NUR 265 – EXAM 4 EXAM with Questions and
Answers/Plus a Rationale Updated 2026 A+/Instant
Download PDF
Table of Contents
1. Complex Medical-Surgical Pathophysiology
2. Advanced Pharmacological Interventions
3. Critical Care Nursing Management
4. Ethical and Legal Considerations in Acute Care
5. Evidence-Based Clinical Decision Making
1. A patient with acute respiratory distress syndrome (ARDS) is being mechanically ventilated with
positive end-expiratory pressure (PEEP) set at 15 cm $H_2O$. The patient suddenly develops
hypotension and tachycardia, and breath sounds are absent on the right side. Which action is the
priority nursing intervention?
A. Increase the intravenous fluid infusion rate to stabilize blood pressure.
B. Perform immediate needle decompression or assist with chest tube insertion.
C. Decrease the PEEP setting to 5 cm $H_2O$ to reduce intrathoracic pressure.
D. Obtain an urgent portable chest X-ray to confirm the suspected diagnosis.
Answer: B
Rationale: The clinical presentation of sudden hypotension, tachycardia, and absent breath
sounds in a patient on high-PEEP ventilation is classic for a tension pneumothorax, a life-
threatening complication. Immediate decompression is required to relieve intrathoracic
pressure; waiting for an X-ray (D) would delay life-saving intervention. Fluids (A) will not fix
the mechanical obstruction, and decreasing PEEP (C) is insufficient for a pneumothorax.
, CORRECT ANSWER : B
2. A patient in the ICU is receiving a dopamine infusion for septic shock. The nurse notes the
infusion site is cool, pale, and indurated, and the pump is alarming for high pressure. What is the
priority action?
A. Stop the infusion and administer phentolamine into the affected area.
B. Flush the IV line with 10 mL of normal saline to clear the obstruction.
C. Apply a warm compress to the site to promote vasodilation and absorption.
D. Elevate the extremity and notify the provider to continue the infusion elsewhere.
Answer: A
Rationale: Dopamine is a potent vasoconstrictor and a vesicant; infiltration can lead to severe
tissue necrosis. Stopping the infusion is mandatory to prevent further damage, and administering
phentolamine, an alpha-adrenergic antagonist, serves as an antidote to counteract the
vasoconstriction. Flushing (B) may worsen the extravasation, and heat (C) is contraindicated for
some extravasations.
CORRECT ANSWER : A
3. Which finding in a patient with a suspected myocardial infarction (MI) is most concerning and
requires immediate reporting to the interdisciplinary team?
A. Reported fatigue and generalized muscle aches for the past 48 hours.
B. A new systolic murmur heard at the apex radiating to the axilla.
C. Mild epigastric discomfort that is relieved by sitting upright.
D. ST-segment depression of 0.5 mm in leads V4 through V6.
Answer: B
Rationale: A new systolic murmur in the context of an MI suggests acute mitral valve
regurgitation due to papillary muscle rupture, a mechanical complication with high mortality
that requires surgical intervention. While ST depression (D) is concerning for ischemia, it is not
as acutely life-threatening as a ruptured papillary muscle. Fatigue (A) and epigastric pain (C)
are common but less specific than a new mechanical heart murmur.
CORRECT ANSWER : B
,4. A patient with advanced cirrhosis presents with hematemesis. After stabilizing the airway, the
nurse prepares for an endoscopic procedure. Which medication order does the nurse anticipate to
manage active esophageal variceal bleeding?
A. Furosemide to manage potential fluid overload from IV resuscitation.
B. Octreotide infusion to decrease splanchnic blood flow.
C. Propranolol to decrease systemic heart rate and cardiac output.
D. Vitamin K to correct coagulopathy associated with liver failure.
Answer: B
Rationale: Octreotide is the gold standard pharmacological treatment for acute esophageal
variceal bleeding because it causes selective vasoconstriction of the splanchnic circulation,
reducing portal pressure. Propranolol (C) is used for long-term prophylaxis but is ineffective
during acute hemorrhage. Furosemide (A) and Vitamin K (D) are important in cirrhosis
management but do not address the acute mechanical bleeding of varices.
CORRECT ANSWER : B
5. A patient is undergoing a weaning trial from mechanical ventilation. Which parameter indicates
the patient is failing the trial and requires immediate intervention?
