NUR 2790 Exam 4 Actual Exam V1 | NUR 2790 Professional Nursing III
/ PN3 (NUR2790 Exam 4) | Rasmussen
1. A patient is admitted to the ICU with a diagnosis of septic shock. Which assessment finding
most clearly indicates that the patient is progressing toward Multi-Organ Dysfunction
Syndrome (MODS)?
A. Blood glucose level of 145 mg/dL.
B. Increase in serum creatinine from 1.0 to 2.8 mg/dL.
C. Mean Arterial Pressure (MAP) of 70 mmHg.
D. Urinary output of 35 mL/hr for two hours.
Answer: B
Rationale: MODS is characterized by the failure of two or more organ systems in an acutely
ill patient. A significant rise in serum creatinine indicates the progression of acute kidney
injury, which is a classic sign of worsening systemic dysfunction. Nurses must monitor
biochemical markers closely to identify early signs of organ failure in critical care settings.
2. A nurse is caring for a patient on mechanical ventilation with High-Efficiency Positive End-
Expiratory Pressure (PEEP) for ARDS. Which assessment finding requires immediate
intervention?
A. SpO2 of 92% on 50% FiO2.
B. Sudden drop in blood pressure and absent breath sounds on the right side.
C. Symmetrical chest expansion with inspiration.
D. Heart rate of 105 beats per minute.
Answer: B
Rationale: High levels of PEEP increase the risk of barotrauma, which can lead to a tension
pneumothorax. Sudden hypotension and absent breath sounds are hallmark signs of a
collapsed lung and mediastinal shift. The nurse must immediately notify the provider to
facilitate needle decompression or chest tube insertion.
3. Which lab value would the nurse expect to see in a patient who is experiencing the early
stages of Disseminated Intravascular Coagulation (DIC)?
A. Decreased D-Dimer level.
B. Increased platelet count.
C. Increased fibrinogen levels.
D. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT).
,Answer: D
Rationale: In DIC, the coagulation cascade is overactive, leading to the depletion of clotting
factors and platelets. This depletion results in prolonged PT and PTT values as the body
loses its ability to form clots effectively. Monitoring these values is essential for identifying
the shift from the thrombotic phase to the bleeding phase.
4. A patient with a C5 spinal cord injury is complaining of a severe, throbbing headache and
has a blood pressure of 190/100 mmHg. What should be the nurse’s first action?
A. Administer an ordered PRN antihypertensive medication.
B. Notify the healthcare provider immediately.
C. Lower the head of the bed to a flat position.
D. Check the patient’s bladder for distension or a kinked catheter.
Answer: D
Rationale: Autonomic dysreflexia is a medical emergency occurring in patients with spinal
cord injuries at T6 or above. The most common trigger is bladder distension, and the
immediate nursing priority is to identify and remove the noxious stimulus. The nurse
should sit the patient upright first and then check for bladder or bowel impaction.
5. Using the Parkland formula, calculate the total fluid volume for the first 24 hours for an 80
kg patient with a 40% Total Body Surface Area (TBSA) burn.
A. 16,000 mL
B. 6,400 mL
C. 12,800 mL
D. 3,200 mL
Answer: C
Rationale: The Parkland formula is calculated as 4 mL x kg x %TBSA (4 x 80 x 40 = 12,800
mL). Half of this volume is administered in the first 8 hours, and the rest over the following
16 hours. Accurate calculation is critical to prevent hypovolemic shock and organ failure in
the burn patient.
6. A patient is admitted in Diabetic Ketoacidosis (DKA) with a serum potassium of 3.2 mEq/L.
What is the priority nursing intervention before starting the insulin drip?
A. Initiate potassium replacement therapy as ordered.
B. Administer an intravenous bolus of 50% dextrose.
C. Check the patient’s arterial blood gas for metabolic acidosis.
D. Ensure the patient has a patent urinary catheter.
, Answer: A
Rationale: Insulin causes potassium to shift into the intracellular space, which can lead to
life-threatening hypokalemia. If the initial potassium level is already low, it must be
replaced before insulin is administered to avoid cardiac arrhythmias. The nurse must
continuously monitor ECG and electrolyte levels during DKA management.
7. During a mass casualty event, the triage nurse evaluates a patient with an open sucking
chest wound and significant respiratory distress. Which color tag should this patient receive?
A. Green
B. Red
C. Yellow
D. Black
Answer: B
Rationale: Red tags are assigned to patients with immediate life-threatening injuries who
have a high chance of survival if treated quickly. An open sucking chest wound causes
severe respiratory impairment and requires immediate intervention. Triage ensures that
resources are allocated to those who need urgent stabilization to survive.
8. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg.
Which intervention should the nurse include in the plan of care to help decrease ICP?
A. Suction the patient every hour to maintain a clear airway.
B. Maintain the head in a neutral, midline position.
C. Keep the head of the bed flat to improve cerebral blood flow.
D. Encourage the patient to perform isometric exercises.
Answer: B
Rationale: Maintaining the head in a neutral, midline position facilitates venous drainage
from the brain, which helps lower intracranial pressure. Suctioning and isometric exercises
can increase intrathoracic and intra-abdominal pressure, leading to dangerous ICP spikes.
The head of the bed should typically be elevated to 30 degrees unless contraindicated.
9. The low-pressure alarm on a patient’s mechanical ventilator sounds. What is the nurse’s
first action?
