NUR 2790 Exam 2 Actual Exam V3 | NUR 2790 Professional Nursing III
/ PN3 (NUR2790 Exam 2) | Rasmussen
1. A client is admitted to the ICU with a diagnosis of Acute Respiratory Distress Syndrome
(ARDS). The nurse observes the ventilator is set to deliver high levels of Positive End-
Expiratory Pressure (PEEP). What is the primary physiological goal of increasing PEEP in this
client?
A. To decrease the risk of barotrauma to the lung tissue.
B. To reduce the respiratory rate to prevent metabolic alkalosis.
C. To lower the fraction of inspired oxygen (FiO2) to 21%.
D. To increase functional residual capacity and open collapsed alveoli.
Answer: D
Rationale: Increasing PEEP helps to keep alveoli open at the end of expiration, which
improves gas exchange and functional residual capacity. This intervention is crucial in
ARDS to combat refractory hypoxemia caused by alveolar collapse. The nurse must monitor
for complications such as decreased cardiac output or pneumothorax due to the high
intrathoracic pressure.
2. An 80-kg client arrives in the emergency department with second and third-degree burns
covering 40% of the total body surface area (TBSA). Using the Parkland Formula, calculate the
total volume of Lactated Ringer’s solution required in the first 8 hours.
A. 6,400 mL
B. 12,800 mL
C. 3,200 mL
D. 9,600 mL
Answer: A
Rationale: The Parkland Formula calculates total 24-hour fluid needs as 4 mL x kg x %
TBSA, which equals 12,800 mL for this client. Half of this total volume must be
administered within the first 8 hours from the time of the burn injury. Therefore, the nurse
should ensure 6,400 mL is infused during the initial 8-hour window.
3. A charge nurse is planning assignments for the day. Which client is most appropriate to
assign to an experienced Licensed Practical Nurse (LPN)?
A. A client with a new onset of chest pain and a history of myocardial infarction.
B. A client with a stable abdominal wound requiring a sterile dressing change.
,C. A client requiring discharge teaching regarding a new tracheostomy.
D. A client who just returned from a cardiac catheterization procedure.
Answer: B
Rationale: LPNs are trained to perform specific tasks such as sterile dressing changes for
stable clients. Tasks involving initial assessments, unstable clients, or complex discharge
teaching are within the scope of the Registered Nurse. Assigning a stable wound care task
to the LPN allows the RN to focus on high-acuity assessments and care coordination.
4. A client with a C6 spinal cord injury reports a sudden, severe headache and blurred vision.
The nurse notes the client is bradycardic and has a blood pressure of 190/110 mmHg. What is
the nurse’s priority action?
A. Administer an ordered PRN dose of hydralazine.
B. Perform a neurological assessment including a Glasgow Coma Scale.
C. Place the client in a supine position immediately.
D. Check the client’s bladder for distension or a kinked catheter.
Answer: D
Rationale: The symptoms indicate autonomic dysreflexia, a life-threatening emergency
often triggered by a full bladder or fecal impaction. The priority is to identify and remove
the noxious stimulus while sitting the client upright to lower blood pressure. Failure to
address the cause can lead to seizures, stroke, or myocardial infarction.
5. The nurse is reviewing the arterial blood gas (ABG) results for a client with a history of
chronic obstructive pulmonary disease (COPD): pH 7.32, PaCO2 58 mmHg, HCO3 30 mEq/L.
How should the nurse interpret these results?
A. Compensated respiratory acidosis
B. Uncompensated metabolic alkalosis
C. Partially compensated respiratory acidosis
D. Normal blood gas for a COPD patient
Answer: C
Rationale: The pH is acidic, the PaCO2 is high indicating a respiratory origin, and the HCO3
is elevated as the kidneys attempt to compensate. Because the pH has not yet returned to
the normal range, the compensation is considered partial. This finding is common in clients
with chronic lung disease who retain carbon dioxide over long periods.
6. A nurse is caring for a client in the early stages of septic shock. Which clinical manifestation
should the nurse expect to find?
A. Warm, flushed skin and increased cardiac output.
, B. Cool, clammy skin and bradycardia.
C. Decreased urine output and severe hypotension.
D. Respiratory depression and lethargy.
Answer: A
Rationale: In the hyperdynamic (warm) phase of septic shock, vasodilation leads to warm,
flushed skin and a compensatory increase in heart rate and cardiac output. This is distinct
from other types of shock where the skin is typically cool and pale due to vasoconstriction.
Early identification during this phase is vital for successful fluid resuscitation and antibiotic
therapy.
7. During a massive disaster, the nurse uses the START triage system. A victim is breathing at
a rate of 24 breaths/minute, has a capillary refill of 4 seconds, and follows simple commands.
Which color tag should the nurse assign?
A. Green (Minor)
B. Red (Immediate)
C. Yellow (Delayed)
D. Black (Deceased)
Answer: B
Rationale: According to the START (Simple Triage and Rapid Treatment) algorithm, a
capillary refill greater than 2 seconds indicates poor perfusion and warrants a Red tag.
Even if the respiratory rate and mental status are acceptable, the circulatory compromise
takes precedence for immediate care. Red-tagged victims are the first priority for transport
to a hospital facility.
8. The nurse is monitoring a client with acute pancreatitis. Which finding is most suggestive of
the development of Cullen’s sign?
A. Numbness and tingling in the extremities.
B. Pain that radiates to the left shoulder.
C. Ecchymosis on the flank area.
D. Bluish discoloration around the umbilicus.
Answer: D
Rationale: Cullen’s sign is a superficial edema and bruising in the subcutaneous fatty tissue
around the umbilicus, indicating intraperitoneal hemorrhage. It is a significant clinical sign
associated with severe necrotizing pancreatitis. The nurse should report this finding
immediately as it suggests worsening disease progression and potential shock.
