NUR 2790 Final Exam Actual Exam V1 | NUR 2790 Professional
Nursing III / PN3 (NUR2790 Final Exam) | Rasmussen
1. A nurse in the ICU is caring for a patient on mechanical ventilation. The high-pressure
alarm sounds. Which action should the nurse take first?
A. Check for kinks in the ventilator tubing.
B. Notify the respiratory therapist immediately.
C. Assess the patient’s oxygen saturation levels.
D. Suction the patient’s airway for secretions.
Answer: D
Rationale: The high-pressure alarm is often triggered by increased resistance, such as
secretions or biting the tube. Suctioning is a priority intervention to clear the airway and
reduce pressure. This analysis shows that the nurse must prioritize immediate
physiological needs over equipment checks.
2. A patient with a traumatic brain injury (TBI) exhibits a blood pressure of 160/60 mmHg, a
pulse of 50 bpm, and irregular respirations. What does the nurse identify this as?
A. Beck’s Triad
B. Virchow’s Triad
C. Cushing’s Triad
D. Horner’s Syndrome
Answer: C
Rationale: Cushing’s triad consists of bradycardia, widening pulse pressure, and irregular
respirations, indicating increased intracranial pressure. This is a medical emergency
requiring immediate intervention to prevent brain herniation. Clinical judgment involves
recognizing these late signs of neurological deterioration.
3. A patient arrives at the emergency department with full-thickness burns to the entire left
arm and anterior trunk. Using the Rule of Nines, what is the estimated TBSA percentage?
A. 27%
B. 18%
C. 36%
D. 45%
Answer: A
,Rationale: The entire arm is 9% and the anterior trunk is 18%, totaling 27%. Correct
calculation of TBSA is vital for fluid resuscitation protocols like the Parkland formula.
Accurate assessment at this stage directly impacts the patient’s survival in the first 24
hours.
4. Which lab value is the most sensitive indicator of acute renal failure in a critically ill
patient?
A. Blood Urea Nitrogen (BUN)
B. Urine Specific Gravity
C. Serum Creatinine
D. Glomerular Filtration Rate (GFR)
Answer: C
Rationale: Serum creatinine is more specific to kidney function than BUN, which can be
affected by diet and hydration. While GFR is calculated, the raw creatinine level provides
the baseline for identifying acute changes. Professional nursing judgment requires
monitoring trends in these values to adjust medication dosages.
5. A nurse is caring for a patient in septic shock. Which hemodynamic finding is expected in
the hyperdynamic (early) phase?
A. Decreased cardiac output
B. Increased systemic vascular resistance (SVR)
C. Increased cardiac output
D. Low central venous pressure (CVP)
Answer: C
Rationale: In early septic shock, the body compensates with a high cardiac output and
vasodilation (low SVR). This warm phase is deceptive because the patient may appear
flushed despite underlying tissue hypoxia. Recognizing this phase allows for aggressive
fluid resuscitation before the patient decompensates.
6. A patient with a chest tube has continuous bubbling in the water seal chamber. What
should the nurse suspect?
A. An air leak in the system.
B. Normal functioning of the chest tube.
C. The patient has a large pneumothorax.
D. The suction is set too high.
Answer: A
, Rationale: Intermittent bubbling is normal for a pneumothorax, but continuous bubbling
indicates a leak in the tube or the connection. The nurse must troubleshoot the system
from the patient site down to the drainage unit. Patient safety is maintained by ensuring
the integrity of the closed drainage system.
7. The nurse is assigned to four patients. Which patient should be assessed first?
A. A patient receiving IV antibiotics for cellulitis.
B. A patient 2 hours post-op with 50 mL of serosanguinous drainage.
C. A patient with chronic COPD and an O2 saturation of 89%.
D. A patient with a C6 spinal cord injury reporting a severe headache.
Answer: D
Rationale: The patient with the spinal cord injury and headache is likely experiencing
autonomic dysreflexia, which is a life-threatening hypertensive crisis. This requires
immediate intervention to identify the noxious stimulus, such as a full bladder.
Prioritization reflects the critical nature of potential neurological and vascular
complications.
8. What is the primary goal of PEEP (Positive End-Expiratory Pressure) in ARDS management?
A. To increase tidal volume.
B. To decrease the work of breathing.
C. To keep alveoli open at the end of expiration.
D. To decrease intracranial pressure.
Answer: C
Rationale: PEEP prevents alveolar collapse (atelectasis), which improves gas exchange and
oxygenation in patients with stiff lungs. While it improves oxygenation, high levels can also
cause barotrauma or decreased cardiac output. This synthesized understanding helps the
nurse monitor for potential adverse hemodynamic effects.
