NUR 2790 Exam 4 Actual Exam V3 | NUR 2790 Professional Nursing III
/ PN3 (NUR2790 Exam 4) | Rasmussen
1. A nurse is caring for a patient in the ICU with a suspected diagnosis of septic shock. Which
of the following assessment findings would the nurse identify as the earliest clinical sign of
this condition?
A. Systolic blood pressure less than 90 mmHg
B. Change in mental status or confusion
C. Urine output less than 30 mL/hr
D. Cool, clammy, and cyanotic skin
Answer: B
Rationale: In the early stages of septic shock, often called the hyperdynamic or warm
phase, a change in mental status is often the first indicator of decreased cerebral perfusion.
While hypotension and decreased urine output are significant, they often follow initial
neurological changes. The skin is usually warm and flushed initially, rather than cool and
clammy, which occurs in the later cold phase.
2. A patient with a traumatic brain injury (TBI) is being monitored for increased intracranial
pressure (ICP). The nurse notes a widening pulse pressure and bradycardia. Which action
should the nurse take first?
A. Document the findings as a normal compensatory response
B. Prepare for immediate intubation and hyperventilation
C. Administer a PRN dose of IV antihypertensive medication
D. Notify the healthcare provider of Cushing’s triad
Answer: D
Rationale: Widening pulse pressure, bradycardia, and irregular respirations are known as
Cushing’s triad, a late sign of increased ICP and impending brain herniation. This is a
medical emergency that requires immediate notification of the provider to initiate life-
saving interventions. Administering antihypertensives might dangerously lower cerebral
perfusion pressure during this crisis.
3. A nurse is managing a patient on a mechanical ventilator. The high-pressure alarm sounds.
Which of the following should the nurse assess for first?
A. The patient biting the endotracheal tube
B. Disconnection of the ventilator tubing
,C. A leak in the endotracheal tube cuff
D. Extubation of the endotracheal tube
Answer: A
Rationale: High-pressure alarms are triggered by increased resistance in the circuit, such
as a patient biting the tube, secretions in the airway, or the patient coughing. Low-pressure
alarms are typically triggered by disconnections or leaks. Assessing the patient’s
interaction with the tube is the priority for a high-pressure trigger.
4. During a mass casualty incident, the nurse is performing triage using the START method. A
victim is found with a respiratory rate of 32 breaths per minute. What color tag should this
victim receive?
A. Green
B. Yellow
C. Black
D. Red
Answer: D
Rationale: According to the Simple Triage and Rapid Treatment (START) method, any
patient with a respiratory rate greater than 30 breaths per minute is classified as
immediate and assigned a red tag. Green is for the walking wounded, yellow for delayed,
and black for deceased or expectant. Rapid respirations indicate significant physiological
distress requiring priority care.
5. A patient with Acute Respiratory Distress Syndrome (ARDS) is being placed in the prone
position. What is the primary physiological benefit of this intervention?
A. It decreases the workload of the diaphragm
B. It improves oxygenation by recruiting collapsed posterior alveoli
C. It facilitates easier suctioning of tracheal secretions
D. It prevents the development of ventilator-associated pneumonia
Answer: B
Rationale: Prone positioning in ARDS helps shift the weight of the heart and abdominal
contents away from the posterior lung segments, which are often the most congested. This
allows for better recruitment of alveoli and improves ventilation-perfusion (V/Q)
matching. While it may help with secretions, its primary goal is improving arterial oxygen
saturation.
, 6. The nurse is caring for a patient with acute kidney injury (AKI) who has a serum potassium
level of 6.8 mEq/L. Which cardiac rhythm change is the nurse most likely to observe on the
EKG?
A. U waves
B. Tall, peaked T waves
C. Prolonged QT interval
D. Presence of a Delta wave
Answer: B
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on an EKG as tall,
peaked T waves followed by a widened QRS complex and a flattened P wave. U waves are
associated with hypokalemia. Recognizing these changes is critical to prevent progression
to ventricular fibrillation or asystole.
7. A patient is admitted with suspected Diabetic Ketoacidosis (DKA). Which of the following
initial provider orders should the nurse question?
A. Stat potassium chloride 40 mEq IV push
B. Regular insulin infusion at 0.1 units/kg/hr
C. Intravenous infusion of 0.9% Normal Saline at 1000 mL/hr
D. Frequent blood glucose monitoring every hour
Answer: A
Rationale: Potassium chloride should never be administered via IV push as it can cause
immediate cardiac arrest. It must be diluted and administered via infusion pump. In DKA,
fluid resuscitation and insulin are priorities, but potassium levels must be monitored and
replaced carefully as insulin moves potassium into cells.
8. A nurse is caring for a patient who has suffered 40% total body surface area (TBSA) burns.
Using the Parkland formula, the calculated fluid requirement for the first 24 hours is 12,000
mL. How much should be administered in the first 8 hours?
