NUR 2790 Final Exam Actual Exam V2 | 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 on
mechanical ventilation with High Positive End-Expiratory Pressure (PEEP). Which assessment
finding most clearly indicates a complication related specifically to the high PEEP?
A. Presence of fine crackles at the lung bases.
B. Increased oxygen saturation from 88% to 94%.
C. Blood pressure drop from 120/80 to 90/60 mmHg.
D. Elevated white blood cell count.
Answer: C
Rationale: High PEEP increases intrathoracic pressure, which can lead to decreased
venous return to the heart and a subsequent drop in cardiac output and blood pressure.
This hemodynamic instability is a well-known risk of aggressive ventilator settings in ARDS
patients. The nurse must monitor blood pressure closely to ensure that the benefits of
improved oxygenation do not compromise systemic perfusion.
2. A patient arrives in the emergency department after a house fire with burns to the entire
left arm, the anterior trunk, and the entire left leg. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) burned?
A. 45%
B. 36%
C. 27%
D. 54%
Answer: A
Rationale: According to the Rule of Nines, the entire arm is 9%, the anterior trunk is 18%,
and the entire leg is 18%. Adding these values (9 + 18 + 18) results in a total of 45% TBSA.
Accurate calculation of TBSA is critical for determining fluid resuscitation needs using
formulas like the Parkland formula.
3. Which of the following laboratory values would the nurse expect to find in a patient
experiencing the early stages of Compensated Septic Shock?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Hyperkalemia
,D. Increased Serum Bicarbonate
Answer: B
Rationale: In the early stages of shock, the body’s compensatory mechanism involves
tachypnea to increase oxygen delivery, which leads to the blowing off of carbon dioxide.
This results in respiratory alkalosis as the initial acid-base imbalance. As the shock
progresses and tissue perfusion worsens, the patient will eventually shift into metabolic
acidosis due to lactic acid accumulation.
4. A patient with a T6 spinal cord injury reports a sudden, severe headache and nasal
congestion. The nurse notes a blood pressure of 190/100 mmHg and bradycardia. What is the
nurse’s priority action?
A. Administer PRN antihypertensive medication.
B. Perform a digital rectal exam to check for impaction.
C. Check the urinary catheter for kinks or obstruction.
D. Elevate the head of the bed to 90 degrees.
Answer: D
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency triggered by noxious stimuli below the level of injury. The immediate priority is
to sit the patient upright (High-Fowler’s) to utilize orthostatic pressure to help lower the
blood pressure. Once the patient is positioned, the nurse should then systematically
identify and remove the triggering stimulus, such as a distended bladder or bowel.
5. A patient is admitted with Acute Pancreatitis. Which assessment finding should the nurse
report immediately as a potential sign of hemorrhagic pancreatitis?
A. Epigastric pain radiating to the back.
B. Nausea and vomiting after eating.
C. Elevated serum amylase levels.
D. Bluish discoloration around the umbilicus.
Answer: D
Rationale: Cullen’s sign is a bluish discoloration around the umbilicus that indicates
retroperitoneal hemorrhage. This is a severe complication of acute pancreatitis and
suggests significant tissue necrosis and vascular damage. The nurse must recognize this
sign quickly to facilitate emergency interventions and fluid resuscitation.
6. A nurse is monitoring a patient with a head injury. Which of the following changes in vital
signs constitutes Cushing’s Triad, indicating increased intracranial pressure (ICP)?
A. Tachycardia, Hypotension, Tachypnea
, B. Bradycardia, Widening Pulse Pressure, Irregular Respirations
C. Bradycardia, Hypotension, Shallow Respirations
D. Tachycardia, Hypertension, Cheyne-Stokes Respirations
Answer: B
Rationale: Cushing’s Triad is a late sign of increased ICP and impending brain herniation. It
consists of a systolic hypertension with a widening pulse pressure, bradycardia, and
irregular or slowed respirations. Immediate medical intervention is required to reduce ICP
and prevent permanent neurological damage.
7. In a mass casualty incident, a nurse triages a victim who is unconscious, has a respiratory
rate of 8 breaths/minute, and a weak radial pulse. Which color tag should the nurse assign to
this patient?
A. Red
B. Yellow
C. Green
D. Black
Answer: A
Rationale: According to the START (Simple Triage and Rapid Treatment) algorithm, a
patient who is unconscious or has abnormal respiratory rates (less than 10 or more than
30) is categorized as ‘Immediate’ or Red tag. This patient requires life-saving interventions
immediately to survive. Green tags are for the ‘walking wounded,’ while Black tags are for
those who are deceased or have injuries incompatible with life.
8. A patient with cirrhosis and esophageal varices is prescribed Lactulose. What is the primary
therapeutic goal of this medication in this patient?
A. To reduce portal hypertension.
B. To improve protein metabolism in the liver.
C. To prevent gastrointestinal bleeding.
D. To promote the excretion of ammonia through the stool.
Answer: D
Rationale: Lactulose is used in patients with end-stage liver disease to prevent or treat
hepatic encephalopathy. It works by creating an acidic environment in the gut that converts
ammonia to ammonium, which is then trapped and excreted via bowel movements.
Successful therapy is measured by improved mental status and a specific number of soft
stools per day.
