NSG233/NSG 233 Exam 2 V1 | Medical-
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient is admitted to the Intensive Care Unit (ICU) with a diagnosis of Acute Respiratory
Distress Syndrome (ARDS). Which clinical finding should the nurse identify as a hallmark sign
of this condition?
A. An increase in pulmonary compliance.
B. Hypoxemia that remains refractory to supplemental oxygen.
C. Respiratory alkalosis resulting from hypoventilation.
D. Decreased pulmonary artery wedge pressure (PAWP) below 8 mmHg.
Correct Answer: B
Rationale: ARDS is characterized by refractory hypoxemia, which means the patient’s
arterial oxygen levels do not improve despite increasing concentrations of supplemental
oxygen. This occurs due to severe ventilation-perfusion mismatching and intrapulmonary
shunting. In contrast, pulmonary compliance actually decreases (stiff lungs) in ARDS
patients, and respiratory acidosis is more common as the condition progresses.
,2. A 45-year-old male arrives at the emergency department with 40% Total Body Surface Area
(TBSA) burns. Using the Parkland formula (4 mL/kg/%TBSA), the patient weighs 80 kg. How
much fluid should be administered in the first 8 hours of resuscitation?
A. 6,400 mL
B. 12,800 mL
C. 3,200 mL
D. 1,600 mL
Correct Answer: A
Rationale: The Parkland formula calculation is 4 mL × 80 kg × 40% = 12,800 mL for the
first 24 hours. According to clinical protocols, half of the total volume (6,400 mL) must be
administered during the first 8 hours from the time of injury. The remaining 6,400 mL is
then infused over the subsequent 16 hours to maintain hemodynamic stability.
3. A nurse is caring for a patient who sustained a T4 spinal cord injury. The patient suddenly
reports a severe, throbbing headache and has a blood pressure of 210/110 mmHg. What is
the priority nursing action?
A. Administer an ordered PRN antihypertensive medication immediately.
B. Place the patient in a supine position to stabilize the spine.
C. Check the patient for bladder distention or a kinked urinary catheter.
D. Perform a neurological assessment to check for deteriorating motor function.
,Correct Answer: C
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
triggered by noxious stimuli below the level of the injury. Distended bladders or impacted
bowels are the most common triggers for this massive sympathetic discharge. The priority
is to remove the stimulus (like emptying the bladder) while sitting the patient upright to
help lower blood pressure.
4. A patient in the compensatory stage of shock exhibits which of the following physiological
manifestations?
A. Decreased heart rate to conserve myocardial oxygen demand.
B. Significant metabolic alkalosis due to lactic acid clearance.
C. Increased heart rate and narrowing pulse pressure.
D. Increased urinary output due to fluid shifts from the intracellular space.
Correct Answer: C
Rationale: During the compensatory stage of shock, the body activates the sympathetic
nervous system to maintain cardiac output, leading to tachycardia. Vasoconstriction occurs,
which may cause a narrowing pulse pressure even if the systolic blood pressure appears
normal. Decreased blood flow to the kidneys at this stage results in decreased, not
increased, urinary output through the activation of the RAAS.
, 5. While assessing a patient with a traumatic brain injury, the nurse notes the patient’s blood
pressure is 180/60 mmHg, heart rate is 45 beats/min, and respirations are irregular. Which
condition does this triad indicate?
A. Increased intracranial pressure (Cushing’s triad).
B. Autonomic dysreflexia.
C. Septic shock syndrome.
D. Hypovolemic shock following hemorrhage.
Correct Answer: A
Rationale: Cushing’s Triad consists of hypertension with a widened pulse pressure,
bradycardia, and irregular respirations. This is a late sign of significantly increased
intracranial pressure (ICP) and indicates imminent brain herniation. The nurse must
recognize this as a critical neurological emergency requiring immediate intervention to
reduce pressure.
6. The nurse is monitoring a patient with Disseminated Intravascular Coagulation (DIC).
Which laboratory result is most consistent with this diagnosis?
A. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT).