A. A spontaneous tidal volume of 6 mL/kg of ideal body weight.
B. A rapid shallow breathing index (RSBI) of 130 breaths/min/L.
C. A respiratory rate of 22 breaths per minute.
D. An arterial oxygen saturation of 94% on 40% FiO2.
Answer: B
Rationale: The RSBI (frequency/tidal volume in liters) is a clinical predictor of weaning success;
an RSBI greater than 105 generally indicates failure and a high likelihood of needing continued
ventilation. A tidal volume of 6 mL/kg (A), respiratory rate of 22 (C), and oxygenation of 94%
(D) are all within acceptable ranges for a patient successfully tolerating a trial.
CORRECT ANSWER : B
6. When caring for a patient with increased intracranial pressure (ICP), which position is optimal
for facilitating venous drainage?
A. Trendelenburg position to increase cerebral perfusion pressure.
, B. Head of bed elevated to 30 degrees with the neck in neutral alignment.
C. Side-lying position with the knees flexed to promote comfort.
D. Prone position to improve oxygenation and pulmonary mechanics.
Answer: B
Rationale: Elevating the head of the bed to 30 degrees and maintaining neutral neck alignment
are critical to optimize cerebral venous outflow, which minimizes ICP. Trendelenburg (A)
increases ICP by impeding venous drainage. Prone positioning (D) is used for ARDS but is
generally avoided in patients with intracranial instability. Side-lying (C) may cause neck flexion,
which obstructs jugular venous return.
CORRECT ANSWER : B
7. A patient with a traumatic brain injury (TBI) has an ICP of 22 mmHg. The mean arterial pressure
(MAP) is 70 mmHg. What is the calculated cerebral perfusion pressure (CPP), and is it within
the target range?
A. CPP 48 mmHg; it is within the target range.
B. CPP 48 mmHg; it is below the target range.
C. CPP 92 mmHg; it is within the target range.
D. CPP 92 mmHg; it is above the target range.
Answer: B
Rationale: CPP is calculated as $MAP - ICP$. With a MAP of 70 and an ICP of 22, the result is
48 mmHg. The goal for a patient with a TBI is typically a CPP of 60–70 mmHg to ensure
adequate cerebral blood flow. Therefore, 48 mmHg is significantly below the acceptable
therapeutic threshold.
CORRECT ANSWER : B
8. Which laboratory finding most strongly supports the diagnosis of disseminated intravascular
coagulation (DIC) in a critically ill patient?
A. Elevated platelet count and shortened prothrombin time.
B. Decreased fibrinogen level and elevated D-dimer.
C. Normal fibrinogen level and normal D-dimer levels.
Answers/Plus a Rationale Updated 2026 A+/Instant
Download PDF
Table of Contents
1. Complex Medical-Surgical Pathophysiology
2. Advanced Pharmacological Interventions
3. Critical Care Nursing Management
4. Ethical and Legal Considerations in Acute Care
5. Evidence-Based Clinical Decision Making
1. A patient with acute respiratory distress syndrome (ARDS) is being mechanically ventilated with
positive end-expiratory pressure (PEEP) set at 15 cm $H_2O$. The patient suddenly develops
hypotension and tachycardia, and breath sounds are absent on the right side. Which action is the
priority nursing intervention?
A. Increase the intravenous fluid infusion rate to stabilize blood pressure.
B. Perform immediate needle decompression or assist with chest tube insertion.
C. Decrease the PEEP setting to 5 cm $H_2O$ to reduce intrathoracic pressure.
D. Obtain an urgent portable chest X-ray to confirm the suspected diagnosis.
Answer: B
Rationale: The clinical presentation of sudden hypotension, tachycardia, and absent breath
sounds in a patient on high-PEEP ventilation is classic for a tension pneumothorax, a life-
threatening complication. Immediate decompression is required to relieve intrathoracic
pressure; waiting for an X-ray (D) would delay life-saving intervention. Fluids (A) will not fix
the mechanical obstruction, and decreasing PEEP (C) is insufficient for a pneumothorax.
, CORRECT ANSWER : B
2. A patient in the ICU is receiving a dopamine infusion for septic shock. The nurse notes the
infusion site is cool, pale, and indurated, and the pump is alarming for high pressure. What is the
priority action?
A. Stop the infusion and administer phentolamine into the affected area.
B. Flush the IV line with 10 mL of normal saline to clear the obstruction.
C. Apply a warm compress to the site to promote vasodilation and absorption.
D. Elevate the extremity and notify the provider to continue the infusion elsewhere.
Answer: A
Rationale: Dopamine is a potent vasoconstrictor and a vesicant; infiltration can lead to severe
tissue necrosis. Stopping the infusion is mandatory to prevent further damage, and administering
phentolamine, an alpha-adrenergic antagonist, serves as an antidote to counteract the
vasoconstriction. Flushing (B) may worsen the extravasation, and heat (C) is contraindicated for
some extravasations.