A. Increase the tidal volume on the ventilator settings.
B. Suction the patient to clear secretions.
C. Check for a disconnection in the ventilator tubing.
D. Administer a sedative to the patient.
/ PN3 (NUR2790 Exam 4) | Rasmussen
1. A patient is admitted to the ICU with a diagnosis of septic shock. Which assessment finding
most clearly indicates that the patient is progressing toward Multi-Organ Dysfunction
Syndrome (MODS)?
A. Blood glucose level of 145 mg/dL.
B. Increase in serum creatinine from 1.0 to 2.8 mg/dL.
C. Mean Arterial Pressure (MAP) of 70 mmHg.
D. Urinary output of 35 mL/hr for two hours.
Answer: B
Rationale: MODS is characterized by the failure of two or more organ systems in an acutely
ill patient. A significant rise in serum creatinine indicates the progression of acute kidney
injury, which is a classic sign of worsening systemic dysfunction. Nurses must monitor
biochemical markers closely to identify early signs of organ failure in critical care settings.
2. A nurse is caring for a patient on mechanical ventilation with High-Efficiency Positive End-
Expiratory Pressure (PEEP) for ARDS. Which assessment finding requires immediate
intervention?
A. SpO2 of 92% on 50% FiO2.
B. Sudden drop in blood pressure and absent breath sounds on the right side.
C. Symmetrical chest expansion with inspiration.
D. Heart rate of 105 beats per minute.
Answer: B
Rationale: High levels of PEEP increase the risk of barotrauma, which can lead to a tension
pneumothorax. Sudden hypotension and absent breath sounds are hallmark signs of a
collapsed lung and mediastinal shift. The nurse must immediately notify the provider to
facilitate needle decompression or chest tube insertion.
3. Which lab value would the nurse expect to see in a patient who is experiencing the early
stages of Disseminated Intravascular Coagulation (DIC)?
A. Decreased D-Dimer level.
B. Increased platelet count.
C. Increased fibrinogen levels.
D. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT).
,Answer: D
Rationale: In DIC, the coagulation cascade is overactive, leading to the depletion of clotting
factors and platelets. This depletion results in prolonged PT and PTT values as the body
loses its ability to form clots effectively. Monitoring these values is essential for identifying
the shift from the thrombotic phase to the bleeding phase.
4. A patient with a C5 spinal cord injury is complaining of a severe, throbbing headache and
has a blood pressure of 190/100 mmHg. What should be the nurse’s first action?
A. Administer an ordered PRN antihypertensive medication.
B. Notify the healthcare provider immediately.
C. Lower the head of the bed to a flat position.
D. Check the patient’s bladder for distension or a kinked catheter.
Answer: D
Rationale: Autonomic dysreflexia is a medical emergency occurring in patients with spinal
cord injuries at T6 or above. The most common trigger is bladder distension, and the
immediate nursing priority is to identify and remove the noxious stimulus. The nurse
should sit the patient upright first and then check for bladder or bowel impaction.
5. Using the Parkland formula, calculate the total fluid volume for the first 24 hours for an 80
kg patient with a 40% Total Body Surface Area (TBSA) burn.
A. 16,000 mL
B. 6,400 mL
C. 12,800 mL
D. 3,200 mL
Answer: C
Rationale: The Parkland formula is calculated as 4 mL x kg x %TBSA (4 x 80 x 40 = 12,800
mL). Half of this volume is administered in the first 8 hours, and the rest over the following
16 hours. Accurate calculation is critical to prevent hypovolemic shock and organ failure in
the burn patient.
6. A patient is admitted in Diabetic Ketoacidosis (DKA) with a serum potassium of 3.2 mEq/L.
What is the priority nursing intervention before starting the insulin drip?
A. Initiate potassium replacement therapy as ordered.
B. Administer an intravenous bolus of 50% dextrose.
C. Check the patient’s arterial blood gas for metabolic acidosis.
D. Ensure the patient has a patent urinary catheter.
, Answer: A
Rationale: Insulin causes potassium to shift into the intracellular space, which can lead to
life-threatening hypokalemia. If the initial potassium level is already low, it must be
replaced before insulin is administered to avoid cardiac arrhythmias. The nurse must
continuously monitor ECG and electrolyte levels during DKA management.
7. During a mass casualty event, the triage nurse evaluates a patient with an open sucking
chest wound and significant respiratory distress. Which color tag should this patient receive?
A. Green
B. Red
C. Yellow
D. Black
Answer: B
Rationale: Red tags are assigned to patients with immediate life-threatening injuries who
have a high chance of survival if treated quickly. An open sucking chest wound causes
severe respiratory impairment and requires immediate intervention. Triage ensures that
resources are allocated to those who need urgent stabilization to survive.
8. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg.
Which intervention should the nurse include in the plan of care to help decrease ICP?
A. Suction the patient every hour to maintain a clear airway.
B. Maintain the head in a neutral, midline position.
C. Keep the head of the bed flat to improve cerebral blood flow.
D. Encourage the patient to perform isometric exercises.
Answer: B
Rationale: Maintaining the head in a neutral, midline position facilitates venous drainage
from the brain, which helps lower intracranial pressure. Suctioning and isometric exercises
can increase intrathoracic and intra-abdominal pressure, leading to dangerous ICP spikes.
The head of the bed should typically be elevated to 30 degrees unless contraindicated.
9. The low-pressure alarm on a patient’s mechanical ventilator sounds. What is the nurse’s
first action?
A. Increase the tidal volume on the ventilator settings.
B. Suction the patient to clear secretions.
C. Check for a disconnection in the ventilator tubing.
D. Administer a sedative to the patient.
