NUR 2571 Exam 3 Actual Exam V3 | NUR 2571 Professional Nursing II /
PN2 (NUR2571 Exam 3) | Rasmussen
1. A nurse is caring for a patient in the ICU who is being mechanically ventilated. The high-
pressure alarm on the ventilator begins to sound. Which action should the nurse take first?
A. Check for a leak in the ventilator circuit.
B. Increase the oxygen concentration to 100%.
C. Manually ventilate the patient with an Ambu bag.
D. Assess the patient’s breath sounds and need for suctioning.
Answer: D
Rationale: The high-pressure alarm indicates that the ventilator is encountering resistance
while trying to deliver a breath. This can be caused by secretions, biting the tube, or
coughing, so assessing the patient’s airway and lungs is the priority intervention. If the
patient is in immediate distress and the cause is not found, manual ventilation may be
necessary, but assessment comes first.
2. A patient with a traumatic brain injury (TBI) is showing signs of increased intracranial
pressure (ICP). Which position should the nurse place the patient in to promote venous
drainage?
A. Flat on their back (Supine)
B. Trendelenburg position
C. Head of bed elevated to 30-45 degrees
D. Side-lying with the neck flexed
Answer: C
Rationale: Elevating the head of the bed (HOB) to 30-45 degrees facilitates venous
drainage from the head through the jugular veins, which helps to decrease ICP. The nurse
must also ensure the head is in a neutral, midline position to avoid obstruction of venous
flow. Keeping the patient flat or in Trendelenburg would worsen cerebral edema and
increase pressure significantly.
3. A nurse is evaluating the arterial blood gas (ABG) results of a patient with acute respiratory
distress syndrome (ARDS). The results are: pH 7.25, PaCO2 52, HCO3 24, PaO2 55. How should
the nurse interpret these findings?
A. Respiratory Alkalosis with hypoxemia
B. Metabolic Acidosis
,C. Respiratory Acidosis with hypoxemia
D. Compensated Metabolic Alkalosis
Answer: C
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45,
indicating the cause is respiratory. The PaO2 is significantly low (below 80), confirming
hypoxemia which is a hallmark of ARDS. This clinical picture suggests that the lungs are
failing to remove CO2 and provide adequate oxygenation to the tissues.
4. A patient who was admitted with severe thermal burns over 40% of their body is in the
emergent phase. Which laboratory value is the nurse most likely to find?
A. Hypokalemia
B. Metabolic Alkalosis
C. Decreased Hematocrit
D. Hyperkalemia
Answer: D
Rationale: During the emergent phase of a burn injury, cell destruction occurs, causing
potassium to leak from the intracellular space into the extracellular fluid, resulting in
hyperkalemia. Additionally, massive fluid shifts lead to hemoconcentration, which typically
increases the hematocrit rather than decreasing it. Monitoring electrolytes is crucial during
this phase to prevent cardiac arrhythmias.
5. A patient with chronic liver cirrhosis presents with worsening hepatic encephalopathy. The
nurse anticipates administering lactulose. What is the primary therapeutic goal of this
medication?
A. To decrease serum ammonia levels
B. To reduce abdominal girth and ascites
C. To prevent gastrointestinal bleeding
D. To increase serum albumin production
Answer: A
Rationale: Lactulose works by promoting the excretion of ammonia through the stool,
which is essential in managing hepatic encephalopathy caused by high ammonia levels. The
nurse should monitor the patient for increased bowel movements, as this indicates the
medication is effective. Reducing ammonia helps improve the patient’s neurological status
and cognitive function.
, 6. The nurse is caring for a patient with a spinal cord injury at the T4 level. The patient reports
a sudden, severe headache and the nurse notes a blood pressure of 190/110 mmHg. What is
the priority nursing action?
A. Check the patient’s bladder for distension or a kinked catheter.
B. Place the patient in a supine position to stabilize blood pressure.
C. Administer an ordered antihypertensive medication immediately.
D. Notify the healthcare provider to request a CT scan of the head.
Answer: A
Rationale: These symptoms are classic signs of autonomic dysreflexia, a life-threatening
emergency in patients with spinal cord injuries above T6. The most common trigger is
bladder distension or fecal impaction, so the nurse must immediately identify and remove
the stimulus. Sitting the patient upright is also an immediate action to help lower blood
pressure through orthostatic changes.
7. A patient in the emergency department is being triaged after a motor vehicle accident. The
patient is conscious but has a sucking chest wound. Which type of dressing should the nurse
apply?
A. A dry sterile gauze secured on all four sides
B. No dressing, to allow for air escape
C. A wet-to-dry dressing to promote healing
D. An occlusive dressing taped on three sides
Answer: D
Rationale: A sucking chest wound (open pneumothorax) requires a vented dressing, which
is an occlusive dressing taped on three sides. This allows air to escape from the pleural
space during exhalation but prevents atmospheric air from entering during inhalation.
Taping all four sides could lead to a tension pneumothorax, which is a lethal complication.
8. A nurse is assessing a patient with suspected sepsis. Which finding is most indicative of the
‘cold’ or late stage of septic shock?
