NUR 445 Exam 3: Acute & Chronic Health Disruptions In
Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient in the intensive care unit is being monitored with a pulmonary artery catheter. The nurse notes
a Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg. Which clinical manifestation should the nurse
expect to find during the assessment?
A. Flat neck veins and dry mucous membranes
B. Decreased cardiac output and peripheral edema
C. Bilateral crackles and dyspnea
D. Hyperactive bowel sounds and increased urine output
Ans: C
Explanation: A normal PAWP ranges from 6 to 12 mmHg, meaning a value of 22 mmHg indicates
significant left ventricular fluid overload. This elevation causes fluid to back up into the pulmonary
vasculature, leading to pulmonary edema. The nurse would expect to hear crackles upon auscultation due
to the presence of fluid in the alveoli. This condition is a hallmark of cardiogenic shock or severe left-
sided heart failure. Prompt intervention with diuretics or vasodilators is typically required to reduce
preload.
2. The nurse is caring for a client with septic shock. Despite adequate fluid resuscitation with 30 mL/kg of
crystalloids, the client’s Mean Arterial Pressure (MAP) remains 52 mmHg. What is the priority nursing
intervention?
A. Start an infusion of Norepinephrine
B. Administer an additional 1 liter of Normal Saline
C. Increase the IV maintenance rate
,D. Administer intravenous Furosemide
Ans: A
Explanation: Septic shock is characterized by persistent hypotension that does not respond to fluid
resuscitation. Once the fluid bolus is completed and the MAP remains below 65 mmHg, vasopressors are
indicated. Norepinephrine is considered the first-line vasopressor to restore vascular tone and improve
perfusion. Delaying vasopressor therapy can lead to irreversible organ damage due to prolonged
hypoperfusion. The nurse must monitor the infusion site closely to prevent tissue necrosis from
extravasation.
3. A client is admitted with Acute Respiratory Distress Syndrome (ARDS) and is placed on mechanical
ventilation with High Positive End-Expiratory Pressure (PEEP). What is the primary complication the nurse
must monitor for related to high PEEP?
A. Increased cardiac output
B. Pneumothorax due to barotrauma
C. Metabolic alkalosis
D. Respiratory muscle atrophy
Ans: B
Explanation: High PEEP levels are used to keep alveoli open and improve oxygenation in ARDS patients.
However, excessive pressure can lead to barotrauma, which may manifest as a pneumothorax or
subcutaneous emphysema. This pressure can also decrease venous return to the heart, potentially
lowering the cardiac output. The nurse must frequently assess breath sounds and monitor for sudden
drops in oxygen saturation. Providing the minimum amount of PEEP necessary to maintain adequate
PaO2 is the clinical goal.
, 4. A patient with Acute Kidney Injury (AKI) has a potassium level of 6.8 mEq/L and shows peaked T-waves
on the ECG. Which medication should the nurse expect to administer first to protect the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin and Dextrose 50%
C. Sodium Bicarbonate
D. Calcium Gluconate
Ans: D
Explanation: Hyperkalemia is a life-threatening complication of AKI that causes cardiac excitability.
Calcium Gluconate does not lower potassium levels but stabilizes the myocardial cell membrane to
prevent lethal arrhythmias. While insulin and Kayexalate are used to actually lower potassium, they do
not act as quickly to protect the heart. The nurse must prioritize cardiac stability in the presence of ECG
changes. Following calcium administration, other therapies to shift or remove potassium are initiated
immediately.
5. The nurse is managing a client with Diabetic Ketoacidosis (DKA). The current blood glucose is 240 mg/dL,
down from 550 mg/dL. What should be the nurse’s next action regarding IV fluids?
A. Stop the insulin infusion immediately
B. Increase the rate of Normal Saline
C. Switch to a solution containing 5% Dextrose
D. Administer a glucagon injection
Ans: C
Explanation: In DKA management, when blood glucose levels reach approximately 200-250 mg/dL,
dextrose is added to the IV fluids. This prevents a rapid drop in glucose which could lead to cerebral
Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient in the intensive care unit is being monitored with a pulmonary artery catheter. The nurse notes
a Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg. Which clinical manifestation should the nurse
expect to find during the assessment?
