1. A nurse is assessing a client admitted with acute hypovolemic shock following a motor
vehicle collision. Which Central Venous Pressure (CVP) reading should the nurse anticipate?
A. 1 mmHg
B. 4 mmHg
C. 8 mmHg
D. 12 mmHg
Correct Answer: A. 1 mmHg
Why:
Normal CVP range is 2 to 6 mmHg.
CVP < 2 mmHg indicates reduced preload and severe intravascular volume depletion.
CVP > 6 mmHg indicates hypervolemia or right-sided ventricular failure.
Total: CVP of 1 mmHg reflects severe loss of circulating fluid requiring immediate fluid resuscitation.
Test-Taking Tip: Remember CVP reflects right-heart preload; low numbers indicate dehydration/shock,
high numbers indicate fluid overload.
2. A client on mechanical ventilation suddenly displays severe hypotension, unilateral
absence of right lung sounds, and high peak airway pressure alarms. Which action is the
priority?
A. Administer a 500 mL IV Normal Saline bolus
B. Suction the endotracheal tube for secretions
C. Disconnect the ventilator and manually bag while preparing for urgent chest needle decompression
D. Increase the PEEP setting on the mechanical ventilator
Correct Answer: C. Disconnect the ventilator and manually bag while preparing for urgent
chest needle decompression
Why:
Unilateral loss of breath sounds, hypotension, and high ventilator pressures indicate a tension
pneumothorax.
High PEEP levels increase risk of alveolar rupture and ventilator-induced barotrauma.
Manual ventilation provides tactile compliance feedback while thoracic decompression relieves intra-
pleural pressure.
Total: Airway and thoracic decompression take priority over non-emergent suctioning or fluids.
Test-Taking Tip: Sudden hypotension plus loss of unilateral breath sounds in a ventilated client signals
tension pneumothorax—prepare for immediate chest decompression!
3. A client with Addison's disease reports new palpitations along with fatigue and salt
craving. Which action is the priority?
A. Administer scheduled hydrocortisone dose
B. Encourage oral fluids and rest
C. Obtain a 12-lead ECG and check serum potassium; notify the provider
D. Document findings and reassess in 30 minutes
Correct Answer: C. Obtain a 12-lead ECG and check serum potassium; notify the provider
NR 341 Exam 2 Study Guide Page 1 of 4
vehicle collision. Which Central Venous Pressure (CVP) reading should the nurse anticipate?
A. 1 mmHg
B. 4 mmHg
C. 8 mmHg
D. 12 mmHg
Correct Answer: A. 1 mmHg
Why:
Normal CVP range is 2 to 6 mmHg.
CVP < 2 mmHg indicates reduced preload and severe intravascular volume depletion.
CVP > 6 mmHg indicates hypervolemia or right-sided ventricular failure.
Total: CVP of 1 mmHg reflects severe loss of circulating fluid requiring immediate fluid resuscitation.
Test-Taking Tip: Remember CVP reflects right-heart preload; low numbers indicate dehydration/shock,
high numbers indicate fluid overload.
2. A client on mechanical ventilation suddenly displays severe hypotension, unilateral
absence of right lung sounds, and high peak airway pressure alarms. Which action is the
priority?
A. Administer a 500 mL IV Normal Saline bolus
B. Suction the endotracheal tube for secretions
C. Disconnect the ventilator and manually bag while preparing for urgent chest needle decompression
D. Increase the PEEP setting on the mechanical ventilator
Correct Answer: C. Disconnect the ventilator and manually bag while preparing for urgent
chest needle decompression
Why:
Unilateral loss of breath sounds, hypotension, and high ventilator pressures indicate a tension
pneumothorax.
High PEEP levels increase risk of alveolar rupture and ventilator-induced barotrauma.
Manual ventilation provides tactile compliance feedback while thoracic decompression relieves intra-
pleural pressure.
Total: Airway and thoracic decompression take priority over non-emergent suctioning or fluids.
Test-Taking Tip: Sudden hypotension plus loss of unilateral breath sounds in a ventilated client signals
tension pneumothorax—prepare for immediate chest decompression!
3. A client with Addison's disease reports new palpitations along with fatigue and salt
craving. Which action is the priority?
A. Administer scheduled hydrocortisone dose
B. Encourage oral fluids and rest
C. Obtain a 12-lead ECG and check serum potassium; notify the provider
D. Document findings and reassess in 30 minutes
Correct Answer: C. Obtain a 12-lead ECG and check serum potassium; notify the provider
NR 341 Exam 2 Study Guide Page 1 of 4