A. Warm, flushed skin and tachycardia
B. Respiratory alkalosis and bounding pulses
C. Increased urine output and high cardiac output
D. Hypotension and cool, clammy skin
Answer: D
PN2 (NUR2571 Exam 3) | Rasmussen
1. A nurse is caring for a patient in the ICU who is being mechanically ventilated. The high-
pressure alarm on the ventilator begins to sound. Which action should the nurse take first?
A. Check for a leak in the ventilator circuit.
B. Increase the oxygen concentration to 100%.
C. Manually ventilate the patient with an Ambu bag.
D. Assess the patient’s breath sounds and need for suctioning.
Answer: D
Rationale: The high-pressure alarm indicates that the ventilator is encountering resistance
while trying to deliver a breath. This can be caused by secretions, biting the tube, or
coughing, so assessing the patient’s airway and lungs is the priority intervention. If the
patient is in immediate distress and the cause is not found, manual ventilation may be
necessary, but assessment comes first.
2. A patient with a traumatic brain injury (TBI) is showing signs of increased intracranial
pressure (ICP). Which position should the nurse place the patient in to promote venous
drainage?
A. Flat on their back (Supine)
B. Trendelenburg position
C. Head of bed elevated to 30-45 degrees
D. Side-lying with the neck flexed
Answer: C
Rationale: Elevating the head of the bed (HOB) to 30-45 degrees facilitates venous
drainage from the head through the jugular veins, which helps to decrease ICP. The nurse
must also ensure the head is in a neutral, midline position to avoid obstruction of venous
flow. Keeping the patient flat or in Trendelenburg would worsen cerebral edema and
increase pressure significantly.
3. A nurse is evaluating the arterial blood gas (ABG) results of a patient with acute respiratory
distress syndrome (ARDS). The results are: pH 7.25, PaCO2 52, HCO3 24, PaO2 55. How should
the nurse interpret these findings?
A. Respiratory Alkalosis with hypoxemia
B. Metabolic Acidosis
,C. Respiratory Acidosis with hypoxemia
D. Compensated Metabolic Alkalosis
Answer: C
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45,
indicating the cause is respiratory. The PaO2 is significantly low (below 80), confirming
hypoxemia which is a hallmark of ARDS. This clinical picture suggests that the lungs are
failing to remove CO2 and provide adequate oxygenation to the tissues.
4. A patient who was admitted with severe thermal burns over 40% of their body is in the
emergent phase. Which laboratory value is the nurse most likely to find?
A. Hypokalemia
B. Metabolic Alkalosis
C. Decreased Hematocrit
D. Hyperkalemia
Answer: D
Rationale: During the emergent phase of a burn injury, cell destruction occurs, causing
potassium to leak from the intracellular space into the extracellular fluid, resulting in
hyperkalemia. Additionally, massive fluid shifts lead to hemoconcentration, which typically
increases the hematocrit rather than decreasing it. Monitoring electrolytes is crucial during
this phase to prevent cardiac arrhythmias.
5. A patient with chronic liver cirrhosis presents with worsening hepatic encephalopathy. The
nurse anticipates administering lactulose. What is the primary therapeutic goal of this
medication?
A. To decrease serum ammonia levels
B. To reduce abdominal girth and ascites
C. To prevent gastrointestinal bleeding
D. To increase serum albumin production
Answer: A
Rationale: Lactulose works by promoting the excretion of ammonia through the stool,
which is essential in managing hepatic encephalopathy caused by high ammonia levels. The
nurse should monitor the patient for increased bowel movements, as this indicates the
medication is effective. Reducing ammonia helps improve the patient’s neurological status
and cognitive function.
, 6. The nurse is caring for a patient with a spinal cord injury at the T4 level. The patient reports
a sudden, severe headache and the nurse notes a blood pressure of 190/110 mmHg. What is
the priority nursing action?
A. Check the patient’s bladder for distension or a kinked catheter.
B. Place the patient in a supine position to stabilize blood pressure.
C. Administer an ordered antihypertensive medication immediately.
D. Notify the healthcare provider to request a CT scan of the head.
Answer: A
Rationale: These symptoms are classic signs of autonomic dysreflexia, a life-threatening
emergency in patients with spinal cord injuries above T6. The most common trigger is
bladder distension or fecal impaction, so the nurse must immediately identify and remove
the stimulus. Sitting the patient upright is also an immediate action to help lower blood
pressure through orthostatic changes.
7. A patient in the emergency department is being triaged after a motor vehicle accident. The
patient is conscious but has a sucking chest wound. Which type of dressing should the nurse
apply?
A. A dry sterile gauze secured on all four sides
B. No dressing, to allow for air escape
C. A wet-to-dry dressing to promote healing
D. An occlusive dressing taped on three sides
Answer: D
Rationale: A sucking chest wound (open pneumothorax) requires a vented dressing, which
is an occlusive dressing taped on three sides. This allows air to escape from the pleural
space during exhalation but prevents atmospheric air from entering during inhalation.
Taping all four sides could lead to a tension pneumothorax, which is a lethal complication.
8. A nurse is assessing a patient with suspected sepsis. Which finding is most indicative of the
‘cold’ or late stage of septic shock?
A. Warm, flushed skin and tachycardia
B. Respiratory alkalosis and bounding pulses
C. Increased urine output and high cardiac output
D. Hypotension and cool, clammy skin
Answer: D
