NUR 2790 Exam 4 Actual Exam V2 | NUR 2790 Professional Nursing III
/ PN3 (NUR2790 Exam 4) | Rasmussen
1. A nurse is caring for a client in the compensatory stage of shock. Which of the following
findings should the nurse expect?
A. Metabolic acidosis
B. Anuria and lethargy
C. Tachycardia and narrowing pulse pressure
D. Mottled skin and bradycardia
Answer: C
Rationale: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. This results in an
increased heart rate to maintain cardiac output and vasoconstriction which leads to a
narrowed pulse pressure. These findings represent the body’s successful, though
temporary, attempt to preserve perfusion to vital organs.
2. A client is admitted with full-thickness burns to the entire left arm and the anterior trunk.
Using the Rule of Nines, what is the total body surface area (TBSA) percentage affected?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Rationale: According to the Rule of Nines, the entire arm accounts for 9% and the anterior
trunk accounts for 18%. Adding these two values together (9 + 18) results in a total of 27%
TBSA. Accurate calculation is vital for determining fluid resuscitation needs in the
emergency phase of burn management.
3. A client with a T4 spinal cord injury reports a sudden, severe headache and is found to have
a blood pressure of 190/110 mmHg. What is the nurse’s priority action?
A. Administer PRN antihypertensive medication
B. Place the client in a high-Fowler’s position
C. Perform a digital rectal exam to check for impaction
D. Check the urinary catheter for kinks or occlusion
,Answer: B
Rationale: The client is experiencing symptoms of autonomic dysreflexia, which is a
medical emergency. The first priority is to sit the client upright (high-Fowler’s) to lower the
blood pressure through orthostatic changes. After positioning, the nurse should then
identify and remove the triggering stimulus, such as a full bladder or impacted bowel.
4. Which assessment finding in a client with Acute Respiratory Distress Syndrome (ARDS)
indicates that the condition is worsening despite oxygen therapy?
A. Increased partial pressure of arterial oxygen (PaO2)
B. Refractory hypoxemia
C. Respiratory alkalosis on ABG
D. Improved lung compliance
Answer: B
Rationale: Refractory hypoxemia is a hallmark sign of ARDS where the client’s oxygen
levels do not improve even with high concentrations of supplemental oxygen. This occurs
due to the shunting of blood through fluid-filled alveoli that cannot participate in gas
exchange. It signifies severe lung injury and the need for advanced interventions like
mechanical ventilation with PEEP.
5. A nurse is caring for a client with a Glasglow Coma Scale (GCS) score of 7. What is the
primary nursing concern for this client?
A. Risk for skin breakdown
B. Maintenance of a patent airway
C. Assessment of deep vein thrombosis
D. Management of nutritional intake
Answer: B
Rationale: A GCS score of 8 or less typically indicates a severe brain injury and the inability
of the client to protect their own airway. In these cases, intubation is often required to
prevent aspiration and ensure adequate ventilation. While skin care and nutrition are
important, airway management is always the highest priority in emergency neurosurgical
nursing.
6. A client in the ICU is being treated for Septic Shock. The nurse notes the client’s MAP is 55
mmHg. Which of the following is the most appropriate initial intervention?
A. Start a norepinephrine infusion
B. Administer a 30 mL/kg isotonic crystalloid bolus
C. Draw blood cultures from two separate sites
, D. Apply a cooling blanket for a fever of 102.4 F
Answer: B
Rationale: The Surviving Sepsis Campaign guidelines recommend initial fluid resuscitation
with at least 30 mL/kg of crystalloid for sepsis-induced hypotension. Vasopressors like
norepinephrine are indicated only if the MAP remains below 65 mmHg after adequate fluid
resuscitation. Early fluid volume replacement is critical to improving tissue perfusion and
organ function.
7. Which of the following clients should the nurse prioritize during a mass casualty incident?
A. A client with 90% TBSA full-thickness burns
B. A client with a closed fracture of the tibia
C. A client with a sucking chest wound and cyanosis
D. A client with a 2 cm superficial laceration on the forearm
Answer: C
Rationale: In disaster triage, the ‘Red’ tag (Immediate) is for clients with life-threatening
injuries who have a high chance of survival if treated immediately, such as a sucking chest
wound. The client with 90% burns would likely be tagged ‘Black’ (Expectant) because their
chance of survival is minimal despite treatment. This prioritization ensures the greatest
good for the greatest number of people.
8. A nurse is monitoring a client receiving hemodialysis. The client complains of a headache,
becomes restless, and begins to have a seizure. The nurse should recognize these as signs of:
A. Disequilibrium syndrome
B. Air embolism
C. Hypovolemic shock
D. Hypertensive crisis
Answer: A
Rationale: Disequilibrium syndrome is a rare but serious complication of hemodialysis
characterized by cerebral edema. It typically occurs when solutes are removed too rapidly
from the blood, leading to an osmotic shift that pulls water into the brain cells. Nurses must
monitor for neurological changes and be prepared to slow or stop the dialysis treatment if
these symptoms occur.
9. When assessing a client with a history of liver cirrhosis, the nurse notes flapping tremors of
the hands (asterixis). Which laboratory value is likely to be elevated?
