NUR 425 Exam 2: Acute & Chronic Health Disruptions In
Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient’s hemodynamic monitor shows a Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg.
Which assessment finding is most consistent with this data?
A. Dry mucus membranes and flat neck veins
B. Elevated BUN and Creatinine levels
C. Hypotension with a map of 50 mmHg
D. Bilateral crackles in the lung bases
Ans: D
Explanation: A PAWP of 22 mmHg indicates significantly elevated left ventricular end-diastolic pressure.
This pressure backflow into the pulmonary vasculature often leads to pulmonary edema and the
presence of crackles. Jugular venous distention is more commonly associated with right-sided heart
failure but PAWP specifically tracks the left side. Monitoring respiratory status is the priority nursing
action for this patient. Early intervention with diuretics or vasodilators can help reduce these pressures
effectively.
2. A ventilator alarm sounds indicating ‘High Pressure’ for a patient on mechanical ventilation. What is the
priority nursing action?
A. Check for a leak in the ventilator circuit
B. Suction the patient for possible secretions
C. Increase the FiO2 to 100 percent immediately
D. Administer a dose of IV lorazepam
,Ans: B
Explanation: High pressure alarms usually indicate an obstruction or resistance within the ventilator
circuit or the patient’s airway. Suctioning is a primary intervention to clear secretions that may be
causing the high pressure. A leak in the circuit would typically trigger a low pressure alarm instead of a
high one. Increasing oxygen does not address the mechanical cause of the high pressure alarm. The nurse
should also assess for tube kinking or the patient biting the endotracheal tube.
3. A patient with 40 percent total body surface area (TBSA) burns weighs 70 kg. Using the Parkland Formula,
calculate the total fluid volume needed in the first 24 hours.
A. 5,600 mL
B. 11,200 mL
C. 8,400 mL
D. 14,000 mL
Ans: B
Explanation: The Parkland Formula is calculated as 4 mL x kg x percentage of TBSA burned. For this
patient, the calculation is 4 mL x 70 kg x 40, which equals 11,200 mL. Half of this total volume must be
administered within the first 8 hours from the time of the burn. Accurate fluid resuscitation is critical to
prevent hypovolemic shock in burn patients. The nurse must monitor hourly urine output to evaluate the
effectiveness of the fluid titration.
4. Which lab value is most expected in a patient diagnosed with Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)?
A. Hematocrit level of 55 percent
B. Serum osmolality of 320 mOsm/kg
, C. Urine specific gravity of 1.001
D. Serum sodium of 120 mEq/L
Ans: D
Explanation: SIADH involves excessive release of ADH, leading to water retention and dilutional
hyponatremia. A serum sodium of 120 mEq/L is a classic finding due to the relative excess of water. In
contrast, Diabetes Insipidus would present with a very low urine specific gravity and high serum
osmolality. The nurse must monitor for neurological changes associated with severe hyponatremia. Fluid
restriction is typically the primary treatment for these patients.
5. A patient in the early stage of septic shock is likely to exhibit which hemodynamic profile?
A. Low systemic vascular resistance (SVR) and high CO
B. High systemic vascular resistance (SVR) and low CO
C. Low heart rate and high blood pressure
D. Increased pulmonary artery wedge pressure (PAWP)
Ans: A
Explanation: In the early or hyperdynamic phase of septic shock, massive vasodilation leads to low SVR.
The body compensates by increasing cardiac output (CO), resulting in warm, flushed skin. This differs
from hypovolemic or cardiogenic shock, where CO is low and SVR is high. Early recognition of these signs
is vital for initiating appropriate antibiotic and fluid therapy. Monitoring lactate levels is also a standard
part of the sepsis resuscitation bundle.
6. The nurse is caring for a patient with acute respiratory distress syndrome (ARDS). Which ventilator setting
is specifically used to prevent alveolar collapse?
A. Fraction of inspired oxygen (FiO2)
Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient’s hemodynamic monitor shows a Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg.
Which assessment finding is most consistent with this data?
A. Dry mucus membranes and flat neck veins
B. Elevated BUN and Creatinine levels
C. Hypotension with a map of 50 mmHg
D. Bilateral crackles in the lung bases
Ans: D
Explanation: A PAWP of 22 mmHg indicates significantly elevated left ventricular end-diastolic pressure.
This pressure backflow into the pulmonary vasculature often leads to pulmonary edema and the
presence of crackles. Jugular venous distention is more commonly associated with right-sided heart
failure but PAWP specifically tracks the left side. Monitoring respiratory status is the priority nursing
action for this patient. Early intervention with diuretics or vasodilators can help reduce these pressures
effectively.
2. A ventilator alarm sounds indicating ‘High Pressure’ for a patient on mechanical ventilation. What is the
priority nursing action?
A. Check for a leak in the ventilator circuit
B. Suction the patient for possible secretions
C. Increase the FiO2 to 100 percent immediately
D. Administer a dose of IV lorazepam
,Ans: B
Explanation: High pressure alarms usually indicate an obstruction or resistance within the ventilator
circuit or the patient’s airway. Suctioning is a primary intervention to clear secretions that may be
causing the high pressure. A leak in the circuit would typically trigger a low pressure alarm instead of a
high one. Increasing oxygen does not address the mechanical cause of the high pressure alarm. The nurse
should also assess for tube kinking or the patient biting the endotracheal tube.
3. A patient with 40 percent total body surface area (TBSA) burns weighs 70 kg. Using the Parkland Formula,
calculate the total fluid volume needed in the first 24 hours.
A. 5,600 mL
B. 11,200 mL
C. 8,400 mL
D. 14,000 mL
Ans: B
Explanation: The Parkland Formula is calculated as 4 mL x kg x percentage of TBSA burned. For this
patient, the calculation is 4 mL x 70 kg x 40, which equals 11,200 mL. Half of this total volume must be
administered within the first 8 hours from the time of the burn. Accurate fluid resuscitation is critical to
prevent hypovolemic shock in burn patients. The nurse must monitor hourly urine output to evaluate the
effectiveness of the fluid titration.
4. Which lab value is most expected in a patient diagnosed with Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)?
A. Hematocrit level of 55 percent
B. Serum osmolality of 320 mOsm/kg
, C. Urine specific gravity of 1.001
D. Serum sodium of 120 mEq/L
Ans: D
Explanation: SIADH involves excessive release of ADH, leading to water retention and dilutional
hyponatremia. A serum sodium of 120 mEq/L is a classic finding due to the relative excess of water. In
contrast, Diabetes Insipidus would present with a very low urine specific gravity and high serum
osmolality. The nurse must monitor for neurological changes associated with severe hyponatremia. Fluid
restriction is typically the primary treatment for these patients.
5. A patient in the early stage of septic shock is likely to exhibit which hemodynamic profile?
A. Low systemic vascular resistance (SVR) and high CO
B. High systemic vascular resistance (SVR) and low CO
C. Low heart rate and high blood pressure
D. Increased pulmonary artery wedge pressure (PAWP)
Ans: A
Explanation: In the early or hyperdynamic phase of septic shock, massive vasodilation leads to low SVR.
The body compensates by increasing cardiac output (CO), resulting in warm, flushed skin. This differs
from hypovolemic or cardiogenic shock, where CO is low and SVR is high. Early recognition of these signs
is vital for initiating appropriate antibiotic and fluid therapy. Monitoring lactate levels is also a standard
part of the sepsis resuscitation bundle.
6. The nurse is caring for a patient with acute respiratory distress syndrome (ARDS). Which ventilator setting
is specifically used to prevent alveolar collapse?
A. Fraction of inspired oxygen (FiO2)
