NUR 2790 Final Exam Actual Exam V3 | NUR 2790 Professional
Nursing III / PN3 (NUR2790 Final Exam) | Rasmussen
1. A nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) who is
currently on mechanical ventilation with a PEEP of 15 cm H2O. The nurse notes a sudden drop
in blood pressure and increased heart rate. Which complication should the nurse suspect
first?
A. Development of pulmonary edema
B. Tension pneumothorax
C. Acute renal failure
D. Disseminated intravascular coagulation
Answer: B
Rationale: High levels of PEEP increase the risk of barotrauma, which can lead to a tension
pneumothorax. A sudden drop in blood pressure and tachycardia are classic signs of
decreased cardiac output due to increased intrathoracic pressure. The nurse must
immediately assess breath sounds and notify the provider for potential chest tube
insertion.
2. A patient arrives at the emergency department with 40% Total Body Surface Area (TBSA)
burns. Using the Parkland Formula (4mL x kg x %TBSA), how much fluid should the nurse
administer in the first 8 hours for a patient weighing 80 kg?
A. 12,800 mL
B. 9,600 mL
C. 3,200 mL
D. 6,400 mL
Answer: D
Rationale: The total 24-hour fluid requirement is 4 mL x 80 kg x 40 = 12,800 mL.
According to the Parkland Formula, half of this volume (6,400 mL) must be administered
within the first 8 hours from the time of the burn injury. Accurate fluid resuscitation is
critical to prevent hypovolemic shock in the emergent phase of burn care.
3. During a mass casualty incident, which patient should the triage nurse assign a ‘Red Tag’
(Immediate) to?
A. A patient with a traumatic amputation of the leg and no palpable pulse
B. A patient with an open fracture of the forearm but stable vitals
,C. A patient with a sucking chest wound and respiratory distress
D. A patient with 90% full-thickness burns and agonal gasps
Answer: C
Rationale: Red tags are for patients with life-threatening injuries who have a high chance
of survival if treated immediately, such as those with airway or breathing compromise. A
sucking chest wound represents a respiratory emergency that can be stabilized quickly
with an occlusive dressing. Patients with no pulse or agonal gasps in a disaster setting are
usually tagged black (expectant) to prioritize resources for those who are salvageable.
4. A patient is admitted with Septic Shock. The provider orders a 30 mL/kg fluid bolus. Which
clinical finding indicates that the fluid resuscitation is effective?
A. A decrease in serum creatinine from 1.5 to 1.2 mg/dL
B. Central Venous Pressure (CVP) increases from 2 mmHg to 10 mmHg
C. A Mean Arterial Pressure (MAP) of 55 mmHg
D. The patient’s heart rate increases from 100 to 120 bpm
Answer: B
Rationale: CVP reflects the filling pressure of the right atrium and is used to monitor fluid
volume status; a range of 8-12 mmHg is often the target in sepsis resuscitation. An increase
from a low CVP toward a normal/target range suggests improved preload. Effective
resuscitation should also result in a MAP > 65 mmHg and adequate urine output.
5. Which assessment finding in a patient with a head injury and increased intracranial
pressure (ICP) should the nurse report to the provider immediately?
A. A Glasgow Coma Scale (GCS) score that changed from 12 to 9
B. A blood pressure of 140/80 mmHg
C. Patient complaints of a headache
D. Pupils that are equal and reactive to light
Answer: A
Rationale: A decrease in GCS score indicates a deterioration in neurological status and may
suggest worsening ICP or brain herniation. A drop of 2 or more points is clinically
significant and requires immediate intervention. Early detection of neurological changes is
the most sensitive indicator of increased ICP.
6. A nurse is caring for a patient who just returned from a kidney transplant. What is the
priority nursing intervention during the first 24 hours?
A. Teaching the patient about lifelong immunosuppressant therapy
, B. Monitoring hourly urine output
C. Assessing the patient’s psychological readiness for the new organ
D. Assisting the patient with ambulation
Answer: B
Rationale: In the immediate post-operative period for a kidney transplant, hourly urine
output is the most critical indicator of graft function and fluid balance. A sudden decrease
in output could indicate a blockage, rejection, or decreased perfusion. While education and
ambulation are important, physiological stability and organ perfusion are the priorities.
7. A patient with Diabetic Ketoacidosis (DKA) is receiving an insulin drip. The nurse notes the
blood glucose has dropped from 500 mg/dL to 250 mg/dL. What is the nurse’s next action?
A. Change the IV fluid to include 5% Dextrose
B. Increase the insulin drip rate
C. Stop the insulin drip immediately
D. Administer glucagon subcutaneously
Answer: A
Rationale: When blood glucose levels reach approximately 250 mg/dL in DKA, dextrose is
added to the IV fluids (e.g., D5 0.45% NS) to prevent hypoglycemia and cerebral edema.
The insulin drip continues until the acidosis is resolved (anion gap is closed), not just until
glucose is normalized. This protocol allows for the continued suppression of ketogenesis
while maintaining safe glucose levels.
8. The nurse is caring for a patient with a chest tube placed for a pneumothorax. The nurse
notes continuous bubbling in the water-seal chamber. How should the nurse interpret this
finding?
A. This is a normal finding while the lung is re-expanding
B. The suction level is set too high
C. There is an air leak in the system
D. The chest tube is occluded
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates a persistent air leak
between the patient and the drainage system. Intermittent bubbling is expected in a patient
with a pneumothorax during coughing or expiration, but continuous bubbling requires
troubleshooting. The nurse should check the connections and the insertion site.