CORRECT ANSWER : A
3. Which finding in a patient with a suspected myocardial infarction (MI) is most concerning and
requires immediate reporting to the interdisciplinary team?
A. Reported fatigue and generalized muscle aches for the past 48 hours.
B. A new systolic murmur heard at the apex radiating to the axilla.
C. Mild epigastric discomfort that is relieved by sitting upright.
D. ST-segment depression of 0.5 mm in leads V4 through V6.
Answer: B
Rationale: A new systolic murmur in the context of an MI suggests acute mitral valve
regurgitation due to papillary muscle rupture, a mechanical complication with high mortality
that requires surgical intervention. While ST depression (D) is concerning for ischemia, it is not
as acutely life-threatening as a ruptured papillary muscle. Fatigue (A) and epigastric pain (C)
are common but less specific than a new mechanical heart murmur.
CORRECT ANSWER : B
,4. A patient with advanced cirrhosis presents with hematemesis. After stabilizing the airway, the
nurse prepares for an endoscopic procedure. Which medication order does the nurse anticipate to
manage active esophageal variceal bleeding?
A. Furosemide to manage potential fluid overload from IV resuscitation.
B. Octreotide infusion to decrease splanchnic blood flow.
C. Propranolol to decrease systemic heart rate and cardiac output.
D. Vitamin K to correct coagulopathy associated with liver failure.
Answer: B
Rationale: Octreotide is the gold standard pharmacological treatment for acute esophageal
variceal bleeding because it causes selective vasoconstriction of the splanchnic circulation,
reducing portal pressure. Propranolol (C) is used for long-term prophylaxis but is ineffective
during acute hemorrhage. Furosemide (A) and Vitamin K (D) are important in cirrhosis
management but do not address the acute mechanical bleeding of varices.
CORRECT ANSWER : B
5. A patient is undergoing a weaning trial from mechanical ventilation. Which parameter indicates
the patient is failing the trial and requires immediate intervention?
A. A spontaneous tidal volume of 6 mL/kg of ideal body weight.
B. A rapid shallow breathing index (RSBI) of 130 breaths/min/L.
C. A respiratory rate of 22 breaths per minute.
D. An arterial oxygen saturation of 94% on 40% FiO2.
Answer: B
Rationale: The RSBI (frequency/tidal volume in liters) is a clinical predictor of weaning success;
an RSBI greater than 105 generally indicates failure and a high likelihood of needing continued
ventilation. A tidal volume of 6 mL/kg (A), respiratory rate of 22 (C), and oxygenation of 94%
(D) are all within acceptable ranges for a patient successfully tolerating a trial.
CORRECT ANSWER : B
6. When caring for a patient with increased intracranial pressure (ICP), which position is optimal
for facilitating venous drainage?
A. Trendelenburg position to increase cerebral perfusion pressure.
, B. Head of bed elevated to 30 degrees with the neck in neutral alignment.
C. Side-lying position with the knees flexed to promote comfort.
D. Prone position to improve oxygenation and pulmonary mechanics.
Answer: B
Rationale: Elevating the head of the bed to 30 degrees and maintaining neutral neck alignment
are critical to optimize cerebral venous outflow, which minimizes ICP. Trendelenburg (A)
increases ICP by impeding venous drainage. Prone positioning (D) is used for ARDS but is
generally avoided in patients with intracranial instability. Side-lying (C) may cause neck flexion,
which obstructs jugular venous return.
CORRECT ANSWER : B
7. A patient with a traumatic brain injury (TBI) has an ICP of 22 mmHg. The mean arterial pressure
(MAP) is 70 mmHg. What is the calculated cerebral perfusion pressure (CPP), and is it within
the target range?
A. CPP 48 mmHg; it is within the target range.
B. CPP 48 mmHg; it is below the target range.
C. CPP 92 mmHg; it is within the target range.
D. CPP 92 mmHg; it is above the target range.
Answer: B
Rationale: CPP is calculated as $MAP - ICP$. With a MAP of 70 and an ICP of 22, the result is
48 mmHg. The goal for a patient with a TBI is typically a CPP of 60–70 mmHg to ensure
adequate cerebral blood flow. Therefore, 48 mmHg is significantly below the acceptable
therapeutic threshold.
CORRECT ANSWER : B
8. Which laboratory finding most strongly supports the diagnosis of disseminated intravascular
coagulation (DIC) in a critically ill patient?
A. Elevated platelet count and shortened prothrombin time.
B. Decreased fibrinogen level and elevated D-dimer.
C. Normal fibrinogen level and normal D-dimer levels.
