NUR 425 Final Exam: Medical Surgical V3 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with a spinal cord injury at T6 reports a sudden, severe headache and is found to have a blood
pressure of 210/110 mmHg. What is the priority nursing action?
A. Administer the prescribed PRN antihypertensive medication immediately.
B. Assess the patient for signs of a pulmonary embolism or deep vein thrombosis.
C. Perform a neurological assessment to check for signs of a stroke.
D. Place the patient in a sitting position and check the bladder for distension.
Ans: D
Explanation: These symptoms are classic signs of autonomic dysreflexia, which is a medical emergency
in spinal cord injury patients. The first step is to elevate the head of the bed to 45 degrees or sit the
patient upright to help lower blood pressure. Following this, the nurse must identify and remove the
noxious stimulus, most commonly a full bladder or impacted bowel. Antihypertensives may be used if the
blood pressure remains high after removing the trigger. Failure to treat this promptly can lead to
seizures, stroke, or death.
2. A nurse is caring for a patient in the early stages of septic shock. Which of the following clinical findings
would the nurse expect to observe?
A. Cool, clammy skin and bradycardia.
B. Oliguria and massive generalized edema.
C. Severe hypotension and decreased respiratory rate.
D. Increased cardiac output and warm, flushed skin.
,Ans: D
Explanation: In the early or hyperdynamic phase of septic shock, the body attempts to compensate for
systemic infection. The patient typically exhibits a high cardiac output and systemic vasodilation,
resulting in warm, dry, or flushed skin. This compensatory phase is unique compared to other types of
shock where the skin is usually cold. Pulse rate and respiratory rate are typically elevated during this
time as well. Identifying sepsis in this early stage is crucial for improving patient outcomes through rapid
fluid and antibiotic administration.
3. A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation with high
levels of Positive End-Expiratory Pressure (PEEP). What is a primary complication the nurse should monitor
for?
A. Increased intracranial pressure due to hypercapnia.
B. Pneumothorax resulting from barotrauma.
C. Pulmonary edema from excessive fluid resuscitation.
D. Metabolic alkalosis from ventilator settings.
Ans: B
Explanation: High levels of PEEP are used in ARDS to keep alveoli open and improve oxygenation.
However, the increased pressure within the lungs can lead to barotrauma, which may result in a
pneumothorax or subcutaneous emphysema. The nurse must monitor for sudden decreased breath
sounds or tracheal deviation. Additionally, high PEEP can decrease venous return and cardiac output by
increasing intrathoracic pressure. Careful monitoring of hemodynamic stability and lung sounds is
essential for these patients.
, 4. A nurse is calculating the fluid resuscitation for a burn patient using the Parkland formula. The patient
weighs 80 kg and has burns over 40% of their body. How much fluid should be administered in the first 8
hours?
A. 3,200 mL
B. 12,800 mL
C. 6,400 mL
D. 1,600 mL
Ans: C
Explanation: The Parkland formula is calculated as 4 mL x kg x % TBSA (Total Body Surface Area)
burned. For this patient, the total 24-hour requirement is 4 mL x 80 kg x 40, which equals 12,800 mL.
According to the formula guidelines, half of the total volume must be given in the first 8 hours post-injury.
Therefore, 12,800 mL divided by 2 results in 6,400 mL for the first 8-hour period. Precise fluid
management is vital to prevent hypovolemic shock in the emergent phase of burn care.
5. Which laboratory value is the most sensitive indicator of acute kidney injury (AKI) in a critically ill patient?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium
C. Serum Creatinine
D. Urine Specific Gravity
Ans: C
Explanation: Serum creatinine is the most reliable indicator of kidney function because it is not
significantly affected by diet or fluid status like BUN is. An increase in creatinine levels indicates a
decrease in the glomerular filtration rate (GFR). While BUN can rise due to dehydration or high protein
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with a spinal cord injury at T6 reports a sudden, severe headache and is found to have a blood
pressure of 210/110 mmHg. What is the priority nursing action?
A. Administer the prescribed PRN antihypertensive medication immediately.
B. Assess the patient for signs of a pulmonary embolism or deep vein thrombosis.
C. Perform a neurological assessment to check for signs of a stroke.
D. Place the patient in a sitting position and check the bladder for distension.
Ans: D
Explanation: These symptoms are classic signs of autonomic dysreflexia, which is a medical emergency
in spinal cord injury patients. The first step is to elevate the head of the bed to 45 degrees or sit the
patient upright to help lower blood pressure. Following this, the nurse must identify and remove the
noxious stimulus, most commonly a full bladder or impacted bowel. Antihypertensives may be used if the
blood pressure remains high after removing the trigger. Failure to treat this promptly can lead to
seizures, stroke, or death.
2. A nurse is caring for a patient in the early stages of septic shock. Which of the following clinical findings
would the nurse expect to observe?
A. Cool, clammy skin and bradycardia.
B. Oliguria and massive generalized edema.
C. Severe hypotension and decreased respiratory rate.
D. Increased cardiac output and warm, flushed skin.
,Ans: D
Explanation: In the early or hyperdynamic phase of septic shock, the body attempts to compensate for
systemic infection. The patient typically exhibits a high cardiac output and systemic vasodilation,
resulting in warm, dry, or flushed skin. This compensatory phase is unique compared to other types of
shock where the skin is usually cold. Pulse rate and respiratory rate are typically elevated during this
time as well. Identifying sepsis in this early stage is crucial for improving patient outcomes through rapid
fluid and antibiotic administration.
3. A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation with high
levels of Positive End-Expiratory Pressure (PEEP). What is a primary complication the nurse should monitor
for?
A. Increased intracranial pressure due to hypercapnia.
B. Pneumothorax resulting from barotrauma.
C. Pulmonary edema from excessive fluid resuscitation.
D. Metabolic alkalosis from ventilator settings.
Ans: B
Explanation: High levels of PEEP are used in ARDS to keep alveoli open and improve oxygenation.
However, the increased pressure within the lungs can lead to barotrauma, which may result in a
pneumothorax or subcutaneous emphysema. The nurse must monitor for sudden decreased breath
sounds or tracheal deviation. Additionally, high PEEP can decrease venous return and cardiac output by
increasing intrathoracic pressure. Careful monitoring of hemodynamic stability and lung sounds is
essential for these patients.
, 4. A nurse is calculating the fluid resuscitation for a burn patient using the Parkland formula. The patient
weighs 80 kg and has burns over 40% of their body. How much fluid should be administered in the first 8
hours?
A. 3,200 mL
B. 12,800 mL
C. 6,400 mL
D. 1,600 mL
Ans: C
Explanation: The Parkland formula is calculated as 4 mL x kg x % TBSA (Total Body Surface Area)
burned. For this patient, the total 24-hour requirement is 4 mL x 80 kg x 40, which equals 12,800 mL.
According to the formula guidelines, half of the total volume must be given in the first 8 hours post-injury.
Therefore, 12,800 mL divided by 2 results in 6,400 mL for the first 8-hour period. Precise fluid
management is vital to prevent hypovolemic shock in the emergent phase of burn care.
5. Which laboratory value is the most sensitive indicator of acute kidney injury (AKI) in a critically ill patient?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium
C. Serum Creatinine
D. Urine Specific Gravity
Ans: C
Explanation: Serum creatinine is the most reliable indicator of kidney function because it is not
significantly affected by diet or fluid status like BUN is. An increase in creatinine levels indicates a
decrease in the glomerular filtration rate (GFR). While BUN can rise due to dehydration or high protein
