NUR 2790 Exam 3 Actual Exam V2 | NUR 2790 Professional Nursing III
/ PN3 (NUR2790 Exam 3) | Rasmussen
1. A patient with a T4 spinal cord injury reports a sudden, severe, pounding headache and the
nurse notes the blood pressure is 180/100 mmHg. What is the priority nursing intervention?
A. Administer the PRN prescribed antihypertensive medication.
B. Assess the patient for a possible pulmonary embolism.
C. Place the patient in a supine position immediately.
D. Check the patient’s bladder for distention or a kinked catheter.
Answer: D
Rationale: The patient is experiencing signs of autonomic dysreflexia, which is a medical
emergency often triggered by a full bladder or bowel. The first priority is to identify and
remove the noxious stimulus to prevent further complications like a stroke. Sitting the
patient upright is also a priority, but checking for the trigger is the most definitive
immediate action among these choices.
2. A nurse is caring for a patient in the resuscitative phase of burn injury. Which laboratory
finding should the nurse expect?
A. Hyponatremia and Hyperkalemia
B. Hypernatremia and Hypokalemia
C. Decreased Hematocrit and Hemoglobin
D. Metabolic Alkalosis
Answer: A
Rationale: In the early phase of a burn, fluid shifts from the intravascular to the interstitial
space, leading to sodium loss. Potassium is released from damaged cells, resulting in
hyperkalemia. These electrolyte imbalances require careful monitoring to prevent cardiac
arrhythmias and other complications.
3. A patient with severe burns on the chest and neck develops a brassy cough and wheezing.
What is the nurse’s primary concern?
A. Impending airway obstruction
B. Hypovolemic shock from fluid loss
C. Developing bacterial pneumonia
D. Systemic inflammatory response syndrome
,Answer: A
Rationale: Brassy cough, wheezing, and burns to the upper body are classic signs of an
inhalation injury. This can lead to rapid edema of the airway and complete obstruction.
Immediate assessment for intubation is often necessary to ensure the airway remains
patent.
4. Using the Parkland formula, calculate the total fluid needed in the first 24 hours for a 70 kg
patient with 40% TBSA burns.
A. 11,200 mL
B. 5,600 mL
C. 8,400 mL
D. 14,000 mL
Answer: A
Rationale: The Parkland formula is 4 mL x weight (kg) x % TBSA burned. For this patient,
4 x 70 x 40 equals 11,200 mL. This total volume is used to guide resuscitation, with half
given in the first eight hours after the injury occurred.
5. Which clinical manifestation would the nurse observe in a patient transitioning from the
compensatory stage to the progressive stage of shock?
A. Increased urinary output and warm skin
B. Cold, clammy skin and metabolic acidosis
C. Respiratory alkalosis and bradycardia
D. Hyperglycemia and increased bowel sounds
Answer: B
Rationale: In the progressive stage, compensatory mechanisms fail and organ perfusion
decreases significantly. This leads to anaerobic metabolism and a build-up of lactic acid,
causing metabolic acidosis. Skin becomes cold and clammy as blood is shunted to the core
organs.
6. A nurse is caring for a patient with septic shock. Which intervention should be prioritized
within the first hour of treatment?
A. Initiating a continuous insulin infusion to maintain glucose.
B. Administering a broad-spectrum antibiotic after obtaining cultures.
C. Administering a dose of loop diuretics to improve renal flow.
D. Applying a cooling blanket to treat a high fever.
Answer: B
, Rationale: The 1-hour sepsis bundle emphasizes obtaining blood cultures and starting
antibiotics immediately. Early antibiotic therapy is associated with improved survival rates
in septic patients. Fluid resuscitation with crystalloids is also a top priority during this
initial hour.
7. A patient has a Mean Arterial Pressure (MAP) of 55 mmHg. What is the nurse’s
interpretation of this finding?
A. The MAP is too low to maintain adequate organ perfusion.
B. The MAP is normal for a resting adult.
C. The MAP is high, indicating fluid volume excess.
D. The MAP is low, but acceptable for a patient in shock.
Answer: A
Rationale: A MAP of at least 60 to 65 mmHg is generally required to maintain perfusion to
the brain, kidneys, and heart. A value of 55 mmHg indicates that the patient is at high risk
for organ failure and ischemia. The nurse must intervene with fluids or vasopressors as
ordered to increase pressure.
8. Which assessment finding is most characteristic of neurogenic shock following a spinal cord
injury?
A. Tachycardia and hypertension
B. Narrow pulse pressure and tachypnea
C. Tachycardia and hypothermia
D. Bradycardia and hypotension
Answer: D
Rationale: Neurogenic shock is caused by the loss of sympathetic tone, leading to massive
vasodilation. Unlike other forms of shock that cause tachycardia as a compensatory
mechanism, neurogenic shock typically presents with bradycardia. It is most commonly
seen in injuries above the T6 level.
9. A patient with Disseminated Intravascular Coagulation (DIC) is bleeding from previous
venipuncture sites. What is the underlying pathophysiology?
