NSG233/NSG 233 Exam 2 V2 | Medical-
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient is admitted to the ICU with Acute Respiratory Distress Syndrome (ARDS). The
nurse notes the patient is on a ventilator with high Positive End-Expiratory Pressure (PEEP).
What is the most critical complication the nurse should monitor for?
A. Pneumothorax due to barotrauma
B. Respiratory alkalosis
C. Increased cardiac output
D. Pulmonary hypertension
Correct Answer: A
Rationale: High PEEP settings can cause over-distention of the alveoli, leading to alveolar
rupture or barotrauma, which manifests as a pneumothorax. The nurse must frequently
assess breath sounds and monitor for sudden respiratory distress or tracheal deviation.
Additionally, high PEEP can decrease venous return and cardiac output, making
cardiovascular monitoring essential.
2. A patient with a T4 spinal cord injury reports a sudden, severe pounding headache and is
found to have a blood pressure of 190/110 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication immediately
,B. Place the patient in a sitting position
C. Assess the patient for a distended bladder
D. Check the patient’s skin for pressure ulcers
Correct Answer: B
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
common in injuries at or above T6. The first nursing action is to sit the patient upright to
help lower blood pressure through orthostatic changes. After positioning, the nurse should
then identify and remove the noxious stimulus, such as a full bladder or impacted bowel.
3. A nurse is caring for a patient in the early stage of septic shock. Which clinical finding is
most characteristic of this stage?
A. Warm, flushed skin
B. Decreased heart rate
C. Cool, clammy skin
D. Severe hypotension
Correct Answer: A
Rationale: The early or ‘hyperdynamic’ phase of septic shock is characterized by
vasodilation, which results in warm, flushed skin. This is distinct from other types of shock
where compensatory vasoconstriction causes cool, pale skin. Nurses must recognize this
, early sign to initiate fluid resuscitation and antibiotic therapy promptly to improve
outcomes.
4. A patient weighs 80 kg and has sustained partial-thickness burns over 40% of their body.
Using the Parkland formula, calculate the total fluid volume required in the first 24 hours.
A. 6,400 mL
B. 12,800 mL
C. 9,600 mL
D. 16,000 mL
Correct Answer: B
Rationale: The Parkland formula is calculated as 4 mL x weight in kg x % Total Body
Surface Area (TBSA) burned. For this patient, the calculation is 4 mL x 80 kg x 40 = 12,800
mL. Half of this volume must be administered in the first 8 hours following the injury, with
the remainder given over the next 16 hours.
5. The nurse is monitoring a patient with a traumatic brain injury (TBI). Which set of vital
signs, known as Cushing’s Triad, indicates increased intracranial pressure (ICP)?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypotension, and Cheyne-Stokes respirations
C. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
D. Tachycardia, hypertension, and shallow respirations
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient is admitted to the ICU with Acute Respiratory Distress Syndrome (ARDS). The
nurse notes the patient is on a ventilator with high Positive End-Expiratory Pressure (PEEP).
What is the most critical complication the nurse should monitor for?
A. Pneumothorax due to barotrauma
B. Respiratory alkalosis
C. Increased cardiac output
D. Pulmonary hypertension
Correct Answer: A
Rationale: High PEEP settings can cause over-distention of the alveoli, leading to alveolar
rupture or barotrauma, which manifests as a pneumothorax. The nurse must frequently
assess breath sounds and monitor for sudden respiratory distress or tracheal deviation.
Additionally, high PEEP can decrease venous return and cardiac output, making
cardiovascular monitoring essential.
2. A patient with a T4 spinal cord injury reports a sudden, severe pounding headache and is
found to have a blood pressure of 190/110 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication immediately
,B. Place the patient in a sitting position
C. Assess the patient for a distended bladder
D. Check the patient’s skin for pressure ulcers
Correct Answer: B
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
common in injuries at or above T6. The first nursing action is to sit the patient upright to
help lower blood pressure through orthostatic changes. After positioning, the nurse should
then identify and remove the noxious stimulus, such as a full bladder or impacted bowel.
3. A nurse is caring for a patient in the early stage of septic shock. Which clinical finding is
most characteristic of this stage?
A. Warm, flushed skin
B. Decreased heart rate
C. Cool, clammy skin
D. Severe hypotension
Correct Answer: A
Rationale: The early or ‘hyperdynamic’ phase of septic shock is characterized by
vasodilation, which results in warm, flushed skin. This is distinct from other types of shock
where compensatory vasoconstriction causes cool, pale skin. Nurses must recognize this
, early sign to initiate fluid resuscitation and antibiotic therapy promptly to improve
outcomes.
4. A patient weighs 80 kg and has sustained partial-thickness burns over 40% of their body.
Using the Parkland formula, calculate the total fluid volume required in the first 24 hours.
A. 6,400 mL
B. 12,800 mL
C. 9,600 mL
D. 16,000 mL
Correct Answer: B
Rationale: The Parkland formula is calculated as 4 mL x weight in kg x % Total Body
Surface Area (TBSA) burned. For this patient, the calculation is 4 mL x 80 kg x 40 = 12,800
mL. Half of this volume must be administered in the first 8 hours following the injury, with
the remainder given over the next 16 hours.
5. The nurse is monitoring a patient with a traumatic brain injury (TBI). Which set of vital
signs, known as Cushing’s Triad, indicates increased intracranial pressure (ICP)?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypotension, and Cheyne-Stokes respirations
C. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
D. Tachycardia, hypertension, and shallow respirations