9. A patient’s ABG results are: pH 7.28, PaCO2 55, HCO3 26. How should the nurse interpret
these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: A
Nursing III / PN3 (NUR2790 Final Exam) | Rasmussen
1. A nurse in the ICU is caring for a patient on mechanical ventilation. The high-pressure
alarm sounds. Which action should the nurse take first?
A. Check for kinks in the ventilator tubing.
B. Notify the respiratory therapist immediately.
C. Assess the patient’s oxygen saturation levels.
D. Suction the patient’s airway for secretions.
Answer: D
Rationale: The high-pressure alarm is often triggered by increased resistance, such as
secretions or biting the tube. Suctioning is a priority intervention to clear the airway and
reduce pressure. This analysis shows that the nurse must prioritize immediate
physiological needs over equipment checks.
2. A patient with a traumatic brain injury (TBI) exhibits a blood pressure of 160/60 mmHg, a
pulse of 50 bpm, and irregular respirations. What does the nurse identify this as?
A. Beck’s Triad
B. Virchow’s Triad
C. Cushing’s Triad
D. Horner’s Syndrome
Answer: C
Rationale: Cushing’s triad consists of bradycardia, widening pulse pressure, and irregular
respirations, indicating increased intracranial pressure. This is a medical emergency
requiring immediate intervention to prevent brain herniation. Clinical judgment involves
recognizing these late signs of neurological deterioration.
3. A patient arrives at the emergency department with full-thickness burns to the entire left
arm and anterior trunk. Using the Rule of Nines, what is the estimated TBSA percentage?
A. 27%
B. 18%
C. 36%
D. 45%
Answer: A
,Rationale: The entire arm is 9% and the anterior trunk is 18%, totaling 27%. Correct
calculation of TBSA is vital for fluid resuscitation protocols like the Parkland formula.
Accurate assessment at this stage directly impacts the patient’s survival in the first 24
hours.
4. Which lab value is the most sensitive indicator of acute renal failure in a critically ill
patient?
A. Blood Urea Nitrogen (BUN)
B. Urine Specific Gravity
C. Serum Creatinine
D. Glomerular Filtration Rate (GFR)
Answer: C
Rationale: Serum creatinine is more specific to kidney function than BUN, which can be
affected by diet and hydration. While GFR is calculated, the raw creatinine level provides
the baseline for identifying acute changes. Professional nursing judgment requires
monitoring trends in these values to adjust medication dosages.
5. A nurse is caring for a patient in septic shock. Which hemodynamic finding is expected in
the hyperdynamic (early) phase?
A. Decreased cardiac output
B. Increased systemic vascular resistance (SVR)
C. Increased cardiac output
D. Low central venous pressure (CVP)
Answer: C
Rationale: In early septic shock, the body compensates with a high cardiac output and
vasodilation (low SVR). This warm phase is deceptive because the patient may appear
flushed despite underlying tissue hypoxia. Recognizing this phase allows for aggressive
fluid resuscitation before the patient decompensates.
6. A patient with a chest tube has continuous bubbling in the water seal chamber. What
should the nurse suspect?
A. An air leak in the system.
B. Normal functioning of the chest tube.
C. The patient has a large pneumothorax.
D. The suction is set too high.
Answer: A
, Rationale: Intermittent bubbling is normal for a pneumothorax, but continuous bubbling
indicates a leak in the tube or the connection. The nurse must troubleshoot the system
from the patient site down to the drainage unit. Patient safety is maintained by ensuring
the integrity of the closed drainage system.
7. The nurse is assigned to four patients. Which patient should be assessed first?
A. A patient receiving IV antibiotics for cellulitis.
B. A patient 2 hours post-op with 50 mL of serosanguinous drainage.
C. A patient with chronic COPD and an O2 saturation of 89%.
D. A patient with a C6 spinal cord injury reporting a severe headache.
Answer: D
Rationale: The patient with the spinal cord injury and headache is likely experiencing
autonomic dysreflexia, which is a life-threatening hypertensive crisis. This requires
immediate intervention to identify the noxious stimulus, such as a full bladder.
Prioritization reflects the critical nature of potential neurological and vascular
complications.
8. What is the primary goal of PEEP (Positive End-Expiratory Pressure) in ARDS management?
A. To increase tidal volume.
B. To decrease the work of breathing.
C. To keep alveoli open at the end of expiration.
D. To decrease intracranial pressure.
Answer: C
Rationale: PEEP prevents alveolar collapse (atelectasis), which improves gas exchange and
oxygenation in patients with stiff lungs. While it improves oxygenation, high levels can also
cause barotrauma or decreased cardiac output. This synthesized understanding helps the
nurse monitor for potential adverse hemodynamic effects.
9. A patient’s ABG results are: pH 7.28, PaCO2 55, HCO3 26. How should the nurse interpret
these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: A
