NUR 425 Exam 3: Acute & Chronic Health Disruptions In
Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with ARDS is receiving mechanical ventilation with high PEEP. Which finding should the nurse
prioritize as a potential complication?
A. Increased oxygen saturation
B. Respiratory alkalosis
C. Improved lung compliance
D. Decreased cardiac output and hypotension
Ans: D
Explanation: Positive end-expiratory pressure can increase intrathoracic pressure and decrease venous
return. This physiological change often leads to a significant drop in cardiac output. The nurse must
monitor blood pressure closely to ensure systemic perfusion is maintained. If hypotension occurs, the
medical team may need to adjust the ventilator settings or increase fluids. This is a critical assessment for
patients on high levels of PEEP support.
2. A patient weighing 70kg has 40% TBSA burns. Using the Parkland formula (4mL/kg/%TBSA), how many
mL of fluid should be infused in the first 8 hours?
A. 11,200 mL
B. 2,800 mL
C. 5,600 mL
D. 7,000 mL
Ans: C
,Explanation: The Parkland formula calculates total fluid for the first twenty-four hours after a burn
injury. In this scenario, the total volume is calculated as four times seventy times forty, which equals
eleven thousand two hundred milliliters. Half of this total volume must be administered within the first
eight hours. Therefore, five thousand six hundred milliliters is the correct infusion amount for the initial
period. Accurate fluid resuscitation is vital to prevent hypovolemic shock in burn patients.
3. The nurse is caring for a patient in septic shock. Which lab result most accurately indicates tissue
hypoperfusion?
A. WBC count 15,000/mm3
B. Serum lactate 6.2 mmol/L
C. Creatinine 1.1 mg/dL
D. Blood glucose 140 mg/dL
Ans: B
Explanation: Serum lactate levels are a key marker for anaerobic metabolism and cellular hypoxia. An
elevated lactate level above four indicates significant tissue hypoperfusion and high mortality risk. While
WBC counts reflect infection, they do not directly measure the adequacy of perfusion. Monitoring lactate
allows the nurse to evaluate the effectiveness of fluid resuscitation and oxygenation. Managing lactate
levels is a priority in the surviving sepsis bundle guidelines.
4. A patient with liver failure presents with confusion and asterixis. Which medication should the nurse
anticipate administering?
A. Spironolactone
B. Lactulose
C. Propranolol
, D. Vitamin K
Ans: B
Explanation: Lactulose is the primary treatment for hepatic encephalopathy caused by high ammonia
levels. It works by trapping ammonia in the gut and promoting its excretion through frequent bowel
movements. Asterixis and confusion are hallmark signs that ammonia is crossing the blood-brain barrier.
The goal of therapy is to achieve two to three soft stools daily. This treatment is essential for improving
the patient’s neurological status and overall safety.
5. Which clinical manifestation is part of Cushing’s triad, indicating late-stage increased intracranial
pressure?
A. Tachycardia
B. Widened pulse pressure
C. Hypotension
D. Tachypnea
Ans: B
Explanation: Cushing’s triad consists of bradycardia, irregular respirations, and a widened pulse
pressure. A widened pulse pressure occurs when the systolic blood pressure increases while the diastolic
remains stable or drops. This reflex is an attempt by the body to maintain cerebral perfusion pressure. It
is considered a medical emergency and a late sign of brainstem compression. Nurses must identify these
signs early to prevent irreversible brain herniation and death.
6. The nurse notes blood oozing from IV sites and hematuria in a patient with sepsis. Which condition is
most likely developing?
A. Chronic Kidney Disease
Adults II V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with ARDS is receiving mechanical ventilation with high PEEP. Which finding should the nurse
prioritize as a potential complication?
A. Increased oxygen saturation
B. Respiratory alkalosis
C. Improved lung compliance
D. Decreased cardiac output and hypotension
Ans: D
Explanation: Positive end-expiratory pressure can increase intrathoracic pressure and decrease venous
return. This physiological change often leads to a significant drop in cardiac output. The nurse must
monitor blood pressure closely to ensure systemic perfusion is maintained. If hypotension occurs, the
medical team may need to adjust the ventilator settings or increase fluids. This is a critical assessment for
patients on high levels of PEEP support.
2. A patient weighing 70kg has 40% TBSA burns. Using the Parkland formula (4mL/kg/%TBSA), how many
mL of fluid should be infused in the first 8 hours?
A. 11,200 mL
B. 2,800 mL
C. 5,600 mL
D. 7,000 mL
Ans: C
,Explanation: The Parkland formula calculates total fluid for the first twenty-four hours after a burn
injury. In this scenario, the total volume is calculated as four times seventy times forty, which equals
eleven thousand two hundred milliliters. Half of this total volume must be administered within the first
eight hours. Therefore, five thousand six hundred milliliters is the correct infusion amount for the initial
period. Accurate fluid resuscitation is vital to prevent hypovolemic shock in burn patients.
3. The nurse is caring for a patient in septic shock. Which lab result most accurately indicates tissue
hypoperfusion?
A. WBC count 15,000/mm3
B. Serum lactate 6.2 mmol/L
C. Creatinine 1.1 mg/dL
D. Blood glucose 140 mg/dL
Ans: B
Explanation: Serum lactate levels are a key marker for anaerobic metabolism and cellular hypoxia. An
elevated lactate level above four indicates significant tissue hypoperfusion and high mortality risk. While
WBC counts reflect infection, they do not directly measure the adequacy of perfusion. Monitoring lactate
allows the nurse to evaluate the effectiveness of fluid resuscitation and oxygenation. Managing lactate
levels is a priority in the surviving sepsis bundle guidelines.
4. A patient with liver failure presents with confusion and asterixis. Which medication should the nurse
anticipate administering?
A. Spironolactone
B. Lactulose
C. Propranolol
, D. Vitamin K
Ans: B
Explanation: Lactulose is the primary treatment for hepatic encephalopathy caused by high ammonia
levels. It works by trapping ammonia in the gut and promoting its excretion through frequent bowel
movements. Asterixis and confusion are hallmark signs that ammonia is crossing the blood-brain barrier.
The goal of therapy is to achieve two to three soft stools daily. This treatment is essential for improving
the patient’s neurological status and overall safety.
5. Which clinical manifestation is part of Cushing’s triad, indicating late-stage increased intracranial
pressure?
A. Tachycardia
B. Widened pulse pressure
C. Hypotension
D. Tachypnea
Ans: B
Explanation: Cushing’s triad consists of bradycardia, irregular respirations, and a widened pulse
pressure. A widened pulse pressure occurs when the systolic blood pressure increases while the diastolic
remains stable or drops. This reflex is an attempt by the body to maintain cerebral perfusion pressure. It
is considered a medical emergency and a late sign of brainstem compression. Nurses must identify these
signs early to prevent irreversible brain herniation and death.
6. The nurse notes blood oozing from IV sites and hematuria in a patient with sepsis. Which condition is
most likely developing?
A. Chronic Kidney Disease
