NUR 265 Exam 1 V2 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 1) | Galen
1. A 68-year-old male is admitted to the ICU with a suspected ruptured abdominal aortic
aneurysm. His blood pressure is 82/44 mmHg, heart rate is 126 bpm, and respiratory rate is
28 breaths/min. The nurse notes that the patient is restless and his skin is cool and clammy.
Which stage of shock is this patient most likely experiencing?
A. Initial stage
B. Compensatory stage
C. Progressive stage
D. Refractory stage
Correct Answer: C
Explanation: In the progressive stage of shock, compensatory mechanisms begin to fail,
leading to significant hypotension and signs of poor peripheral perfusion such as cool,
clammy skin. The mean arterial pressure (MAP) typically drops more than 20 mmHg from
baseline, and metabolic acidosis develops due to anaerobic metabolism. Immediate
intervention is required to prevent irreversible organ damage.
,2. A patient with septic shock is receiving a norepinephrine infusion via a central venous
catheter. The nurse observes that the patient’s Mean Arterial Pressure (MAP) is 58 mmHg
despite titration. What is the nurse’s priority action?
A. Increase the norepinephrine infusion rate immediately
B. Administer a dose of IV furosemide to improve renal output
C. Assess the patient’s fluid volume status and notify the provider
D. Change the infusion to a peripheral IV line for better absorption
Correct Answer: C
Explanation: Vasopressors such as norepinephrine are ineffective if the patient is severely
hypovolemic, as there must be adequate intravascular volume to constrict. The nurse must
ensure fluid resuscitation is adequate before or during vasopressor therapy to maintain a
MAP above 65 mmHg. The provider should be notified to potentially order additional
crystalloid boluses.
3. A 45-year-old female was brought to the emergency department after a house fire. She has
soot around her nose, a hoarse voice, and singed nasal hairs. What is the most critical nursing
intervention at this time?
A. Calculate the total body surface area (TBSA) burned
B. Prepare for immediate endotracheal intubation
C. Administer IV pain medication
D. Start a large-bore IV for fluid resuscitation
,Correct Answer: B
Explanation: Signs such as soot in the nares, hoarseness, and singed nasal hairs are
indicative of an inhalation injury, which can lead to rapid airway edema and obstruction.
Airway management is always the first priority in burn care following the ABC protocol.
Securing the airway via intubation before swelling occurs is life-saving.
4. A nurse is caring for a patient who sustained full-thickness burns to both legs and the
anterior trunk. Using the Rule of Nines, what is the estimated percentage of Total Body
Surface Area (TBSA) burned?
A. 54%
B. 45%
C. 36%
D. 63%
Correct Answer: A
Explanation: According to the Rule of Nines, each leg represents 18% (total 36% for both)
and the anterior trunk represents 18%. Adding these together (36 + 18) equals 54% TBSA.
Accurate TBSA calculation is essential for determining the Parkland formula for fluid
resuscitation.
, 5. A patient in the ICU is being monitored for Disseminated Intravascular Coagulation (DIC).
Which laboratory result would the nurse expect to find if the patient is developing this
condition?
A. Decreased D-dimer levels
B. Increased fibrinogen levels
C. Prolonged Prothrombin Time (PT)
D. Increased platelet count
Correct Answer: C
Explanation: In DIC, the consumption of clotting factors leads to a prolonged Prothrombin
Time (PT) and Partial Thromboplastin Time (PTT). You would also expect to see elevated
D-dimer levels (indicating clot breakdown) and decreased fibrinogen and platelets (due to
consumption). This condition represents a paradox of excessive clotting followed by severe
bleeding.
6. A patient with a spinal cord injury at T4 is exhibiting a blood pressure of 78/42 mmHg and a
heart rate of 48 bpm. The skin is warm and dry below the level of injury. The nurse recognizes
this as which type of shock?