A. The patient has a primary vitamin K deficiency.
B. The patient is having an allergic reaction to blood products.
C. The liver has stopped producing all clotting factors.
D. Excessive clotting factors have been depleted by microclots.
Answer: D
/ PN3 (NUR2790 Exam 3) | Rasmussen
1. A patient with a T4 spinal cord injury reports a sudden, severe, pounding headache and the
nurse notes the blood pressure is 180/100 mmHg. What is the priority nursing intervention?
A. Administer the PRN prescribed antihypertensive medication.
B. Assess the patient for a possible pulmonary embolism.
C. Place the patient in a supine position immediately.
D. Check the patient’s bladder for distention or a kinked catheter.
Answer: D
Rationale: The patient is experiencing signs of autonomic dysreflexia, which is a medical
emergency often triggered by a full bladder or bowel. The first priority is to identify and
remove the noxious stimulus to prevent further complications like a stroke. Sitting the
patient upright is also a priority, but checking for the trigger is the most definitive
immediate action among these choices.
2. A nurse is caring for a patient in the resuscitative phase of burn injury. Which laboratory
finding should the nurse expect?
A. Hyponatremia and Hyperkalemia
B. Hypernatremia and Hypokalemia
C. Decreased Hematocrit and Hemoglobin
D. Metabolic Alkalosis
Answer: A
Rationale: In the early phase of a burn, fluid shifts from the intravascular to the interstitial
space, leading to sodium loss. Potassium is released from damaged cells, resulting in
hyperkalemia. These electrolyte imbalances require careful monitoring to prevent cardiac
arrhythmias and other complications.
3. A patient with severe burns on the chest and neck develops a brassy cough and wheezing.
What is the nurse’s primary concern?
A. Impending airway obstruction
B. Hypovolemic shock from fluid loss
C. Developing bacterial pneumonia
D. Systemic inflammatory response syndrome
,Answer: A
Rationale: Brassy cough, wheezing, and burns to the upper body are classic signs of an
inhalation injury. This can lead to rapid edema of the airway and complete obstruction.
Immediate assessment for intubation is often necessary to ensure the airway remains
patent.
4. Using the Parkland formula, calculate the total fluid needed in the first 24 hours for a 70 kg
patient with 40% TBSA burns.
A. 11,200 mL
B. 5,600 mL
C. 8,400 mL
D. 14,000 mL
Answer: A
Rationale: The Parkland formula is 4 mL x weight (kg) x % TBSA burned. For this patient,
4 x 70 x 40 equals 11,200 mL. This total volume is used to guide resuscitation, with half
given in the first eight hours after the injury occurred.
5. Which clinical manifestation would the nurse observe in a patient transitioning from the
compensatory stage to the progressive stage of shock?
A. Increased urinary output and warm skin
B. Cold, clammy skin and metabolic acidosis
C. Respiratory alkalosis and bradycardia
D. Hyperglycemia and increased bowel sounds
Answer: B
Rationale: In the progressive stage, compensatory mechanisms fail and organ perfusion
decreases significantly. This leads to anaerobic metabolism and a build-up of lactic acid,
causing metabolic acidosis. Skin becomes cold and clammy as blood is shunted to the core
organs.
6. A nurse is caring for a patient with septic shock. Which intervention should be prioritized
within the first hour of treatment?
A. Initiating a continuous insulin infusion to maintain glucose.
B. Administering a broad-spectrum antibiotic after obtaining cultures.
C. Administering a dose of loop diuretics to improve renal flow.
D. Applying a cooling blanket to treat a high fever.
Answer: B
, Rationale: The 1-hour sepsis bundle emphasizes obtaining blood cultures and starting
antibiotics immediately. Early antibiotic therapy is associated with improved survival rates
in septic patients. Fluid resuscitation with crystalloids is also a top priority during this
initial hour.
7. A patient has a Mean Arterial Pressure (MAP) of 55 mmHg. What is the nurse’s
interpretation of this finding?
A. The MAP is too low to maintain adequate organ perfusion.
B. The MAP is normal for a resting adult.
C. The MAP is high, indicating fluid volume excess.
D. The MAP is low, but acceptable for a patient in shock.
Answer: A
Rationale: A MAP of at least 60 to 65 mmHg is generally required to maintain perfusion to
the brain, kidneys, and heart. A value of 55 mmHg indicates that the patient is at high risk
for organ failure and ischemia. The nurse must intervene with fluids or vasopressors as
ordered to increase pressure.
8. Which assessment finding is most characteristic of neurogenic shock following a spinal cord
injury?
A. Tachycardia and hypertension
B. Narrow pulse pressure and tachypnea
C. Tachycardia and hypothermia
D. Bradycardia and hypotension
Answer: D
Rationale: Neurogenic shock is caused by the loss of sympathetic tone, leading to massive
vasodilation. Unlike other forms of shock that cause tachycardia as a compensatory
mechanism, neurogenic shock typically presents with bradycardia. It is most commonly
seen in injuries above the T6 level.
9. A patient with Disseminated Intravascular Coagulation (DIC) is bleeding from previous
venipuncture sites. What is the underlying pathophysiology?
A. The patient has a primary vitamin K deficiency.
B. The patient is having an allergic reaction to blood products.
C. The liver has stopped producing all clotting factors.
D. Excessive clotting factors have been depleted by microclots.
Answer: D
