NUR 417 Exam 1 V2 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 1) | Concordia
1. A patient is admitted to the intensive care unit with a diagnosis of acute respiratory
distress syndrome (ARDS). Which clinical manifestation should the nurse expect to find
during the initial assessment?
A. Increased lung compliance and decreased work of breathing
B. Respiratory alkalosis caused by hypoventilation
C. Hypoxemia that does not respond to supplemental oxygen therapy
D. Decreased pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Explanation: Refractory hypoxemia is a hallmark sign of ARDS where the patient remains
hypoxic despite high levels of inspired oxygen. This occurs due to severe intrapulmonary
shunting and the collapse of alveoli. The nurse must monitor for this finding as it indicates
progressive respiratory failure requiring advanced intervention like PEEP.
2. The nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm begins
to sound. Which actions should the nurse take? (Select All That Apply)
A. Assess for the presence of secretions in the airway
B. Check for kinks in the ventilator tubing
,C. Assess the patient for biting the endotracheal tube
D. Check for a disconnection between the tube and the ventilator
E. Auscultate for potential tension pneumothorax
F. Listen for a leak in the endotracheal tube cuff
Correct Answer: A, B, C, E
Explanation: High-pressure alarms are triggered by resistance to airflow, such as
secretions, tubing kinks, biting the tube, or physiological changes like a pneumothorax. In
contrast, low-pressure alarms are triggered by disconnections or cuff leaks. The nurse must
prioritize patient assessment and troubleshoot the circuit to ensure adequate ventilation.
3. A patient with a history of chronic obstructive pulmonary disease (COPD) presents with the
following ABG results: pH 7.28, PaCO2 55 mmHg, HCO3 28 mEq/L. How should the nurse
interpret these findings?
A. Partially compensated respiratory acidosis
B. Uncompensated metabolic acidosis
C. Fully compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Correct Answer: A
Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause), and the HCO3
is elevated (attempting to compensate). Because the pH has not yet returned to the normal
,range, it is considered partially compensated. This condition is common in patients with
chronic lung disease who retain CO2 over time.
4. A patient is experiencing symptomatic sinus bradycardia with a heart rate of 38 bpm and a
blood pressure of 82/50 mmHg. What is the nurse’s first-line pharmacological intervention?
A. Amiodarone 150 mg IV bolus
B. Epinephrine 1 mg IV push
C. Atropine 1 mg IV push
D. Adenosine 6 mg rapid IV push
Correct Answer: C
Explanation: Atropine is the primary medication used to treat symptomatic bradycardia
by blocking vagal stimulation and increasing the heart rate. The nurse should administer 1
mg every 3-5 minutes until the maximum dose is reached or the heart rate improves. If
Atropine is ineffective, transcutaneous pacing or vasopressors like dopamine may be
considered.
5. The nurse is monitoring a patient following a traumatic brain injury (TBI). Which
assessment finding is most indicative of Cushing’s Triad?
A. Tachycardia, hypotension, and tachypnea
B. Narrowed pulse pressure, tachycardia, and hypertension
C. Bradycardia, widened pulse pressure, and irregular respirations
, D. Hypotension, bradycardia, and Cheyne-Stokes respirations
Correct Answer: C
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) and
impending brain herniation. It consists of a widened pulse pressure (systolic
hypertension), bradycardia, and irregular respiratory patterns. Immediate intervention is
required to lower ICP and prevent permanent neurological damage.
6. A patient in the compensatory stage of shock exhibits which of the following physiological
responses?
A. Decreased heart rate to conserve myocardial oxygen demand
B. Vasodilation of peripheral blood vessels to increase skin perfusion
C. Increased urinary output due to increased renal perfusion
D. Activation of the renin-angiotensin-aldosterone system (RAAS)
Correct Answer: D
Explanation: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the RAAS and sympathetic nervous system activation. This leads to
sodium and water retention and peripheral vasoconstriction to divert blood to vital organs.
The nurse will likely observe cool skin and decreased urine output during this phase.
