NUR 282 | Advanced Clinical / Transition Nursing | Exam 3 2026
|Galen College
1. A nurse is caring for a patient on mechanical ventilation when the high-
pressure alarm sounds. Which action should the nurse take first?
A. Check for a leak in the ventilator circuit.
B. Notify the respiratory therapist immediately.
C. Assess for kinks in the tubing or the need for suctioning.
D. Administer a sedative to the patient.
Answer: C
Rationale: High-pressure alarms are triggered by increased resistance, often caused by
kinks in the tubing, secretions requiring suctioning, or the patient biting the tube.
2. When assessing a patient using the Glasgow Coma Scale (GCS), the nurse
notes the patient opens eyes to pain, uses inappropriate words, and withdraws
from pain. What is the GCS score?
A. 7
B. 13
C. 11
D. 9
Answer: D
Rationale: Eyes to pain (2), Inappropriate words (3), Withdraws from pain (4). Total score
= 9.
,3. Using the Parkland Formula, calculate the total fluid volume needed in the
first 24 hours for a 70 kg patient with 40% Total Body Surface Area (TBSA) burns.
A. 5,600 mL
B. 8,400 mL
C. 11,200 mL
D. 14,000 mL
Answer: C
Rationale: Parkland Formula: 4 mL x kg x % TBSA. 4 x 70 x 40 = 11,200 mL.
4. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and
HCO3 26 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: A
Rationale: The pH is low (<7.35) and the PaCO2 is high (>45), indicating respiratory
acidosis.
5. During a mass casualty incident, which patient should be assigned a ‘Red’ tag?
A. A patient with a minor arm fracture and small lacerations.
B. A patient with a closed leg fracture and stable vital signs.
C. A patient with a massive head injury and no spontaneous respirations.
D. A patient with an open pneumothorax and respiratory distress.
Answer: D
Rationale: Red tags are for immediate life-threatening injuries that are treatable, such as
airway or breathing issues.
, 6. A patient with a history of heart failure presents with distended neck veins,
muffled heart sounds, and hypotension. Which condition should the nurse
suspect?
A. Cardiac Tamponade
B. Myocardial Infarction
C. Pulmonary Embolism
D. Tension Pneumothorax
Answer: A
Rationale: Beck’s triad (muffled heart sounds, JVD, and hypotension) is classic for cardiac
tamponade.
7. A patient with a T6 spinal cord injury reports a severe headache and nasal
congestion. Their blood pressure is 190/100 mmHg. What is the priority nursing
action?
A. Administer an antihypertensive medication.
B. Perform a neurological assessment.
C. Place the patient in a supine position.
D. Check the patient’s bladder for distension.
Answer: D
Rationale: These are signs of autonomic dysreflexia. The priority is to sit the patient up
and identify/remove the stimulus, most commonly a full bladder.
8. Which EKG rhythm is characterized by a lack of P waves and a ‘sawtooth’
baseline?
A. Atrial Fibrillation
B. Atrial Flutter
C. Ventricular Tachycardia
D. Sinus Bradycardia
Answer: B
|Galen College
1. A nurse is caring for a patient on mechanical ventilation when the high-
pressure alarm sounds. Which action should the nurse take first?
A. Check for a leak in the ventilator circuit.
B. Notify the respiratory therapist immediately.
C. Assess for kinks in the tubing or the need for suctioning.
D. Administer a sedative to the patient.
Answer: C
Rationale: High-pressure alarms are triggered by increased resistance, often caused by
kinks in the tubing, secretions requiring suctioning, or the patient biting the tube.
2. When assessing a patient using the Glasgow Coma Scale (GCS), the nurse
notes the patient opens eyes to pain, uses inappropriate words, and withdraws
from pain. What is the GCS score?
A. 7
B. 13
C. 11
D. 9
Answer: D
Rationale: Eyes to pain (2), Inappropriate words (3), Withdraws from pain (4). Total score
= 9.
,3. Using the Parkland Formula, calculate the total fluid volume needed in the
first 24 hours for a 70 kg patient with 40% Total Body Surface Area (TBSA) burns.
A. 5,600 mL
B. 8,400 mL
C. 11,200 mL
D. 14,000 mL
Answer: C
Rationale: Parkland Formula: 4 mL x kg x % TBSA. 4 x 70 x 40 = 11,200 mL.
4. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and
HCO3 26 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: A
Rationale: The pH is low (<7.35) and the PaCO2 is high (>45), indicating respiratory
acidosis.
5. During a mass casualty incident, which patient should be assigned a ‘Red’ tag?
A. A patient with a minor arm fracture and small lacerations.
B. A patient with a closed leg fracture and stable vital signs.
C. A patient with a massive head injury and no spontaneous respirations.
D. A patient with an open pneumothorax and respiratory distress.
Answer: D
Rationale: Red tags are for immediate life-threatening injuries that are treatable, such as
airway or breathing issues.
, 6. A patient with a history of heart failure presents with distended neck veins,
muffled heart sounds, and hypotension. Which condition should the nurse
suspect?
A. Cardiac Tamponade
B. Myocardial Infarction
C. Pulmonary Embolism
D. Tension Pneumothorax
Answer: A
Rationale: Beck’s triad (muffled heart sounds, JVD, and hypotension) is classic for cardiac
tamponade.
7. A patient with a T6 spinal cord injury reports a severe headache and nasal
congestion. Their blood pressure is 190/100 mmHg. What is the priority nursing
action?
A. Administer an antihypertensive medication.
B. Perform a neurological assessment.
C. Place the patient in a supine position.
D. Check the patient’s bladder for distension.
Answer: D
Rationale: These are signs of autonomic dysreflexia. The priority is to sit the patient up
and identify/remove the stimulus, most commonly a full bladder.
8. Which EKG rhythm is characterized by a lack of P waves and a ‘sawtooth’
baseline?
A. Atrial Fibrillation
B. Atrial Flutter
C. Ventricular Tachycardia
D. Sinus Bradycardia
Answer: B
