NUR2790/NUR 2790 Final Exam V2
| Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A patient presents with a pH of 7.31, PaCO2 of 38, and HCO3 of 19. How should the nurse
interpret these arterial blood gas (ABG) results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH level is below 7.35, which indicates an acidotic state in the
body. The bicarbonate level is lower than the normal range of 22 to 26, pointing to a
metabolic origin for the imbalance. Because the PaCO2 is within the normal range, the
condition is currently uncompensated metabolic acidosis.
2. During a mass casualty incident, which color tag should the nurse assign to a patient with a
sucking chest wound who is in respiratory distress?
A. Green
,B. Red
C. Yellow
D. Black
Correct Answer: B
Expert Explanation: A red tag is used for patients who have life-threatening injuries but
are likely to survive if they receive immediate treatment. A sucking chest wound causes
immediate respiratory compromise that requires urgent intervention to maintain life. This
patient represents the highest priority for transport and care among the living survivors.
3. A nurse is caring for a patient in the compensatory stage of shock. Which clinical
manifestation should the nurse expect to find?
A. Decreased heart rate
B. Increased heart rate
C. Significant hypotension
D. Anuria
Correct Answer: B
Expert Explanation: In the compensatory stage of shock, the body activates the
sympathetic nervous system to maintain cardiac output. This results in an increased heart
rate and vasoconstriction to keep the blood pressure within a near-normal range. The
,nurse must monitor for these early signs to prevent the patient from progressing to the
refractory stage.
4. A patient has sustained deep partial-thickness burns to the entire left arm and the anterior
trunk. Using the Rule of Nines, what is the total body surface area (TBSA) percentage burned?
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Expert Explanation: According to the Rule of Nines, the entire arm accounts for 9% of the
body surface area. The anterior trunk is calculated as 18% of the total body surface area.
Adding these two values together results in a total of 27% TBSA burned.
5. The nurse is monitoring a patient with a traumatic brain injury. Which set of vital signs
indicates Cushing’s Triad?
A. BP 120/80, HR 80, normal respirations
B. BP 90/60, HR 120, rapid respirations
C. BP 160/60, HR 50, irregular respirations
D. BP 110/70, HR 100, shallow respirations
Correct Answer: C
, Expert Explanation: Cushing’s Triad is a late sign of increased intracranial pressure and
consists of widened pulse pressure, bradycardia, and irregular respirations. In this case, the
high systolic blood pressure paired with a low heart rate is a classic indicator of
neurological deterioration. Immediate intervention is required to prevent brain herniation
and death.
6. A patient with a history of cirrhosis presents with confusion and a flapping tremor of the
hands (asterixis). Which medication does the nurse anticipate administering?
A. Spironolactone
B. Vitamin K
C. Propranolol
D. Lactulose
Correct Answer: D
Expert Explanation: Lactulose is the primary treatment for hepatic encephalopathy
caused by high ammonia levels in patients with liver failure. It works by drawing ammonia
from the blood into the colon so it can be excreted via stool. The nurse should monitor for 2
to 3 soft stools per day as an indicator of therapeutic efficacy.
7. The nurse notes continuous bubbling in the water seal chamber of a chest tube drainage
system. What is the nurse’s priority action?
A. Document this as a normal finding
B. Increase the suction pressure
| Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A patient presents with a pH of 7.31, PaCO2 of 38, and HCO3 of 19. How should the nurse
interpret these arterial blood gas (ABG) results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH level is below 7.35, which indicates an acidotic state in the
body. The bicarbonate level is lower than the normal range of 22 to 26, pointing to a
metabolic origin for the imbalance. Because the PaCO2 is within the normal range, the
condition is currently uncompensated metabolic acidosis.
2. During a mass casualty incident, which color tag should the nurse assign to a patient with a
sucking chest wound who is in respiratory distress?
A. Green
,B. Red
C. Yellow
D. Black
Correct Answer: B
Expert Explanation: A red tag is used for patients who have life-threatening injuries but
are likely to survive if they receive immediate treatment. A sucking chest wound causes
immediate respiratory compromise that requires urgent intervention to maintain life. This
patient represents the highest priority for transport and care among the living survivors.
3. A nurse is caring for a patient in the compensatory stage of shock. Which clinical
manifestation should the nurse expect to find?
A. Decreased heart rate
B. Increased heart rate
C. Significant hypotension
D. Anuria
Correct Answer: B
Expert Explanation: In the compensatory stage of shock, the body activates the
sympathetic nervous system to maintain cardiac output. This results in an increased heart
rate and vasoconstriction to keep the blood pressure within a near-normal range. The
,nurse must monitor for these early signs to prevent the patient from progressing to the
refractory stage.
4. A patient has sustained deep partial-thickness burns to the entire left arm and the anterior
trunk. Using the Rule of Nines, what is the total body surface area (TBSA) percentage burned?
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Expert Explanation: According to the Rule of Nines, the entire arm accounts for 9% of the
body surface area. The anterior trunk is calculated as 18% of the total body surface area.
Adding these two values together results in a total of 27% TBSA burned.
5. The nurse is monitoring a patient with a traumatic brain injury. Which set of vital signs
indicates Cushing’s Triad?
A. BP 120/80, HR 80, normal respirations
B. BP 90/60, HR 120, rapid respirations
C. BP 160/60, HR 50, irregular respirations
D. BP 110/70, HR 100, shallow respirations
Correct Answer: C
, Expert Explanation: Cushing’s Triad is a late sign of increased intracranial pressure and
consists of widened pulse pressure, bradycardia, and irregular respirations. In this case, the
high systolic blood pressure paired with a low heart rate is a classic indicator of
neurological deterioration. Immediate intervention is required to prevent brain herniation
and death.
6. A patient with a history of cirrhosis presents with confusion and a flapping tremor of the
hands (asterixis). Which medication does the nurse anticipate administering?
A. Spironolactone
B. Vitamin K
C. Propranolol
D. Lactulose
Correct Answer: D
Expert Explanation: Lactulose is the primary treatment for hepatic encephalopathy
caused by high ammonia levels in patients with liver failure. It works by drawing ammonia
from the blood into the colon so it can be excreted via stool. The nurse should monitor for 2
to 3 soft stools per day as an indicator of therapeutic efficacy.
7. The nurse notes continuous bubbling in the water seal chamber of a chest tube drainage
system. What is the nurse’s priority action?
A. Document this as a normal finding
B. Increase the suction pressure