Adult II | Actual Q&A with Rationale (NUR417
Exam 1) | Concordia
1. A patient is admitted to the intensive care unit with a diagnosis of acute respiratory
distress syndrome (ARDS). Which clinical manifestation should the nurse expect to find
during the initial assessment?
A. Increased lung compliance and decreased work of breathing
B. Respiratory alkalosis caused by hypoventilation
C. Hypoxemia that does not respond to supplemental oxygen therapy
D. Decreased pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Explanation: Refractory hypoxemia is a hallmark sign of ARDS where the patient remains
hypoxic despite high levels of inspired oxygen. This occurs due to severe intrapulmonary
shunting and the collapse of alveoli. The nurse must monitor for this finding as it indicates
progressive respiratory failure requiring advanced intervention like PEEP.
2. The nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm begins
to sound. Which actions should the nurse take? (Select All That Apply)
A. Assess for the presence of secretions in the airway
B. Check for kinks in the ventilator tubing
,C. Assess the patient for biting the endotracheal tube
D. Check for a disconnection between the tube and the ventilator
E. Auscultate for potential tension pneumothorax
F. Listen for a leak in the endotracheal tube cuff
Correct Answer: A, B, C, E
Explanation: High-pressure alarms are triggered by resistance to airflow, such as
secretions, tubing kinks, biting the tube, or physiological changes like a pneumothorax. In
contrast, low-pressure alarms are triggered by disconnections or cuff leaks. The nurse must
prioritize patient assessment and troubleshoot the circuit to ensure adequate ventilation.
3. A patient with a history of chronic obstructive pulmonary disease (COPD) presents with the
following ABG results: pH 7.28, PaCO2 55 mmHg, HCO3 28 mEq/L. How should the nurse
interpret these findings?
A. Partially compensated respiratory acidosis
B. Uncompensated metabolic acidosis
C. Fully compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Correct Answer: A
Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause), and the HCO3
is elevated (attempting to compensate). Because the pH has not yet returned to the normal
,range, it is considered partially compensated. This condition is common in patients with
chronic lung disease who retain CO2 over time.
4. A patient is experiencing symptomatic sinus bradycardia with a heart rate of 38 bpm and a
blood pressure of 82/50 mmHg. What is the nurse’s first-line pharmacological intervention?
A. Amiodarone 150 mg IV bolus
B. Epinephrine 1 mg IV push
C. Atropine 1 mg IV push
D. Adenosine 6 mg rapid IV push
Correct Answer: C
Explanation: Atropine is the primary medication used to treat symptomatic bradycardia
by blocking vagal stimulation and increasing the heart rate. The nurse should administer 1
mg every 3-5 minutes until the maximum dose is reached or the heart rate improves. If
Atropine is ineffective, transcutaneous pacing or vasopressors like dopamine may be
considered.
5. The nurse is monitoring a patient following a traumatic brain injury (TBI). Which
assessment finding is most indicative of Cushing’s Triad?
A. Tachycardia, hypotension, and tachypnea
B. Narrowed pulse pressure, tachycardia, and hypertension
C. Bradycardia, widened pulse pressure, and irregular respirations
, D. Hypotension, bradycardia, and Cheyne-Stokes respirations
Correct Answer: C
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) and
impending brain herniation. It consists of a widened pulse pressure (systolic
hypertension), bradycardia, and irregular respiratory patterns. Immediate intervention is
required to lower ICP and prevent permanent neurological damage.
6. A patient in the compensatory stage of shock exhibits which of the following physiological
responses?
A. Decreased heart rate to conserve myocardial oxygen demand
B. Vasodilation of peripheral blood vessels to increase skin perfusion
C. Increased urinary output due to increased renal perfusion
D. Activation of the renin-angiotensin-aldosterone system (RAAS)
Correct Answer: D
Explanation: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the RAAS and sympathetic nervous system activation. This leads to
sodium and water retention and peripheral vasoconstriction to divert blood to vital organs.
The nurse will likely observe cool skin and decreased urine output during this phase.
