NUR 445 Exam 1: Acute & Chronic Health Disruptions In
Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical ventilation with high
levels of Positive End-Expiratory Pressure (PEEP). Which assessment finding most clearly indicates a
common complication of high PEEP?
A. Increased partial pressure of arterial oxygen (PaO2)
B. Blood pressure drop from 120/80 to 90/60 mmHg
C. Decreased intracranial pressure (ICP)
D. Improved lung compliance
Ans: B
Explanation: High levels of PEEP increase intrathoracic pressure, which can lead to decreased venous
return to the heart. This reduction in preload causes a decrease in cardiac output and systemic blood
pressure. Nurses must monitor hemodynamic status closely when adjusting ventilator settings in ARDS
patients. While PEEP improves oxygenation, its cardiovascular side effects are a significant concern. The
drop in blood pressure directly reflects the impact of high intrathoracic pressure on the circulatory
system.
2. During the first 24 hours of care for a patient with 40% total body surface area (TBSA) thermal burns, the
nurse notes a decrease in urine output to 20 mL/hour. What is the priority nursing action?
A. Decrease the rate of IV fluid administration
B. Insert a second Foley catheter
C. Administer a prescribed diuretic
,D. Notify the provider and prepare for a fluid bolus
Ans: D
Explanation: In the resuscitative phase of burn management, urine output is the primary indicator of
adequate fluid resuscitation. For thermal burns, a minimum urine output of 0.5 to 1 mL per kilogram per
hour is typically expected. A drop to 20 mL per hour suggests inadequate volume and the risk of
hypovolemic shock or acute kidney injury. The nurse must act quickly to increase the rate of fluid
replacement as per medical protocols. Diuretics are generally contraindicated during this early phase
because they do not address the underlying volume deficit.
3. A patient is admitted in Septic Shock with a MAP of 55 mmHg despite aggressive fluid resuscitation.
Which medication should the nurse anticipate administering next?
A. Norepinephrine
B. Nitroglycerin
C. Atropine
D. Furosemide
Ans: A
Explanation: Norepinephrine is the first-line vasopressor used in septic shock when fluid resuscitation
fails to maintain a MAP of at least 65 mmHg. It acts primarily as an alpha-adrenergic agonist to increase
systemic vascular resistance through vasoconstriction. Improving MAP is critical to ensuring adequate
perfusion to vital organs like the brain and kidneys. The nurse must monitor the patient closely for signs
of digital ischemia or arrhythmias during infusion. Constant hemodynamic monitoring via an arterial line
is usually required for patients receiving this medication.
, 4. Which clinical manifestation would the nurse expect to observe in a patient experiencing the
compensatory stage of shock?
A. Lethargy and decreased responsiveness
B. Anuria and metabolic acidosis
C. Bradypnea and hypotension
D. Tachycardia and narrowed pulse pressure
Ans: D
Explanation: During the compensatory stage of shock, the body activates the sympathetic nervous
system to maintain perfusion. Tachycardia occurs as the heart rate increases to boost cardiac output in
response to low volume or pressure. Narrowed pulse pressure is also common as diastolic pressure rises
due to systemic vasoconstriction. The patient may appear restless or anxious, but blood pressure is often
maintained within a near-normal range initially. Early identification of these signs is vital for preventing
progression to the progressive stage.
5. A patient with a traumatic brain injury (TBI) has an ICP of 22 mmHg. Which positioning is most
appropriate for this patient?
A. Trendelenburg position
B. Prone position
C. Supine with neck flexed
D. Head of bed elevated to 30-45 degrees
Ans: D
Explanation: Elevating the head of the bed to 30-45 degrees promotes venous drainage from the brain,
which helps lower intracranial pressure. It is essential to maintain the neck in a neutral, midline position
Adults III V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical ventilation with high
levels of Positive End-Expiratory Pressure (PEEP). Which assessment finding most clearly indicates a
common complication of high PEEP?
A. Increased partial pressure of arterial oxygen (PaO2)
B. Blood pressure drop from 120/80 to 90/60 mmHg
C. Decreased intracranial pressure (ICP)
D. Improved lung compliance
Ans: B
Explanation: High levels of PEEP increase intrathoracic pressure, which can lead to decreased venous
return to the heart. This reduction in preload causes a decrease in cardiac output and systemic blood
pressure. Nurses must monitor hemodynamic status closely when adjusting ventilator settings in ARDS
patients. While PEEP improves oxygenation, its cardiovascular side effects are a significant concern. The
drop in blood pressure directly reflects the impact of high intrathoracic pressure on the circulatory
system.
2. During the first 24 hours of care for a patient with 40% total body surface area (TBSA) thermal burns, the
nurse notes a decrease in urine output to 20 mL/hour. What is the priority nursing action?
A. Decrease the rate of IV fluid administration
B. Insert a second Foley catheter
C. Administer a prescribed diuretic
,D. Notify the provider and prepare for a fluid bolus
Ans: D
Explanation: In the resuscitative phase of burn management, urine output is the primary indicator of
adequate fluid resuscitation. For thermal burns, a minimum urine output of 0.5 to 1 mL per kilogram per
hour is typically expected. A drop to 20 mL per hour suggests inadequate volume and the risk of
hypovolemic shock or acute kidney injury. The nurse must act quickly to increase the rate of fluid
replacement as per medical protocols. Diuretics are generally contraindicated during this early phase
because they do not address the underlying volume deficit.
3. A patient is admitted in Septic Shock with a MAP of 55 mmHg despite aggressive fluid resuscitation.
Which medication should the nurse anticipate administering next?
A. Norepinephrine
B. Nitroglycerin
C. Atropine
D. Furosemide
Ans: A
Explanation: Norepinephrine is the first-line vasopressor used in septic shock when fluid resuscitation
fails to maintain a MAP of at least 65 mmHg. It acts primarily as an alpha-adrenergic agonist to increase
systemic vascular resistance through vasoconstriction. Improving MAP is critical to ensuring adequate
perfusion to vital organs like the brain and kidneys. The nurse must monitor the patient closely for signs
of digital ischemia or arrhythmias during infusion. Constant hemodynamic monitoring via an arterial line
is usually required for patients receiving this medication.
, 4. Which clinical manifestation would the nurse expect to observe in a patient experiencing the
compensatory stage of shock?
A. Lethargy and decreased responsiveness
B. Anuria and metabolic acidosis
C. Bradypnea and hypotension
D. Tachycardia and narrowed pulse pressure
Ans: D
Explanation: During the compensatory stage of shock, the body activates the sympathetic nervous
system to maintain perfusion. Tachycardia occurs as the heart rate increases to boost cardiac output in
response to low volume or pressure. Narrowed pulse pressure is also common as diastolic pressure rises
due to systemic vasoconstriction. The patient may appear restless or anxious, but blood pressure is often
maintained within a near-normal range initially. Early identification of these signs is vital for preventing
progression to the progressive stage.
5. A patient with a traumatic brain injury (TBI) has an ICP of 22 mmHg. Which positioning is most
appropriate for this patient?
A. Trendelenburg position
B. Prone position
C. Supine with neck flexed
D. Head of bed elevated to 30-45 degrees
Ans: D
Explanation: Elevating the head of the bed to 30-45 degrees promotes venous drainage from the brain,
which helps lower intracranial pressure. It is essential to maintain the neck in a neutral, midline position
