NU189 | NU 189 Medical-Surgical Nursing II Final
Exam v2 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is caring for a client with a full-thickness burn covering 40% of their body.
Which of the following is the priority intervention during the emergent phase of burn
management?
A. Maintaining a patent airway and providing supplemental oxygen
B. Administering broad-spectrum antibiotics
C. Performing a focused neurological assessment
D. Calculating the Parkland formula for fluid resuscitation
Correct Answer: A
Expert Explanation: Airway management is always the first priority in the
emergent phase of burn care, especially if smoke inhalation is suspected. Ensuring a
patent airway and adequate oxygenation prevents hypoxemia and further tissue
damage. Fluid resuscitation and other treatments follow once the airway is secured.
2. A client is diagnosed with Acute Respiratory Distress Syndrome (ARDS) and is being
treated with mechanical ventilation. What is the primary purpose of adding Positive
End-Expiratory Pressure (PEEP)?
A. To decrease the risk of barotrauma
,B. To reduce the need for sedation during ventilation
C. To increase the patient’s respiratory rate
D. To prevent the collapse of alveoli at the end of expiration
Correct Answer: D
Expert Explanation: PEEP is used in ARDS to keep the alveoli open at the end of
expiration, which improves gas exchange and increases functional residual capacity.
By preventing alveolar collapse, it allows for better oxygenation with lower
concentrations of inspired oxygen. This intervention is crucial in managing the
severe hypoxemia associated with ARDS.
3. The nurse is monitoring a client who has just undergone a cardiac catheterization
via the femoral artery. Which assessment finding requires immediate notification of
the healthcare provider?
A. Heart rate of 88 beats per minute
B. A small bruise at the insertion site
C. A diminished pedal pulse on the affected extremity
D. Patient reporting mild soreness at the site
Correct Answer: C
,Expert Explanation: A diminished or absent pulse distal to the catheterization site
may indicate an arterial occlusion or hematoma formation, which is a medical
emergency. The nurse must assess for signs of compromised circulation
immediately. While bruising is common, a loss of pulse indicates a significant
vascular complication.
4. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which of
the following medications should the nurse withhold prior to the procedure?
A. Insulin glargine
B. Lisinopril
C. Calcium carbonate
D. Docusate sodium
Correct Answer: B
Expert Explanation: Antihypertensive medications like Lisinopril are typically
withheld before hemodialysis because the procedure itself can cause hypotension.
Administering these drugs beforehand increases the risk of a dangerous drop in
blood pressure during fluid removal. The nurse should always check the facility
policy and specific provider orders regarding pre-dialysis medications.
, 5. A client presents to the emergency department with symptoms of Cushing’s Triad
following a head injury. Which set of vital signs does the nurse expect to see?
A. BP 80/40, HR 120, RR 30
B. BP 140/90, HR 110, RR 24
C. BP 120/80, HR 70, RR 16
D. BP 190/70, HR 45, RR 10 and irregular
Correct Answer: D
Expert Explanation: Cushing’s Triad is a clinical sign of increased intracranial
pressure and consists of bradycardia, hypertension with a widening pulse pressure,
and irregular respirations. These signs indicate that the brain is no longer able to
compensate for the increased pressure. Immediate intervention is required to
prevent brain herniation and death.
6. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following
laboratory findings is most characteristic of this condition?
A. Blood glucose 110 mg/dL and pH 7.45
B. Blood glucose 200 mg/dL and HCO3 26 mEq/L
C. Blood glucose 800 mg/dL and pH 7.38
D. Blood glucose 450 mg/dL and pH 7.25
Exam v2 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is caring for a client with a full-thickness burn covering 40% of their body.
Which of the following is the priority intervention during the emergent phase of burn
management?
A. Maintaining a patent airway and providing supplemental oxygen
B. Administering broad-spectrum antibiotics
C. Performing a focused neurological assessment
D. Calculating the Parkland formula for fluid resuscitation
Correct Answer: A
Expert Explanation: Airway management is always the first priority in the
emergent phase of burn care, especially if smoke inhalation is suspected. Ensuring a
patent airway and adequate oxygenation prevents hypoxemia and further tissue
damage. Fluid resuscitation and other treatments follow once the airway is secured.
2. A client is diagnosed with Acute Respiratory Distress Syndrome (ARDS) and is being
treated with mechanical ventilation. What is the primary purpose of adding Positive
End-Expiratory Pressure (PEEP)?
A. To decrease the risk of barotrauma
,B. To reduce the need for sedation during ventilation
C. To increase the patient’s respiratory rate
D. To prevent the collapse of alveoli at the end of expiration
Correct Answer: D
Expert Explanation: PEEP is used in ARDS to keep the alveoli open at the end of
expiration, which improves gas exchange and increases functional residual capacity.
By preventing alveolar collapse, it allows for better oxygenation with lower
concentrations of inspired oxygen. This intervention is crucial in managing the
severe hypoxemia associated with ARDS.
3. The nurse is monitoring a client who has just undergone a cardiac catheterization
via the femoral artery. Which assessment finding requires immediate notification of
the healthcare provider?
A. Heart rate of 88 beats per minute
B. A small bruise at the insertion site
C. A diminished pedal pulse on the affected extremity
D. Patient reporting mild soreness at the site
Correct Answer: C
,Expert Explanation: A diminished or absent pulse distal to the catheterization site
may indicate an arterial occlusion or hematoma formation, which is a medical
emergency. The nurse must assess for signs of compromised circulation
immediately. While bruising is common, a loss of pulse indicates a significant
vascular complication.
4. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which of
the following medications should the nurse withhold prior to the procedure?
A. Insulin glargine
B. Lisinopril
C. Calcium carbonate
D. Docusate sodium
Correct Answer: B
Expert Explanation: Antihypertensive medications like Lisinopril are typically
withheld before hemodialysis because the procedure itself can cause hypotension.
Administering these drugs beforehand increases the risk of a dangerous drop in
blood pressure during fluid removal. The nurse should always check the facility
policy and specific provider orders regarding pre-dialysis medications.
, 5. A client presents to the emergency department with symptoms of Cushing’s Triad
following a head injury. Which set of vital signs does the nurse expect to see?
A. BP 80/40, HR 120, RR 30
B. BP 140/90, HR 110, RR 24
C. BP 120/80, HR 70, RR 16
D. BP 190/70, HR 45, RR 10 and irregular
Correct Answer: D
Expert Explanation: Cushing’s Triad is a clinical sign of increased intracranial
pressure and consists of bradycardia, hypertension with a widening pulse pressure,
and irregular respirations. These signs indicate that the brain is no longer able to
compensate for the increased pressure. Immediate intervention is required to
prevent brain herniation and death.
6. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following
laboratory findings is most characteristic of this condition?
A. Blood glucose 110 mg/dL and pH 7.45
B. Blood glucose 200 mg/dL and HCO3 26 mEq/L
C. Blood glucose 800 mg/dL and pH 7.38
D. Blood glucose 450 mg/dL and pH 7.25
