NSG233/NSG 233 Exam 1 V2 | Medical-
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient with ARDS is being mechanically ventilated with high levels of PEEP. The nurse
monitors for which primary complication related to high PEEP settings?
A. Increased cardiac output
B. Barotrauma and pneumothorax
C. Decreased intracranial pressure
D. Respiratory alkalosis
Correct Answer: B
Rationale: High Positive End-Expiratory Pressure (PEEP) increases the risk of alveolar
overdistension, leading to barotrauma or a pneumothorax. It can also decrease venous
return and cardiac output by increasing intrathoracic pressure. Monitoring breath sounds
and hemodynamic stability is critical in these patients.
2. Which clinical manifestation would the nurse expect to find in a patient experiencing the
compensatory stage of shock?
A. Refractory hypotension
B. Anuria and metabolic acidosis
C. Lethargy and decreased consciousness
,D. Narrowed pulse pressure and tachycardia
Correct Answer: D
Rationale: In the compensatory stage of shock, the body attempts to maintain homeostasis
through the activation of the sympathetic nervous system. This results in tachycardia and
peripheral vasoconstriction, which often presents as a narrowed pulse pressure. Assessing
for early signs like subtle changes in heart rate can prevent progression to the progressive
stage.
3. A patient’s ABG results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24 mEq/L. How should
the nurse interpret these findings?
A. Uncompensated metabolic alkalosis
B. Fully compensated metabolic acidosis
C. Partially compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Correct Answer: D
Rationale: The pH of 7.31 indicates acidosis since it is below the normal range of 7.35-
7.45. The PaCO2 is elevated at 50 mmHg, which is the primary cause of the acidic pH.
Because the HCO3 remains within the normal range, the body has not yet begun to
compensate for the respiratory imbalance.
, 4. The nurse is caring for a patient with a suspected T3 spinal cord injury. Which assessment
finding is most indicative of neurogenic shock?
A. Tachycardia and hypertension
B. Cool, clammy extremities
C. Bradycardia and hypotension
D. Increased systemic vascular resistance
Correct Answer: C
Rationale: Neurogenic shock is characterized by the loss of sympathetic tone, leading to
massive vasodilation. This typically manifests as the classic triad of hypotension,
bradycardia, and poikilothermia (inability to regulate temperature). Unlike other forms of
shock, the heart rate does not increase because the sympathetic pathways are interrupted.
5. A patient with full-thickness burns over 40% of their body is in the emergent phase. What
is the priority nursing intervention?
A. Administering IV antibiotics
B. Applying topical silver sulfadiazine
C. Fluid resuscitation using the Parkland formula
D. Initiating enteral feedings
Correct Answer: C
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient with ARDS is being mechanically ventilated with high levels of PEEP. The nurse
monitors for which primary complication related to high PEEP settings?
A. Increased cardiac output
B. Barotrauma and pneumothorax
C. Decreased intracranial pressure
D. Respiratory alkalosis
Correct Answer: B
Rationale: High Positive End-Expiratory Pressure (PEEP) increases the risk of alveolar
overdistension, leading to barotrauma or a pneumothorax. It can also decrease venous
return and cardiac output by increasing intrathoracic pressure. Monitoring breath sounds
and hemodynamic stability is critical in these patients.
2. Which clinical manifestation would the nurse expect to find in a patient experiencing the
compensatory stage of shock?
A. Refractory hypotension
B. Anuria and metabolic acidosis
C. Lethargy and decreased consciousness
,D. Narrowed pulse pressure and tachycardia
Correct Answer: D
Rationale: In the compensatory stage of shock, the body attempts to maintain homeostasis
through the activation of the sympathetic nervous system. This results in tachycardia and
peripheral vasoconstriction, which often presents as a narrowed pulse pressure. Assessing
for early signs like subtle changes in heart rate can prevent progression to the progressive
stage.
3. A patient’s ABG results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24 mEq/L. How should
the nurse interpret these findings?
A. Uncompensated metabolic alkalosis
B. Fully compensated metabolic acidosis
C. Partially compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Correct Answer: D
Rationale: The pH of 7.31 indicates acidosis since it is below the normal range of 7.35-
7.45. The PaCO2 is elevated at 50 mmHg, which is the primary cause of the acidic pH.
Because the HCO3 remains within the normal range, the body has not yet begun to
compensate for the respiratory imbalance.
, 4. The nurse is caring for a patient with a suspected T3 spinal cord injury. Which assessment
finding is most indicative of neurogenic shock?
A. Tachycardia and hypertension
B. Cool, clammy extremities
C. Bradycardia and hypotension
D. Increased systemic vascular resistance
Correct Answer: C
Rationale: Neurogenic shock is characterized by the loss of sympathetic tone, leading to
massive vasodilation. This typically manifests as the classic triad of hypotension,
bradycardia, and poikilothermia (inability to regulate temperature). Unlike other forms of
shock, the heart rate does not increase because the sympathetic pathways are interrupted.
5. A patient with full-thickness burns over 40% of their body is in the emergent phase. What
is the priority nursing intervention?
A. Administering IV antibiotics
B. Applying topical silver sulfadiazine
C. Fluid resuscitation using the Parkland formula
D. Initiating enteral feedings
Correct Answer: C