B. Decreased D-dimer levels.
C. Elevated fibrinogen levels.
D. Increased platelet count due to compensatory mechanism.
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient is admitted to the Intensive Care Unit (ICU) with a diagnosis of Acute Respiratory
Distress Syndrome (ARDS). Which clinical finding should the nurse identify as a hallmark sign
of this condition?
A. An increase in pulmonary compliance.
B. Hypoxemia that remains refractory to supplemental oxygen.
C. Respiratory alkalosis resulting from hypoventilation.
D. Decreased pulmonary artery wedge pressure (PAWP) below 8 mmHg.
Correct Answer: B
Rationale: ARDS is characterized by refractory hypoxemia, which means the patient’s
arterial oxygen levels do not improve despite increasing concentrations of supplemental
oxygen. This occurs due to severe ventilation-perfusion mismatching and intrapulmonary
shunting. In contrast, pulmonary compliance actually decreases (stiff lungs) in ARDS
patients, and respiratory acidosis is more common as the condition progresses.
,2. A 45-year-old male arrives at the emergency department with 40% Total Body Surface Area
(TBSA) burns. Using the Parkland formula (4 mL/kg/%TBSA), the patient weighs 80 kg. How
much fluid should be administered in the first 8 hours of resuscitation?
A. 6,400 mL
B. 12,800 mL
C. 3,200 mL
D. 1,600 mL
Correct Answer: A
Rationale: The Parkland formula calculation is 4 mL × 80 kg × 40% = 12,800 mL for the
first 24 hours. According to clinical protocols, half of the total volume (6,400 mL) must be
administered during the first 8 hours from the time of injury. The remaining 6,400 mL is
then infused over the subsequent 16 hours to maintain hemodynamic stability.
3. A nurse is caring for a patient who sustained a T4 spinal cord injury. The patient suddenly
reports a severe, throbbing headache and has a blood pressure of 210/110 mmHg. What is
the priority nursing action?
A. Administer an ordered PRN antihypertensive medication immediately.
B. Place the patient in a supine position to stabilize the spine.
C. Check the patient for bladder distention or a kinked urinary catheter.
D. Perform a neurological assessment to check for deteriorating motor function.
,Correct Answer: C
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
triggered by noxious stimuli below the level of the injury. Distended bladders or impacted
bowels are the most common triggers for this massive sympathetic discharge. The priority
is to remove the stimulus (like emptying the bladder) while sitting the patient upright to
help lower blood pressure.
4. A patient in the compensatory stage of shock exhibits which of the following physiological
manifestations?
A. Decreased heart rate to conserve myocardial oxygen demand.
B. Significant metabolic alkalosis due to lactic acid clearance.
C. Increased heart rate and narrowing pulse pressure.
D. Increased urinary output due to fluid shifts from the intracellular space.
Correct Answer: C
Rationale: During the compensatory stage of shock, the body activates the sympathetic
nervous system to maintain cardiac output, leading to tachycardia. Vasoconstriction occurs,
which may cause a narrowing pulse pressure even if the systolic blood pressure appears
normal. Decreased blood flow to the kidneys at this stage results in decreased, not
increased, urinary output through the activation of the RAAS.
, 5. While assessing a patient with a traumatic brain injury, the nurse notes the patient’s blood
pressure is 180/60 mmHg, heart rate is 45 beats/min, and respirations are irregular. Which
condition does this triad indicate?
A. Increased intracranial pressure (Cushing’s triad).
B. Autonomic dysreflexia.
C. Septic shock syndrome.
D. Hypovolemic shock following hemorrhage.
Correct Answer: A
Rationale: Cushing’s Triad consists of hypertension with a widened pulse pressure,
bradycardia, and irregular respirations. This is a late sign of significantly increased
intracranial pressure (ICP) and indicates imminent brain herniation. The nurse must
recognize this as a critical neurological emergency requiring immediate intervention to
reduce pressure.
6. The nurse is monitoring a patient with Disseminated Intravascular Coagulation (DIC).
Which laboratory result is most consistent with this diagnosis?
A. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT).
B. Decreased D-dimer levels.
C. Elevated fibrinogen levels.
D. Increased platelet count due to compensatory mechanism.
