NUR 417 Exam 2 V3 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 2) | Concordia
1. A patient in the ICU is being monitored for increased intracranial pressure (ICP). The nurse
notes a blood pressure of 190/70 mmHg, a pulse of 48 beats/min, and irregular respirations.
Which condition is the patient likely experiencing?
A. Hypovolemic shock
B. Septic shock
C. Cushing’s Triad
D. Cardiac tamponade
Correct Answer: C
Explanation: Cushing’s triad consists of bradycardia, hypertension with a widening pulse
pressure, and irregular respirations. It is a late sign of increased intracranial pressure and
indicates impending brain herniation. The nurse must recognize this as a medical
emergency requiring immediate intervention to reduce pressure.
2. The nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) on
mechanical ventilation. Which ventilator setting should the nurse anticipate to improve
oxygenation by keeping alveoli open at the end of expiration?
A. Positive End-Expiratory Pressure (PEEP)
B. Inspiratory reserve volume
,C. Fraction of inspired oxygen (FiO2) at 100%
D. Tidal volume of 10 mL/kg
Correct Answer: A
Explanation: PEEP is used in ARDS to prevent alveolar collapse at the end of expiration,
which improves gas exchange. By increasing functional residual capacity, it allows for
lower FiO2 levels to be used, reducing oxygen toxicity risks. High levels of PEEP can,
however, lead to complications like barotrauma or decreased cardiac output.
3. A patient with Acute Kidney Injury (AKI) has a potassium level of 6.8 mEq/L and ECG
changes including peaked T waves. Which medication should the nurse expect to administer
first to stabilize the myocardium?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular insulin and D50W
D. Calcium gluconate
Correct Answer: D
Explanation: Calcium gluconate is administered in severe hyperkalemia to antagonize the
toxic effects of potassium on the heart muscle. While it does not lower the potassium level,
it protects the patient from life-threatening arrhythmias. Other treatments like insulin or
Kayexalate are then used to actually reduce the serum potassium level.
,4. A nurse is assessing a patient with left-sided heart failure. Which clinical manifestations
should the nurse expect to find? (Select All That Apply)
A. Dyspnea and Orthopnea
B. Peripheral edema and Jugular Venous Distension
C. Crackles in lung bases
D. S3 heart sound
E. Hepatomegaly
Correct Answer: A, C, D
Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to respiratory symptoms such as dyspnea, orthopnea, and crackles. The
S3 gallop is a classic sign of ventricular overfilling seen in heart failure. Peripheral edema
and hepatomegaly are characteristic of right-sided heart failure.
5. During the assessment of a patient who had a liver biopsy 2 hours ago, the nurse notes the
patient is tachycardia and has a blood pressure of 88/50 mmHg. What is the nurse’s priority
action?
A. Administer pain medication
B. Turn the patient onto their left side
C. Assess the biopsy site for bleeding
D. Encourage deep breathing exercises
, Correct Answer: C
Explanation: Liver biopsy carries a high risk of hemorrhage due to the vascular nature of
the liver and potential coagulopathy in liver disease patients. Tachycardia and hypotension
are classic signs of hypovolemic shock from internal bleeding. The nurse must immediately
assess the site and prepare for emergency interventions.
6. A patient with a spinal cord injury at the T4 level reports a severe, throbbing headache and
nasal congestion. The nurse finds the patient’s BP is 210/110 mmHg. What is the first action
the nurse should take?
A. Administer an antihypertensive medication
B. Elevate the head of the bed to 45 degrees
C. Notify the healthcare provider
D. Check the patient for fecal impaction
Correct Answer: B
Explanation: The patient is demonstrating symptoms of autonomic dysreflexia, which is a
medical emergency in spinal cord injuries above T6. The immediate priority is to sit the
patient up to help lower blood pressure through orthostatic changes. After positioning, the
nurse should identify and remove the triggering stimulus, such as a full bladder or
impacted bowel.