A. Serum Potassium
B. Serum Amylase
/ PN3 (NUR2790 Exam 4) | Rasmussen
1. A nurse is caring for a client in the compensatory stage of shock. Which of the following
findings should the nurse expect?
A. Metabolic acidosis
B. Anuria and lethargy
C. Tachycardia and narrowing pulse pressure
D. Mottled skin and bradycardia
Answer: C
Rationale: During the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. This results in an
increased heart rate to maintain cardiac output and vasoconstriction which leads to a
narrowed pulse pressure. These findings represent the body’s successful, though
temporary, attempt to preserve perfusion to vital organs.
2. A client is admitted with full-thickness burns to the entire left arm and the anterior trunk.
Using the Rule of Nines, what is the total body surface area (TBSA) percentage affected?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Rationale: According to the Rule of Nines, the entire arm accounts for 9% and the anterior
trunk accounts for 18%. Adding these two values together (9 + 18) results in a total of 27%
TBSA. Accurate calculation is vital for determining fluid resuscitation needs in the
emergency phase of burn management.
3. A client with a T4 spinal cord injury reports a sudden, severe headache and is found to have
a blood pressure of 190/110 mmHg. What is the nurse’s priority action?
A. Administer PRN antihypertensive medication
B. Place the client in a high-Fowler’s position
C. Perform a digital rectal exam to check for impaction
D. Check the urinary catheter for kinks or occlusion
,Answer: B
Rationale: The client is experiencing symptoms of autonomic dysreflexia, which is a
medical emergency. The first priority is to sit the client upright (high-Fowler’s) to lower the
blood pressure through orthostatic changes. After positioning, the nurse should then
identify and remove the triggering stimulus, such as a full bladder or impacted bowel.
4. Which assessment finding in a client with Acute Respiratory Distress Syndrome (ARDS)
indicates that the condition is worsening despite oxygen therapy?
A. Increased partial pressure of arterial oxygen (PaO2)
B. Refractory hypoxemia
C. Respiratory alkalosis on ABG
D. Improved lung compliance
Answer: B
Rationale: Refractory hypoxemia is a hallmark sign of ARDS where the client’s oxygen
levels do not improve even with high concentrations of supplemental oxygen. This occurs
due to the shunting of blood through fluid-filled alveoli that cannot participate in gas
exchange. It signifies severe lung injury and the need for advanced interventions like
mechanical ventilation with PEEP.
5. A nurse is caring for a client with a Glasglow Coma Scale (GCS) score of 7. What is the
primary nursing concern for this client?
A. Risk for skin breakdown
B. Maintenance of a patent airway
C. Assessment of deep vein thrombosis
D. Management of nutritional intake
Answer: B
Rationale: A GCS score of 8 or less typically indicates a severe brain injury and the inability
of the client to protect their own airway. In these cases, intubation is often required to
prevent aspiration and ensure adequate ventilation. While skin care and nutrition are
important, airway management is always the highest priority in emergency neurosurgical
nursing.
6. A client in the ICU is being treated for Septic Shock. The nurse notes the client’s MAP is 55
mmHg. Which of the following is the most appropriate initial intervention?
A. Start a norepinephrine infusion
B. Administer a 30 mL/kg isotonic crystalloid bolus
C. Draw blood cultures from two separate sites
, D. Apply a cooling blanket for a fever of 102.4 F
Answer: B
Rationale: The Surviving Sepsis Campaign guidelines recommend initial fluid resuscitation
with at least 30 mL/kg of crystalloid for sepsis-induced hypotension. Vasopressors like
norepinephrine are indicated only if the MAP remains below 65 mmHg after adequate fluid
resuscitation. Early fluid volume replacement is critical to improving tissue perfusion and
organ function.
7. Which of the following clients should the nurse prioritize during a mass casualty incident?
A. A client with 90% TBSA full-thickness burns
B. A client with a closed fracture of the tibia
C. A client with a sucking chest wound and cyanosis
D. A client with a 2 cm superficial laceration on the forearm
Answer: C
Rationale: In disaster triage, the ‘Red’ tag (Immediate) is for clients with life-threatening
injuries who have a high chance of survival if treated immediately, such as a sucking chest
wound. The client with 90% burns would likely be tagged ‘Black’ (Expectant) because their
chance of survival is minimal despite treatment. This prioritization ensures the greatest
good for the greatest number of people.
8. A nurse is monitoring a client receiving hemodialysis. The client complains of a headache,
becomes restless, and begins to have a seizure. The nurse should recognize these as signs of:
A. Disequilibrium syndrome
B. Air embolism
C. Hypovolemic shock
D. Hypertensive crisis
Answer: A
Rationale: Disequilibrium syndrome is a rare but serious complication of hemodialysis
characterized by cerebral edema. It typically occurs when solutes are removed too rapidly
from the blood, leading to an osmotic shift that pulls water into the brain cells. Nurses must
monitor for neurological changes and be prepared to slow or stop the dialysis treatment if
these symptoms occur.
9. When assessing a client with a history of liver cirrhosis, the nurse notes flapping tremors of
the hands (asterixis). Which laboratory value is likely to be elevated?
A. Serum Potassium
B. Serum Amylase
