient closely for signs of fluid volume
overload during this process.
2. A patient with Diabetic Ketoacidosis (DKA) has a serum glucose of 240 mg/dL and the
insulin infusion is ongoing. Which action is most appropriate for the nurse to take next?
A. Discontinue the insulin infusion immediately
B. Increase the insulin infusion rate to clear ketones
,C. Switch the intravenous fluid to 5% dextrose in 0.45% normal saline
D. Administer subcutaneous glargine and stop the IV insulin
Correct Answer: C
Explanation: When blood glucose levels reach approximately 200-250 mg/dL in a DKA
patient, dextrose is added to the intravenous fluids to prevent hypoglycemia and allow for
the continued administration of insulin. The continued insulin is necessary to suppress
ketogenesis and resolve the underlying acidosis. Stopping the insulin prematurely can lead
to a rebound of ketoacidosis even if the blood sugar is lower.
3. The nurse is caring for a patient on mechanical ventilation. The high-pressure alarm begins
to sound. Which conditions could be the cause? (Select All That Apply)
A. Excessive secretions in the airway
B. The patient is biting the endotracheal tube
C. Disconnection of the ventilator circuit
D. Development of a tension pneumothorax
E. Extubation of the patient
F. Kinked ventilator tubing
Correct Answer: A, B, D, F
Explanation: High-pressure alarms are triggered by increased resistance in the system or
the patient’s lungs, such as secretions, biting the tube, kinks, or decreased lung compliance
,as seen in pneumothorax. Low-pressure alarms, conversely, are usually caused by
disconnections or leaks where the expected pressure is not met. The nurse must quickly
assess the patient’s respiratory status and check the equipment to identify the specific
cause.
4. Which clinical manifestation is a late sign of increased intracranial pressure (ICP)?
A. Restlessness and irritability
B. Slurred speech
C. Cushing’s triad
D. Constant headache
Correct Answer: C
Explanation: Cushing’s triad, which consists of bradycardia, hypertension with a widening
pulse pressure, and irregular respirations, is a late and ominous sign of brainstem
compression and increased ICP. Early signs of increased ICP are usually neurological
changes such as restlessness or a decreased level of consciousness. Once Cushing’s triad
appears, immediate intervention is required to prevent brain herniation.
5. A patient admitted with septic shock is receiving aggressive fluid resuscitation. Which
finding indicates the therapy is effective?
A. Heart rate of 115 beats per minute
B. Serum lactate level of 5.2 mmol/L
C. Mean Arterial Pressure (MAP) of 50 mmHg
, D. Urine output of 0.5 mL/kg/hr
Correct Answer: D
Explanation: Adequate urine output (minimum 0.5 mL/kg/hr) is a gold standard indicator
of end-organ perfusion during fluid resuscitation in shock. A MAP of at least 65 mmHg is
typically targeted; 50 mmHg is too low and indicates ongoing shock. A decrease in serum
lactate would be a positive sign, but a level of 5.2 mmol/L remains high and indicates
persistent tissue hypoxia.
6. A patient with Acute Respiratory Distress Syndrome (ARDS) is being placed in the prone
position. What is the primary physiological benefit of this intervention?
A. To increase the ease of suctioning secretions
B. To recruit alveoli and improve oxygenation in dorsal lung regions
C. To decrease the patient’s work of breathing
D. To prevent the development of ventilator-associated pneumonia
Correct Answer: B
Explanation: Prone positioning in ARDS helps to improve ventilation-perfusion (V/Q)
matching by recruiting collapsed alveoli in the dorsal lung fields, which are often the most
affected in ARDS. By shifting the weight of the heart and abdominal contents away from the
dorsal lungs, oxygenation is enhanced. This technique is often used as a rescue therapy for
patients with severe refractory hypoxemia.