Nursing III / PN3 (NUR2790 Final Exam) | Rasmussen
1. A nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) who is on
mechanical ventilation with High Positive End-Expiratory Pressure (PEEP). Which assessment
finding most clearly indicates a complication related specifically to the high PEEP?
A. Presence of fine crackles at the lung bases.
B. Increased oxygen saturation from 88% to 94%.
C. Blood pressure drop from 120/80 to 90/60 mmHg.
D. Elevated white blood cell count.
Answer: C
Rationale: High PEEP increases intrathoracic pressure, which can lead to decreased
venous return to the heart and a subsequent drop in cardiac output and blood pressure.
This hemodynamic instability is a well-known risk of aggressive ventilator settings in ARDS
patients. The nurse must monitor blood pressure closely to ensure that the benefits of
improved oxygenation do not compromise systemic perfusion.
2. A patient arrives in the emergency department after a house fire with burns to the entire
left arm, the anterior trunk, and the entire left leg. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) burned?
A. 45%
B. 36%
C. 27%
D. 54%
Answer: A
Rationale: According to the Rule of Nines, the entire arm is 9%, the anterior trunk is 18%,
and the entire leg is 18%. Adding these values (9 + 18 + 18) results in a total of 45% TBSA.
Accurate calculation of TBSA is critical for determining fluid resuscitation needs using
formulas like the Parkland formula.
3. Which of the following laboratory values would the nurse expect to find in a patient
experiencing the early stages of Compensated Septic Shock?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Hyperkalemia
,D. Increased Serum Bicarbonate
Answer: B
Rationale: In the early stages of shock, the body’s compensatory mechanism involves
tachypnea to increase oxygen delivery, which leads to the blowing off of carbon dioxide.
This results in respiratory alkalosis as the initial acid-base imbalance. As the shock
progresses and tissue perfusion worsens, the patient will eventually shift into metabolic
acidosis due to lactic acid accumulation.
4. A patient with a T6 spinal cord injury reports a sudden, severe headache and nasal
congestion. The nurse notes a blood pressure of 190/100 mmHg and bradycardia. What is the
nurse’s priority action?
A. Administer PRN antihypertensive medication.
B. Perform a digital rectal exam to check for impaction.
C. Check the urinary catheter for kinks or obstruction.
D. Elevate the head of the bed to 90 degrees.
Answer: D
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency triggered by noxious stimuli below the level of injury. The immediate priority is
to sit the patient upright (High-Fowler’s) to utilize orthostatic pressure to help lower the
blood pressure. Once the patient is positioned, the nurse should then systematically
identify and remove the triggering stimulus, such as a distended bladder or bowel.
5. A patient is admitted with Acute Pancreatitis. Which assessment finding should the nurse
report immediately as a potential sign of hemorrhagic pancreatitis?
A. Epigastric pain radiating to the back.
B. Nausea and vomiting after eating.
C. Elevated serum amylase levels.
D. Bluish discoloration around the umbilicus.
Answer: D
Rationale: Cullen’s sign is a bluish discoloration around the umbilicus that indicates
retroperitoneal hemorrhage. This is a severe complication of acute pancreatitis and
suggests significant tissue necrosis and vascular damage. The nurse must recognize this
sign quickly to facilitate emergency interventions and fluid resuscitation.
6. A nurse is monitoring a patient with a head injury. Which of the following changes in vital
signs constitutes Cushing’s Triad, indicating increased intracranial pressure (ICP)?
A. Tachycardia, Hypotension, Tachypnea
, B. Bradycardia, Widening Pulse Pressure, Irregular Respirations
C. Bradycardia, Hypotension, Shallow Respirations
D. Tachycardia, Hypertension, Cheyne-Stokes Respirations
Answer: B
Rationale: Cushing’s Triad is a late sign of increased ICP and impending brain herniation. It
consists of a systolic hypertension with a widening pulse pressure, bradycardia, and
irregular or slowed respirations. Immediate medical intervention is required to reduce ICP
and prevent permanent neurological damage.
7. In a mass casualty incident, a nurse triages a victim who is unconscious, has a respiratory
rate of 8 breaths/minute, and a weak radial pulse. Which color tag should the nurse assign to
this patient?
A. Red
B. Yellow
C. Green
D. Black
Answer: A
Rationale: According to the START (Simple Triage and Rapid Treatment) algorithm, a
patient who is unconscious or has abnormal respiratory rates (less than 10 or more than
30) is categorized as ‘Immediate’ or Red tag. This patient requires life-saving interventions
immediately to survive. Green tags are for the ‘walking wounded,’ while Black tags are for
those who are deceased or have injuries incompatible with life.
8. A patient with cirrhosis and esophageal varices is prescribed Lactulose. What is the primary
therapeutic goal of this medication in this patient?
A. To reduce portal hypertension.
B. To improve protein metabolism in the liver.
C. To prevent gastrointestinal bleeding.
D. To promote the excretion of ammonia through the stool.
Answer: D
Rationale: Lactulose is used in patients with end-stage liver disease to prevent or treat
hepatic encephalopathy. It works by creating an acidic environment in the gut that converts
ammonia to ammonium, which is then trapped and excreted via bowel movements.
Successful therapy is measured by improved mental status and a specific number of soft
stools per day.
