NUR 417 Final Exam V1 | NUR 417 Nursing Care of
the Adult II | Actual Q&A with Rationale (NUR417
Final Exam) | Concordia
1. A patient is admitted with severe sepsis. The nurse notes a blood pressure of 82/46 mmHg
and a lactate level of 4.5 mmol/L. Which action should the nurse prioritize first according to
the Surviving Sepsis Bundle?
A. Initiate broad-spectrum antibiotics within the first hour.
B. Start norepinephrine to maintain a MAP greater than 65 mmHg.
C. Obtain two sets of blood cultures from different sites.
D. Administer a 30 mL/kg rapid infusion of isotonic crystalloids.
Correct Answer: D
Explanation: In the management of septic shock and hypotension, aggressive fluid
resuscitation is the first priority to restore tissue perfusion. A minimum of 30 mL/kg of
crystalloid fluid should be administered rapidly. While cultures and antibiotics are critical,
they follow initial volume replacement in cases of profound hypotension and elevated
lactate.
2. A patient with ARDS is being mechanically ventilated with high levels of PEEP. The nurse
notes a sudden drop in SpO2 and absent breath sounds on the right side. What is the most
likely complication?
A. Tension pneumothorax
,B. Ventilator-associated pneumonia
C. Pulmonary embolism
D. Endotracheal tube displacement
Correct Answer: A
Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase the risk of
barotrauma, which can lead to a pneumothorax. The clinical presentation of sudden
desaturation and unilateral absent breath sounds is classic for this emergency. The nurse
must immediately notify the provider for possible needle decompression or chest tube
insertion.
3. A nurse is caring for a patient who sustained full-thickness burns to 40% of the total body
surface area (TBSA). Which finding during the emergent phase indicates effective fluid
resuscitation?
A. Heart rate of 125 beats per minute
B. Urine output of 0.5 to 1.0 mL/kg/hr
C. Central venous pressure (CVP) of 2 mmHg
D. Weight gain of 2 kg in 24 hours
Correct Answer: B
Explanation: Urine output is the most reliable indicator of adequate organ perfusion and
fluid resuscitation in burn patients. For an adult, the goal is typically 0.5 to 1.0 mL/kg/hr or
, roughly 30-50 mL/hr. A heart rate of 125 or a CVP of 2 would suggest continued
hypovolemia rather than effective resuscitation.
4. A patient with a traumatic brain injury is exhibiting Cushing’s Triad. Which clinical
manifestations should the nurse document?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
C. Bradycardia, hypotension, and Cheyne-Stokes respirations
D. Tachycardia, hypertension, and Kussmaul respirations
Correct Answer: B
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) and
impending herniation. It consists of a slow heart rate (bradycardia), an increased systolic
blood pressure with a widening pulse pressure, and abnormal respiratory patterns. This is
a medical emergency that requires immediate intervention to reduce ICP.
5. A patient in the ICU has the following ABG results: pH 7.28, PaCO2 52 mmHg, PaO2 78
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Partially compensated metabolic acidosis
B. Uncompensated respiratory acidosis
C. Fully compensated respiratory alkalosis
D. Uncompensated metabolic alkalosis
the Adult II | Actual Q&A with Rationale (NUR417
Final Exam) | Concordia
1. A patient is admitted with severe sepsis. The nurse notes a blood pressure of 82/46 mmHg
and a lactate level of 4.5 mmol/L. Which action should the nurse prioritize first according to
the Surviving Sepsis Bundle?
A. Initiate broad-spectrum antibiotics within the first hour.
B. Start norepinephrine to maintain a MAP greater than 65 mmHg.
C. Obtain two sets of blood cultures from different sites.
D. Administer a 30 mL/kg rapid infusion of isotonic crystalloids.
Correct Answer: D
Explanation: In the management of septic shock and hypotension, aggressive fluid
resuscitation is the first priority to restore tissue perfusion. A minimum of 30 mL/kg of
crystalloid fluid should be administered rapidly. While cultures and antibiotics are critical,
they follow initial volume replacement in cases of profound hypotension and elevated
lactate.
2. A patient with ARDS is being mechanically ventilated with high levels of PEEP. The nurse
notes a sudden drop in SpO2 and absent breath sounds on the right side. What is the most
likely complication?
A. Tension pneumothorax
,B. Ventilator-associated pneumonia
C. Pulmonary embolism
D. Endotracheal tube displacement
Correct Answer: A
Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase the risk of
barotrauma, which can lead to a pneumothorax. The clinical presentation of sudden
desaturation and unilateral absent breath sounds is classic for this emergency. The nurse
must immediately notify the provider for possible needle decompression or chest tube
insertion.
3. A nurse is caring for a patient who sustained full-thickness burns to 40% of the total body
surface area (TBSA). Which finding during the emergent phase indicates effective fluid
resuscitation?
A. Heart rate of 125 beats per minute
B. Urine output of 0.5 to 1.0 mL/kg/hr
C. Central venous pressure (CVP) of 2 mmHg
D. Weight gain of 2 kg in 24 hours
Correct Answer: B
Explanation: Urine output is the most reliable indicator of adequate organ perfusion and
fluid resuscitation in burn patients. For an adult, the goal is typically 0.5 to 1.0 mL/kg/hr or
, roughly 30-50 mL/hr. A heart rate of 125 or a CVP of 2 would suggest continued
hypovolemia rather than effective resuscitation.
4. A patient with a traumatic brain injury is exhibiting Cushing’s Triad. Which clinical
manifestations should the nurse document?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
C. Bradycardia, hypotension, and Cheyne-Stokes respirations
D. Tachycardia, hypertension, and Kussmaul respirations
Correct Answer: B
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) and
impending herniation. It consists of a slow heart rate (bradycardia), an increased systolic
blood pressure with a widening pulse pressure, and abnormal respiratory patterns. This is
a medical emergency that requires immediate intervention to reduce ICP.
5. A patient in the ICU has the following ABG results: pH 7.28, PaCO2 52 mmHg, PaO2 78
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Partially compensated metabolic acidosis
B. Uncompensated respiratory acidosis
C. Fully compensated respiratory alkalosis
D. Uncompensated metabolic alkalosis