A. 3,000 mL
B. 6,000 mL
C. 4,000 mL
D. 8,000 mL
Answer: B
/ PN3 (NUR2790 Exam 4) | Rasmussen
1. A nurse is caring for a patient in the ICU with a suspected diagnosis of septic shock. Which
of the following assessment findings would the nurse identify as the earliest clinical sign of
this condition?
A. Systolic blood pressure less than 90 mmHg
B. Change in mental status or confusion
C. Urine output less than 30 mL/hr
D. Cool, clammy, and cyanotic skin
Answer: B
Rationale: In the early stages of septic shock, often called the hyperdynamic or warm
phase, a change in mental status is often the first indicator of decreased cerebral perfusion.
While hypotension and decreased urine output are significant, they often follow initial
neurological changes. The skin is usually warm and flushed initially, rather than cool and
clammy, which occurs in the later cold phase.
2. A patient with a traumatic brain injury (TBI) is being monitored for increased intracranial
pressure (ICP). The nurse notes a widening pulse pressure and bradycardia. Which action
should the nurse take first?
A. Document the findings as a normal compensatory response
B. Prepare for immediate intubation and hyperventilation
C. Administer a PRN dose of IV antihypertensive medication
D. Notify the healthcare provider of Cushing’s triad
Answer: D
Rationale: Widening pulse pressure, bradycardia, and irregular respirations are known as
Cushing’s triad, a late sign of increased ICP and impending brain herniation. This is a
medical emergency that requires immediate notification of the provider to initiate life-
saving interventions. Administering antihypertensives might dangerously lower cerebral
perfusion pressure during this crisis.
3. A nurse is managing a patient on a mechanical ventilator. The high-pressure alarm sounds.
Which of the following should the nurse assess for first?
A. The patient biting the endotracheal tube
B. Disconnection of the ventilator tubing
,C. A leak in the endotracheal tube cuff
D. Extubation of the endotracheal tube
Answer: A
Rationale: High-pressure alarms are triggered by increased resistance in the circuit, such
as a patient biting the tube, secretions in the airway, or the patient coughing. Low-pressure
alarms are typically triggered by disconnections or leaks. Assessing the patient’s
interaction with the tube is the priority for a high-pressure trigger.
4. During a mass casualty incident, the nurse is performing triage using the START method. A
victim is found with a respiratory rate of 32 breaths per minute. What color tag should this
victim receive?
A. Green
B. Yellow
C. Black
D. Red
Answer: D
Rationale: According to the Simple Triage and Rapid Treatment (START) method, any
patient with a respiratory rate greater than 30 breaths per minute is classified as
immediate and assigned a red tag. Green is for the walking wounded, yellow for delayed,
and black for deceased or expectant. Rapid respirations indicate significant physiological
distress requiring priority care.
5. A patient with Acute Respiratory Distress Syndrome (ARDS) is being placed in the prone
position. What is the primary physiological benefit of this intervention?
A. It decreases the workload of the diaphragm
B. It improves oxygenation by recruiting collapsed posterior alveoli
C. It facilitates easier suctioning of tracheal secretions
D. It prevents the development of ventilator-associated pneumonia
Answer: B
Rationale: Prone positioning in ARDS helps shift the weight of the heart and abdominal
contents away from the posterior lung segments, which are often the most congested. This
allows for better recruitment of alveoli and improves ventilation-perfusion (V/Q)
matching. While it may help with secretions, its primary goal is improving arterial oxygen
saturation.
, 6. The nurse is caring for a patient with acute kidney injury (AKI) who has a serum potassium
level of 6.8 mEq/L. Which cardiac rhythm change is the nurse most likely to observe on the
EKG?
A. U waves
B. Tall, peaked T waves
C. Prolonged QT interval
D. Presence of a Delta wave
Answer: B
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on an EKG as tall,
peaked T waves followed by a widened QRS complex and a flattened P wave. U waves are
associated with hypokalemia. Recognizing these changes is critical to prevent progression
to ventricular fibrillation or asystole.
7. A patient is admitted with suspected Diabetic Ketoacidosis (DKA). Which of the following
initial provider orders should the nurse question?
A. Stat potassium chloride 40 mEq IV push
B. Regular insulin infusion at 0.1 units/kg/hr
C. Intravenous infusion of 0.9% Normal Saline at 1000 mL/hr
D. Frequent blood glucose monitoring every hour
Answer: A
Rationale: Potassium chloride should never be administered via IV push as it can cause
immediate cardiac arrest. It must be diluted and administered via infusion pump. In DKA,
fluid resuscitation and insulin are priorities, but potassium levels must be monitored and
replaced carefully as insulin moves potassium into cells.
8. A nurse is caring for a patient who has suffered 40% total body surface area (TBSA) burns.
Using the Parkland formula, the calculated fluid requirement for the first 24 hours is 12,000
mL. How much should be administered in the first 8 hours?
A. 3,000 mL
B. 6,000 mL
C. 4,000 mL
D. 8,000 mL
Answer: B
