,ASU NUR 425 Exam 1 | Health & Illness Concepts: Adults &
Peds (2026) Q&A
1. A patient is admitted to the intensive care unit following a motor vehicle accident.
Which assessment finding is the earliest indicator of a change in neurologic status?
A) Pupillary response
B) Level of consciousness
C) Motor function
D) Vital sign changes
Correct Answer: Level of consciousness
Rationale: A change in level of consciousness (LOC) is the earliest and most sensitive
indicator of neurologic deterioration. Pupillary changes, motor changes, and vital
sign changes often occur later as the condition progresses. Frequent assessment of
LOC is a critical nursing priority in the ICU.
2. The nurse is calculating the Mean Arterial Pressure (MAP) for a patient with a
blood pressure of 110/70 mmHg. Which value is correct?
A) 75 mmHg
B) 80 mmHg
C) 83 mmHg
D) 90 mmHg
Correct Answer: 83 mmHg
,Rationale: MAP is calculated as [(2 × Diastolic) + Systolic] / 3. For 110/70, MAP = [(2
× 70) + 110] / 3 = (140 + 110) / 3 = = 83.3 mmHg. The normal MAP range
for adults is 70-105 mmHg.
3. A patient is receiving mechanical ventilation and the high-pressure alarm sounds.
Which of the following is a common cause of a high-pressure alarm?
A) Disconnected tubing
B) Cuff leak
C) Biting the endotracheal tube
D) Extubation
Correct Answer: Biting the endotracheal tube
Rationale: High-pressure alarms are triggered by increased airway resistance, such
as from the patient biting the tube, kinking of the tubing, or excessive secretions.
Low-pressure alarms are triggered by disconnections or leaks.
4. A patient's arterial blood gas (ABG) results show: pH 7.28, PaCO2 55 mmHg, and
HCO3 24 mEq/L. Which acid-base imbalance is present?
A) Metabolic acidosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Respiratory alkalosis
Correct Answer: Respiratory acidosis
Rationale: The pH is below 7.35 (acidosis), PaCO2 is elevated above 45 mmHg
(respiratory component), and HCO3 is normal. This pattern indicates respiratory
acidosis due to hypoventilation and CO2 retention.
, 5. The nurse is preparing a patient for surgery. Which responsibility regarding
informed consent belongs to the nurse?
A) Explaining the risks and benefits of the procedure
B) Ensuring the patient has signed the consent form
C) Determining if the patient is mentally competent
D) Describing alternative treatments
Correct Answer: Ensuring the patient has signed the consent form
Rationale: The provider is responsible for explaining the procedure, risks, benefits,
and alternatives. The nurse's role is to witness the signature, ensure the consent is
signed, and verify the patient understands the information.
6. A patient's central venous pressure (CVP) is 2 mmHg. This finding most likely
indicates:
A) Fluid overload
B) Hypovolemia
C) Right-sided heart failure
D) Pulmonary hypertension
Correct Answer: Hypovolemia
Rationale: Normal CVP is 2-8 mmHg. A low CVP (≤2 mmHg) indicates decreased
right atrial pressure and suggests hypovolemia. An elevated CVP suggests fluid
overload or right-sided heart failure.
Peds (2026) Q&A
1. A patient is admitted to the intensive care unit following a motor vehicle accident.
Which assessment finding is the earliest indicator of a change in neurologic status?
A) Pupillary response
B) Level of consciousness
C) Motor function
D) Vital sign changes
Correct Answer: Level of consciousness
Rationale: A change in level of consciousness (LOC) is the earliest and most sensitive
indicator of neurologic deterioration. Pupillary changes, motor changes, and vital
sign changes often occur later as the condition progresses. Frequent assessment of
LOC is a critical nursing priority in the ICU.
2. The nurse is calculating the Mean Arterial Pressure (MAP) for a patient with a
blood pressure of 110/70 mmHg. Which value is correct?
A) 75 mmHg
B) 80 mmHg
C) 83 mmHg
D) 90 mmHg
Correct Answer: 83 mmHg
,Rationale: MAP is calculated as [(2 × Diastolic) + Systolic] / 3. For 110/70, MAP = [(2
× 70) + 110] / 3 = (140 + 110) / 3 = = 83.3 mmHg. The normal MAP range
for adults is 70-105 mmHg.
3. A patient is receiving mechanical ventilation and the high-pressure alarm sounds.
Which of the following is a common cause of a high-pressure alarm?
A) Disconnected tubing
B) Cuff leak
C) Biting the endotracheal tube
D) Extubation
Correct Answer: Biting the endotracheal tube
Rationale: High-pressure alarms are triggered by increased airway resistance, such
as from the patient biting the tube, kinking of the tubing, or excessive secretions.
Low-pressure alarms are triggered by disconnections or leaks.
4. A patient's arterial blood gas (ABG) results show: pH 7.28, PaCO2 55 mmHg, and
HCO3 24 mEq/L. Which acid-base imbalance is present?
A) Metabolic acidosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Respiratory alkalosis
Correct Answer: Respiratory acidosis
Rationale: The pH is below 7.35 (acidosis), PaCO2 is elevated above 45 mmHg
(respiratory component), and HCO3 is normal. This pattern indicates respiratory
acidosis due to hypoventilation and CO2 retention.
, 5. The nurse is preparing a patient for surgery. Which responsibility regarding
informed consent belongs to the nurse?
A) Explaining the risks and benefits of the procedure
B) Ensuring the patient has signed the consent form
C) Determining if the patient is mentally competent
D) Describing alternative treatments
Correct Answer: Ensuring the patient has signed the consent form
Rationale: The provider is responsible for explaining the procedure, risks, benefits,
and alternatives. The nurse's role is to witness the signature, ensure the consent is
signed, and verify the patient understands the information.
6. A patient's central venous pressure (CVP) is 2 mmHg. This finding most likely
indicates:
A) Fluid overload
B) Hypovolemia
C) Right-sided heart failure
D) Pulmonary hypertension
Correct Answer: Hypovolemia
Rationale: Normal CVP is 2-8 mmHg. A low CVP (≤2 mmHg) indicates decreased
right atrial pressure and suggests hypovolemia. An elevated CVP suggests fluid
overload or right-sided heart failure.