Adult II | Actual Q&A with Rationale (NUR417
Exam 2) | Concordia
1. A patient in the ICU is being monitored for increased intracranial pressure (ICP). The nurse
notes a blood pressure of 190/70 mmHg, a pulse of 48 beats/min, and irregular respirations.
Which condition is the patient likely experiencing?
A. Hypovolemic shock
B. Septic shock
C. Cushing’s Triad
D. Cardiac tamponade
Correct Answer: C
Explanation: Cushing’s triad consists of bradycardia, hypertension with a widening pulse
pressure, and irregular respirations. It is a late sign of increased intracranial pressure and
indicates impending brain herniation. The nurse must recognize this as a medical
emergency requiring immediate intervention to reduce pressure.
2. The nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) on
mechanical ventilation. Which ventilator setting should the nurse anticipate to improve
oxygenation by keeping alveoli open at the end of expiration?
A. Positive End-Expiratory Pressure (PEEP)
B. Inspiratory reserve volume
,C. Fraction of inspired oxygen (FiO2) at 100%
D. Tidal volume of 10 mL/kg
Correct Answer: A
Explanation: PEEP is used in ARDS to prevent alveolar collapse at the end of expiration,
which improves gas exchange. By increasing functional residual capacity, it allows for
lower FiO2 levels to be used, reducing oxygen toxicity risks. High levels of PEEP can,
however, lead to complications like barotrauma or decreased cardiac output.
3. A patient with Acute Kidney Injury (AKI) has a potassium level of 6.8 mEq/L and ECG
changes including peaked T waves. Which medication should the nurse expect to administer
first to stabilize the myocardium?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular insulin and D50W
D. Calcium gluconate
Correct Answer: D
Explanation: Calcium gluconate is administered in severe hyperkalemia to antagonize the
toxic effects of potassium on the heart muscle. While it does not lower the potassium level,
it protects the patient from life-threatening arrhythmias. Other treatments like insulin or
Kayexalate are then used to actually reduce the serum potassium level.
,4. A nurse is assessing a patient with left-sided heart failure. Which clinical manifestations
should the nurse expect to find? (Select All That Apply)
A. Dyspnea and Orthopnea
B. Peripheral edema and Jugular Venous Distension
C. Crackles in lung bases
D. S3 heart sound
E. Hepatomegaly
Correct Answer: A, C, D
Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to respiratory symptoms such as dyspnea, orthopnea, and crackles. The
S3 gallop is a classic sign of ventricular overfilling seen in heart failure. Peripheral edema
and hepatomegaly are characteristic of right-sided heart failure.
5. During the assessment of a patient who had a liver biopsy 2 hours ago, the nurse notes the
patient is tachycardia and has a blood pressure of 88/50 mmHg. What is the nurse’s priority
action?
A. Administer pain medication
B. Turn the patient onto their left side
C. Assess the biopsy site for bleeding
D. Encourage deep breathing exercises
, Correct Answer: C
Explanation: Liver biopsy carries a high risk of hemorrhage due to the vascular nature of
the liver and potential coagulopathy in liver disease patients. Tachycardia and hypotension
are classic signs of hypovolemic shock from internal bleeding. The nurse must immediately
assess the site and prepare for emergency interventions.
6. A patient with a spinal cord injury at the T4 level reports a severe, throbbing headache and
nasal congestion. The nurse finds the patient’s BP is 210/110 mmHg. What is the first action
the nurse should take?
A. Administer an antihypertensive medication
B. Elevate the head of the bed to 45 degrees
C. Notify the healthcare provider
D. Check the patient for fecal impaction
Correct Answer: B
Explanation: The patient is demonstrating symptoms of autonomic dysreflexia, which is a
medical emergency in spinal cord injuries above T6. The immediate priority is to sit the
patient up to help lower blood pressure through orthostatic changes. After positioning, the
nurse should identify and remove the triggering stimulus, such as a full bladder or
impacted bowel.