A. Flat neck veins and dry mucous membranes
B. Decreased cardiac output and peripheral edema
C. Bilateral crackles and dyspnea
D. Hyperactive bowel sounds and increased urine output
Ans: C
Explanation: A normal PAWP ranges from 6 to 12 mmHg, meaning a value of 22 mmHg indicates
significant left ventricular fluid overload. This elevation causes fluid to back up into the pulmonary
vasculature, leading to pulmonary edema. The nurse would expect to hear crackles upon auscultation due
to the presence of fluid in the alveoli. This condition is a hallmark of cardiogenic shock or severe left-
sided heart failure. Prompt intervention with diuretics or vasodilators is typically required to reduce
preload.
2. The nurse is caring for a client with septic shock. Despite adequate fluid resuscitation with 30 mL/kg of
crystalloids, the client’s Mean Arterial Pressure (MAP) remains 52 mmHg. What is the priority nursing
intervention?
A. Start an infusion of Norepinephrine
B. Administer an additional 1 liter of Normal Saline
C. Increase the IV maintenance rate
,D. Administer intravenous Furosemide
Ans: A
Explanation: Septic shock is characterized by persistent hypotension that does not respond to fluid
resuscitation. Once the fluid bolus is completed and the MAP remains below 65 mmHg, vasopressors are
indicated. Norepinephrine is considered the first-line vasopressor to restore vascular tone and improve
perfusion. Delaying vasopressor therapy can lead to irreversible organ damage due to prolonged
hypoperfusion. The nurse must monitor the infusion site closely to prevent tissue necrosis from
extravasation.
3. A client is admitted with Acute Respiratory Distress Syndrome (ARDS) and is placed on mechanical
ventilation with High Positive End-Expiratory Pressure (PEEP). What is the primary complication the nurse
must monitor for related to high PEEP?
A. Increased cardiac output
B. Pneumothorax due to barotrauma
C. Metabolic alkalosis
D. Respiratory muscle atrophy
Ans: B
Explanation: High PEEP levels are used to keep alveoli open and improve oxygenation in ARDS patients.
However, excessive pressure can lead to barotrauma, which may manifest as a pneumothorax or
subcutaneous emphysema. This pressure can also decrease venous return to the heart, potentially
lowering the cardiac output. The nurse must frequently assess breath sounds and monitor for sudden
drops in oxygen saturation. Providing the minimum amount of PEEP necessary to maintain adequate
PaO2 is the clinical goal.
, 4. A patient with Acute Kidney Injury (AKI) has a potassium level of 6.8 mEq/L and shows peaked T-waves
on the ECG. Which medication should the nurse expect to administer first to protect the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin and Dextrose 50%
C. Sodium Bicarbonate
D. Calcium Gluconate
Ans: D
Explanation: Hyperkalemia is a life-threatening complication of AKI that causes cardiac excitability.
Calcium Gluconate does not lower potassium levels but stabilizes the myocardial cell membrane to
prevent lethal arrhythmias. While insulin and Kayexalate are used to actually lower potassium, they do
not act as quickly to protect the heart. The nurse must prioritize cardiac stability in the presence of ECG
changes. Following calcium administration, other therapies to shift or remove potassium are initiated
immediately.
5. The nurse is managing a client with Diabetic Ketoacidosis (DKA). The current blood glucose is 240 mg/dL,
down from 550 mg/dL. What should be the nurse’s next action regarding IV fluids?
A. Stop the insulin infusion immediately
B. Increase the rate of Normal Saline
C. Switch to a solution containing 5% Dextrose
D. Administer a glucagon injection
Ans: C
Explanation: In DKA management, when blood glucose levels reach approximately 200-250 mg/dL,
dextrose is added to the IV fluids. This prevents a rapid drop in glucose which could lead to cerebral
