NUR 445 Exam 1: Acute & Chronic Health Disruptions In
Adults III V1 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient on mechanical ventilation triggers a high-pressure alarm. Which action should the nurse
perform first?
A. Increase the oxygen concentration
B. Suction the patient immediately
C. Administer a sedative to the patient
D. Check for kinks in the ventilator tubing
Ans: D
Explanation: High-pressure alarms indicate that the ventilator is meeting resistance when delivering a
breath. The nurse should first assess for simple mechanical obstructions like kinks in the tubing. If no
kinks are found, the nurse should then assess the patient for a need to suction or biting the tube.
Checking the equipment first prevents unnecessary invasive procedures for the patient. Quick
troubleshooting ensures the patient continues to receive adequate ventilation.
2. Which clinical finding is most characteristic of the early stage of septic shock?
A. Cool, clammy skin
B. Increased systemic vascular resistance
C. Decreased cardiac output
D. Warm, flushed skin
Ans: D
,Explanation: Early septic shock, also known as the hyperdynamic or warm phase, is characterized by
vasodilation. This vasodilation leads to warm and flushed skin in the patient. During this phase, cardiac
output actually increases as the body attempts to compensate for systemic infection. Systemic vascular
resistance decreases significantly due to the massive release of inflammatory mediators. Recognizing
these early signs is critical for initiating timely antibiotic and fluid therapy.
3. An adult patient has sustained burns to both of their legs, front and back. Using the Rule of Nines, what is
the estimated total body surface area (TBSA) affected?
A. 36%
B. 18%
C. 9%
D. 45%
Ans: A
Explanation: According to the Rule of Nines, each entire lower extremity accounts for 18% of the TBSA.
Since both legs are burned entirely on both sides, the calculation is 18% plus 18%. This results in a total
of 36% TBSA for the patient. Accurate calculation of burn surface area is vital for determining fluid
resuscitation needs. This standard method allows healthcare providers to quickly estimate the severity of
the injury.
4. What is the hallmark physiological feature of Acute Respiratory Distress Syndrome (ARDS)?
A. Respiratory alkalosis
B. Increased lung compliance
C. Refractory hypoxemia
D. Excessive surfactant production
, Ans: C
Explanation: ARDS is characterized by a significant mismatch in ventilation and perfusion leading to
severe hypoxia. Refractory hypoxemia occurs when the patient’s oxygen levels do not improve even with
high levels of supplemental oxygen. This condition results from the filling of alveoli with fluid and the
collapse of lung tissue. Lung compliance actually decreases, making the lungs ‘stiff’ and difficult to
ventilate. Understanding this hallmark helps the nurse anticipate the need for advanced ventilatory
strategies like PEEP.
5. A patient has a Central Venous Pressure (CVP) reading of 1 mmHg. Which condition should the nurse
suspect?
A. Hypervolemia
B. Hypovolemia
C. Right-sided heart failure
D. Pulmonary hypertension
Ans: B
Explanation: The normal range for Central Venous Pressure (CVP) is generally between 2 and 8 mmHg.
A CVP of 1 mmHg is low and indicates a lack of fluid volume within the venous system. This finding
typically suggests hypovolemia or dehydration requiring fluid resuscitation. Conversely, high CVP
readings are associated with fluid overload or right ventricular failure. Monitoring CVP provides essential
data regarding the patient’s fluid status and response to therapy.
6. A patient’s cardiac monitor shows ventricular fibrillation. What is the priority nursing action?
A. Perform synchronized cardioversion
B. Administer IV amiodarone
Adults III V1 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient on mechanical ventilation triggers a high-pressure alarm. Which action should the nurse
perform first?
A. Increase the oxygen concentration
B. Suction the patient immediately
C. Administer a sedative to the patient
D. Check for kinks in the ventilator tubing
Ans: D
Explanation: High-pressure alarms indicate that the ventilator is meeting resistance when delivering a
breath. The nurse should first assess for simple mechanical obstructions like kinks in the tubing. If no
kinks are found, the nurse should then assess the patient for a need to suction or biting the tube.
Checking the equipment first prevents unnecessary invasive procedures for the patient. Quick
troubleshooting ensures the patient continues to receive adequate ventilation.
2. Which clinical finding is most characteristic of the early stage of septic shock?
A. Cool, clammy skin
B. Increased systemic vascular resistance
C. Decreased cardiac output
D. Warm, flushed skin
Ans: D
,Explanation: Early septic shock, also known as the hyperdynamic or warm phase, is characterized by
vasodilation. This vasodilation leads to warm and flushed skin in the patient. During this phase, cardiac
output actually increases as the body attempts to compensate for systemic infection. Systemic vascular
resistance decreases significantly due to the massive release of inflammatory mediators. Recognizing
these early signs is critical for initiating timely antibiotic and fluid therapy.
3. An adult patient has sustained burns to both of their legs, front and back. Using the Rule of Nines, what is
the estimated total body surface area (TBSA) affected?
A. 36%
B. 18%
C. 9%
D. 45%
Ans: A
Explanation: According to the Rule of Nines, each entire lower extremity accounts for 18% of the TBSA.
Since both legs are burned entirely on both sides, the calculation is 18% plus 18%. This results in a total
of 36% TBSA for the patient. Accurate calculation of burn surface area is vital for determining fluid
resuscitation needs. This standard method allows healthcare providers to quickly estimate the severity of
the injury.
4. What is the hallmark physiological feature of Acute Respiratory Distress Syndrome (ARDS)?
A. Respiratory alkalosis
B. Increased lung compliance
C. Refractory hypoxemia
D. Excessive surfactant production
, Ans: C
Explanation: ARDS is characterized by a significant mismatch in ventilation and perfusion leading to
severe hypoxia. Refractory hypoxemia occurs when the patient’s oxygen levels do not improve even with
high levels of supplemental oxygen. This condition results from the filling of alveoli with fluid and the
collapse of lung tissue. Lung compliance actually decreases, making the lungs ‘stiff’ and difficult to
ventilate. Understanding this hallmark helps the nurse anticipate the need for advanced ventilatory
strategies like PEEP.
5. A patient has a Central Venous Pressure (CVP) reading of 1 mmHg. Which condition should the nurse
suspect?
A. Hypervolemia
B. Hypovolemia
C. Right-sided heart failure
D. Pulmonary hypertension
Ans: B
Explanation: The normal range for Central Venous Pressure (CVP) is generally between 2 and 8 mmHg.
A CVP of 1 mmHg is low and indicates a lack of fluid volume within the venous system. This finding
typically suggests hypovolemia or dehydration requiring fluid resuscitation. Conversely, high CVP
readings are associated with fluid overload or right ventricular failure. Monitoring CVP provides essential
data regarding the patient’s fluid status and response to therapy.
6. A patient’s cardiac monitor shows ventricular fibrillation. What is the priority nursing action?
A. Perform synchronized cardioversion
B. Administer IV amiodarone