A. Neurogenic shock
B. Septic shock
C. Hypovolemic shock
D. Anaphylactic shock
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 1) | Galen
1. A 68-year-old male is admitted to the ICU with a suspected ruptured abdominal aortic
aneurysm. His blood pressure is 82/44 mmHg, heart rate is 126 bpm, and respiratory rate is
28 breaths/min. The nurse notes that the patient is restless and his skin is cool and clammy.
Which stage of shock is this patient most likely experiencing?
A. Initial stage
B. Compensatory stage
C. Progressive stage
D. Refractory stage
Correct Answer: C
Explanation: In the progressive stage of shock, compensatory mechanisms begin to fail,
leading to significant hypotension and signs of poor peripheral perfusion such as cool,
clammy skin. The mean arterial pressure (MAP) typically drops more than 20 mmHg from
baseline, and metabolic acidosis develops due to anaerobic metabolism. Immediate
intervention is required to prevent irreversible organ damage.
,2. A patient with septic shock is receiving a norepinephrine infusion via a central venous
catheter. The nurse observes that the patient’s Mean Arterial Pressure (MAP) is 58 mmHg
despite titration. What is the nurse’s priority action?
A. Increase the norepinephrine infusion rate immediately
B. Administer a dose of IV furosemide to improve renal output
C. Assess the patient’s fluid volume status and notify the provider
D. Change the infusion to a peripheral IV line for better absorption
Correct Answer: C
Explanation: Vasopressors such as norepinephrine are ineffective if the patient is severely
hypovolemic, as there must be adequate intravascular volume to constrict. The nurse must
ensure fluid resuscitation is adequate before or during vasopressor therapy to maintain a
MAP above 65 mmHg. The provider should be notified to potentially order additional
crystalloid boluses.
3. A 45-year-old female was brought to the emergency department after a house fire. She has
soot around her nose, a hoarse voice, and singed nasal hairs. What is the most critical nursing
intervention at this time?
A. Calculate the total body surface area (TBSA) burned
B. Prepare for immediate endotracheal intubation
C. Administer IV pain medication
D. Start a large-bore IV for fluid resuscitation
,Correct Answer: B
Explanation: Signs such as soot in the nares, hoarseness, and singed nasal hairs are
indicative of an inhalation injury, which can lead to rapid airway edema and obstruction.
Airway management is always the first priority in burn care following the ABC protocol.
Securing the airway via intubation before swelling occurs is life-saving.
4. A nurse is caring for a patient who sustained full-thickness burns to both legs and the
anterior trunk. Using the Rule of Nines, what is the estimated percentage of Total Body
Surface Area (TBSA) burned?
A. 54%
B. 45%
C. 36%
D. 63%
Correct Answer: A
Explanation: According to the Rule of Nines, each leg represents 18% (total 36% for both)
and the anterior trunk represents 18%. Adding these together (36 + 18) equals 54% TBSA.
Accurate TBSA calculation is essential for determining the Parkland formula for fluid
resuscitation.
, 5. A patient in the ICU is being monitored for Disseminated Intravascular Coagulation (DIC).
Which laboratory result would the nurse expect to find if the patient is developing this
condition?
A. Decreased D-dimer levels
B. Increased fibrinogen levels
C. Prolonged Prothrombin Time (PT)
D. Increased platelet count
Correct Answer: C
Explanation: In DIC, the consumption of clotting factors leads to a prolonged Prothrombin
Time (PT) and Partial Thromboplastin Time (PTT). You would also expect to see elevated
D-dimer levels (indicating clot breakdown) and decreased fibrinogen and platelets (due to
consumption). This condition represents a paradox of excessive clotting followed by severe
bleeding.
6. A patient with a spinal cord injury at T4 is exhibiting a blood pressure of 78/42 mmHg and a
heart rate of 48 bpm. The skin is warm and dry below the level of injury. The nurse recognizes
this as which type of shock?
A. Neurogenic shock
B. Septic shock
C. Hypovolemic shock
D. Anaphylactic shock