Nursing III / PN3 (NUR2790 Final Exam) | Rasmussen
1. A nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) who is
currently on mechanical ventilation with a PEEP of 15 cm H2O. The nurse notes a sudden drop
in blood pressure and increased heart rate. Which complication should the nurse suspect
first?
A. Development of pulmonary edema
B. Tension pneumothorax
C. Acute renal failure
D. Disseminated intravascular coagulation
Answer: B
Rationale: High levels of PEEP increase the risk of barotrauma, which can lead to a tension
pneumothorax. A sudden drop in blood pressure and tachycardia are classic signs of
decreased cardiac output due to increased intrathoracic pressure. The nurse must
immediately assess breath sounds and notify the provider for potential chest tube
insertion.
2. A patient arrives at the emergency department with 40% Total Body Surface Area (TBSA)
burns. Using the Parkland Formula (4mL x kg x %TBSA), how much fluid should the nurse
administer in the first 8 hours for a patient weighing 80 kg?
A. 12,800 mL
B. 9,600 mL
C. 3,200 mL
D. 6,400 mL
Answer: D
Rationale: The total 24-hour fluid requirement is 4 mL x 80 kg x 40 = 12,800 mL.
According to the Parkland Formula, half of this volume (6,400 mL) must be administered
within the first 8 hours from the time of the burn injury. Accurate fluid resuscitation is
critical to prevent hypovolemic shock in the emergent phase of burn care.
3. During a mass casualty incident, which patient should the triage nurse assign a ‘Red Tag’
(Immediate) to?
A. A patient with a traumatic amputation of the leg and no palpable pulse
B. A patient with an open fracture of the forearm but stable vitals
,C. A patient with a sucking chest wound and respiratory distress
D. A patient with 90% full-thickness burns and agonal gasps
Answer: C
Rationale: Red tags are for patients with life-threatening injuries who have a high chance
of survival if treated immediately, such as those with airway or breathing compromise. A
sucking chest wound represents a respiratory emergency that can be stabilized quickly
with an occlusive dressing. Patients with no pulse or agonal gasps in a disaster setting are
usually tagged black (expectant) to prioritize resources for those who are salvageable.
4. A patient is admitted with Septic Shock. The provider orders a 30 mL/kg fluid bolus. Which
clinical finding indicates that the fluid resuscitation is effective?
A. A decrease in serum creatinine from 1.5 to 1.2 mg/dL
B. Central Venous Pressure (CVP) increases from 2 mmHg to 10 mmHg
C. A Mean Arterial Pressure (MAP) of 55 mmHg
D. The patient’s heart rate increases from 100 to 120 bpm
Answer: B
Rationale: CVP reflects the filling pressure of the right atrium and is used to monitor fluid
volume status; a range of 8-12 mmHg is often the target in sepsis resuscitation. An increase
from a low CVP toward a normal/target range suggests improved preload. Effective
resuscitation should also result in a MAP > 65 mmHg and adequate urine output.
5. Which assessment finding in a patient with a head injury and increased intracranial
pressure (ICP) should the nurse report to the provider immediately?
A. A Glasgow Coma Scale (GCS) score that changed from 12 to 9
B. A blood pressure of 140/80 mmHg
C. Patient complaints of a headache
D. Pupils that are equal and reactive to light
Answer: A
Rationale: A decrease in GCS score indicates a deterioration in neurological status and may
suggest worsening ICP or brain herniation. A drop of 2 or more points is clinically
significant and requires immediate intervention. Early detection of neurological changes is
the most sensitive indicator of increased ICP.
6. A nurse is caring for a patient who just returned from a kidney transplant. What is the
priority nursing intervention during the first 24 hours?
A. Teaching the patient about lifelong immunosuppressant therapy
, B. Monitoring hourly urine output
C. Assessing the patient’s psychological readiness for the new organ
D. Assisting the patient with ambulation
Answer: B
Rationale: In the immediate post-operative period for a kidney transplant, hourly urine
output is the most critical indicator of graft function and fluid balance. A sudden decrease
in output could indicate a blockage, rejection, or decreased perfusion. While education and
ambulation are important, physiological stability and organ perfusion are the priorities.
7. A patient with Diabetic Ketoacidosis (DKA) is receiving an insulin drip. The nurse notes the
blood glucose has dropped from 500 mg/dL to 250 mg/dL. What is the nurse’s next action?
A. Change the IV fluid to include 5% Dextrose
B. Increase the insulin drip rate
C. Stop the insulin drip immediately
D. Administer glucagon subcutaneously
Answer: A
Rationale: When blood glucose levels reach approximately 250 mg/dL in DKA, dextrose is
added to the IV fluids (e.g., D5 0.45% NS) to prevent hypoglycemia and cerebral edema.
The insulin drip continues until the acidosis is resolved (anion gap is closed), not just until
glucose is normalized. This protocol allows for the continued suppression of ketogenesis
while maintaining safe glucose levels.
8. The nurse is caring for a patient with a chest tube placed for a pneumothorax. The nurse
notes continuous bubbling in the water-seal chamber. How should the nurse interpret this
finding?
A. This is a normal finding while the lung is re-expanding
B. The suction level is set too high
C. There is an air leak in the system
D. The chest tube is occluded
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates a persistent air leak
between the patient and the drainage system. Intermittent bubbling is expected in a patient
with a pneumothorax during coughing or expiration, but continuous bubbling requires
troubleshooting. The nurse should check the connections and the insertion site.