/ PN3 (NUR2790 Exam 2) | Rasmussen
1. A client is admitted to the ICU with a diagnosis of Acute Respiratory Distress Syndrome
(ARDS). The nurse observes the ventilator is set to deliver high levels of Positive End-
Expiratory Pressure (PEEP). What is the primary physiological goal of increasing PEEP in this
client?
A. To decrease the risk of barotrauma to the lung tissue.
B. To reduce the respiratory rate to prevent metabolic alkalosis.
C. To lower the fraction of inspired oxygen (FiO2) to 21%.
D. To increase functional residual capacity and open collapsed alveoli.
Answer: D
Rationale: Increasing PEEP helps to keep alveoli open at the end of expiration, which
improves gas exchange and functional residual capacity. This intervention is crucial in
ARDS to combat refractory hypoxemia caused by alveolar collapse. The nurse must monitor
for complications such as decreased cardiac output or pneumothorax due to the high
intrathoracic pressure.
2. An 80-kg client arrives in the emergency department with second and third-degree burns
covering 40% of the total body surface area (TBSA). Using the Parkland Formula, calculate the
total volume of Lactated Ringer’s solution required in the first 8 hours.
A. 6,400 mL
B. 12,800 mL
C. 3,200 mL
D. 9,600 mL
Answer: A
Rationale: The Parkland Formula calculates total 24-hour fluid needs as 4 mL x kg x %
TBSA, which equals 12,800 mL for this client. Half of this total volume must be
administered within the first 8 hours from the time of the burn injury. Therefore, the nurse
should ensure 6,400 mL is infused during the initial 8-hour window.
3. A charge nurse is planning assignments for the day. Which client is most appropriate to
assign to an experienced Licensed Practical Nurse (LPN)?
A. A client with a new onset of chest pain and a history of myocardial infarction.
B. A client with a stable abdominal wound requiring a sterile dressing change.
,C. A client requiring discharge teaching regarding a new tracheostomy.
D. A client who just returned from a cardiac catheterization procedure.
Answer: B
Rationale: LPNs are trained to perform specific tasks such as sterile dressing changes for
stable clients. Tasks involving initial assessments, unstable clients, or complex discharge
teaching are within the scope of the Registered Nurse. Assigning a stable wound care task
to the LPN allows the RN to focus on high-acuity assessments and care coordination.
4. A client with a C6 spinal cord injury reports a sudden, severe headache and blurred vision.
The nurse notes the client is bradycardic and has a blood pressure of 190/110 mmHg. What is
the nurse’s priority action?
A. Administer an ordered PRN dose of hydralazine.
B. Perform a neurological assessment including a Glasgow Coma Scale.
C. Place the client in a supine position immediately.
D. Check the client’s bladder for distension or a kinked catheter.
Answer: D
Rationale: The symptoms indicate autonomic dysreflexia, a life-threatening emergency
often triggered by a full bladder or fecal impaction. The priority is to identify and remove
the noxious stimulus while sitting the client upright to lower blood pressure. Failure to
address the cause can lead to seizures, stroke, or myocardial infarction.
5. The nurse is reviewing the arterial blood gas (ABG) results for a client with a history of
chronic obstructive pulmonary disease (COPD): pH 7.32, PaCO2 58 mmHg, HCO3 30 mEq/L.
How should the nurse interpret these results?
A. Compensated respiratory acidosis
B. Uncompensated metabolic alkalosis
C. Partially compensated respiratory acidosis
D. Normal blood gas for a COPD patient
Answer: C
Rationale: The pH is acidic, the PaCO2 is high indicating a respiratory origin, and the HCO3
is elevated as the kidneys attempt to compensate. Because the pH has not yet returned to
the normal range, the compensation is considered partial. This finding is common in clients
with chronic lung disease who retain carbon dioxide over long periods.
6. A nurse is caring for a client in the early stages of septic shock. Which clinical manifestation
should the nurse expect to find?
A. Warm, flushed skin and increased cardiac output.
, B. Cool, clammy skin and bradycardia.
C. Decreased urine output and severe hypotension.
D. Respiratory depression and lethargy.
Answer: A
Rationale: In the hyperdynamic (warm) phase of septic shock, vasodilation leads to warm,
flushed skin and a compensatory increase in heart rate and cardiac output. This is distinct
from other types of shock where the skin is typically cool and pale due to vasoconstriction.
Early identification during this phase is vital for successful fluid resuscitation and antibiotic
therapy.
7. During a massive disaster, the nurse uses the START triage system. A victim is breathing at
a rate of 24 breaths/minute, has a capillary refill of 4 seconds, and follows simple commands.
Which color tag should the nurse assign?
A. Green (Minor)
B. Red (Immediate)
C. Yellow (Delayed)
D. Black (Deceased)
Answer: B
Rationale: According to the START (Simple Triage and Rapid Treatment) algorithm, a
capillary refill greater than 2 seconds indicates poor perfusion and warrants a Red tag.
Even if the respiratory rate and mental status are acceptable, the circulatory compromise
takes precedence for immediate care. Red-tagged victims are the first priority for transport
to a hospital facility.
8. The nurse is monitoring a client with acute pancreatitis. Which finding is most suggestive of
the development of Cullen’s sign?
A. Numbness and tingling in the extremities.
B. Pain that radiates to the left shoulder.
C. Ecchymosis on the flank area.
D. Bluish discoloration around the umbilicus.
Answer: D
Rationale: Cullen’s sign is a superficial edema and bruising in the subcutaneous fatty tissue
around the umbilicus, indicating intraperitoneal hemorrhage. It is a significant clinical sign
associated with severe necrotizing pancreatitis. The nurse should report this finding
immediately as it suggests worsening disease progression and potential shock.
