NUR 265 Exam 4 V2 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. A 45-year-old male is admitted to the ICU with a diagnosis of septic shock. His blood
pressure is 80/42 mmHg, heart rate is 122 bpm, and Central Venous Pressure (CVP) is 2
mmHg. Which intervention should the nurse prioritize first?
A. Administer norepinephrine via a central line.
B. Draw blood cultures from two separate sites.
C. Initiate a rapid infusion of 0.9% Normal Saline.
D. Administer broad-spectrum antibiotics.
Correct Answer: C
Explanation: In the initial resuscitation of septic shock, the priority is to restore circulating
volume to improve tissue perfusion. A CVP of 2 mmHg indicates significant hypovolemia,
requiring immediate fluid resuscitation before vasopressors like norepinephrine are
considered. Once the volume is stabilized or if the patient remains hypotensive,
vasopressors and antibiotics should be administered within the first hour.
2. A client is brought to the emergency department after suffering full-thickness burns to the
chest, abdomen, and both anterior arms. Using the Rule of Nines, what is the estimated Total
Body Surface Area (TBSA) affected?
A. 18%
,B. 27%
C. 36%
D. 45%
Correct Answer: B
Explanation: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18% of the TBSA. Each entire arm accounts for 9%, so the anterior portion of
both arms accounts for 4.5% each, totaling 9%. Adding 18% for the trunk and 9% for the
arms results in a total of 27% TBSA.
3. An ICU nurse is caring for a patient on a mechanical ventilator with the following settings:
SIMV, Rate 12, Tidal Volume 500 mL, FiO2 60%, PEEP 15 cm H2O. The nurse notes a sudden
drop in SpO2 to 85% and absent breath sounds on the right side. What is the most likely
complication?
A. Tension pneumothorax
B. Ventilator-associated pneumonia
C. Endotracheal tube displacement
D. Pulmonary embolism
Correct Answer: A
Explanation: High levels of Positive End-Expiratory Pressure (PEEP), such as 15 cm H2O,
increase the risk of barotrauma, which can lead to a tension pneumothorax. The sudden
,drop in oxygen saturation and absent breath sounds on the affected side are classic clinical
indicators of this life-threatening event. Immediate intervention with needle
decompression or chest tube insertion is required to relieve the pressure.
4. A patient with a history of liver cirrhosis is admitted with suspected hepatic
encephalopathy. The patient is lethargic and exhibits asterixis. The nurse should anticipate
administering which medication to reduce ammonia levels?
A. Spironolactone
B. Rifaximin
C. Neomycin
D. Lactulose
Correct Answer: D
Explanation: Lactulose is the primary pharmacological treatment for hepatic
encephalopathy as it promotes the excretion of ammonia through the stool. It works by
creating an acidic environment in the bowel that converts ammonia into ammonium, which
is not absorbable. The effectiveness of the medication is monitored by the number of bowel
movements and the patient’s neurological status.
5. A client in the emergent phase of burn care has a potassium level of 6.2 mEq/L and a
sodium level of 130 mEq/L. Which pathophysiological process best explains these laboratory
findings?
A. Cellular destruction and fluid shifting
, B. Renal failure due to myoglobinuria
C. Excessive fluid resuscitation with Ringers Lactate
D. Inadequate aldosterone secretion
Correct Answer: A
Explanation: During the emergent phase of a burn, massive cellular destruction causes the
release of intracellular potassium into the extracellular space, resulting in hyperkalemia.
Simultaneously, increased capillary permeability allows sodium and water to shift from the
vascular space into the interstitial space, leading to hyponatremia. These electrolyte shifts
are characteristic of the first 24 to 48 hours following a major burn injury.
6. A patient with a T4 spinal cord injury reports a severe, throbbing headache and nasal
congestion. The nurse notes the patient is flushed above the level of injury and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer a prescribed PRN antihypertensive.
B. Place the patient in a high-Fowler’s position.
C. Assess the patient for a full bladder or fecal impaction.
D. Notify the rapid response team immediately.
Correct Answer: B
Explanation: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
triggered by noxious stimuli below the level of injury. The immediate priority is to sit the
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. A 45-year-old male is admitted to the ICU with a diagnosis of septic shock. His blood
pressure is 80/42 mmHg, heart rate is 122 bpm, and Central Venous Pressure (CVP) is 2
mmHg. Which intervention should the nurse prioritize first?
A. Administer norepinephrine via a central line.
B. Draw blood cultures from two separate sites.
C. Initiate a rapid infusion of 0.9% Normal Saline.
D. Administer broad-spectrum antibiotics.
Correct Answer: C
Explanation: In the initial resuscitation of septic shock, the priority is to restore circulating
volume to improve tissue perfusion. A CVP of 2 mmHg indicates significant hypovolemia,
requiring immediate fluid resuscitation before vasopressors like norepinephrine are
considered. Once the volume is stabilized or if the patient remains hypotensive,
vasopressors and antibiotics should be administered within the first hour.
2. A client is brought to the emergency department after suffering full-thickness burns to the
chest, abdomen, and both anterior arms. Using the Rule of Nines, what is the estimated Total
Body Surface Area (TBSA) affected?
A. 18%
,B. 27%
C. 36%
D. 45%
Correct Answer: B
Explanation: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18% of the TBSA. Each entire arm accounts for 9%, so the anterior portion of
both arms accounts for 4.5% each, totaling 9%. Adding 18% for the trunk and 9% for the
arms results in a total of 27% TBSA.
3. An ICU nurse is caring for a patient on a mechanical ventilator with the following settings:
SIMV, Rate 12, Tidal Volume 500 mL, FiO2 60%, PEEP 15 cm H2O. The nurse notes a sudden
drop in SpO2 to 85% and absent breath sounds on the right side. What is the most likely
complication?
A. Tension pneumothorax
B. Ventilator-associated pneumonia
C. Endotracheal tube displacement
D. Pulmonary embolism
Correct Answer: A
Explanation: High levels of Positive End-Expiratory Pressure (PEEP), such as 15 cm H2O,
increase the risk of barotrauma, which can lead to a tension pneumothorax. The sudden
,drop in oxygen saturation and absent breath sounds on the affected side are classic clinical
indicators of this life-threatening event. Immediate intervention with needle
decompression or chest tube insertion is required to relieve the pressure.
4. A patient with a history of liver cirrhosis is admitted with suspected hepatic
encephalopathy. The patient is lethargic and exhibits asterixis. The nurse should anticipate
administering which medication to reduce ammonia levels?
A. Spironolactone
B. Rifaximin
C. Neomycin
D. Lactulose
Correct Answer: D
Explanation: Lactulose is the primary pharmacological treatment for hepatic
encephalopathy as it promotes the excretion of ammonia through the stool. It works by
creating an acidic environment in the bowel that converts ammonia into ammonium, which
is not absorbable. The effectiveness of the medication is monitored by the number of bowel
movements and the patient’s neurological status.
5. A client in the emergent phase of burn care has a potassium level of 6.2 mEq/L and a
sodium level of 130 mEq/L. Which pathophysiological process best explains these laboratory
findings?
A. Cellular destruction and fluid shifting
, B. Renal failure due to myoglobinuria
C. Excessive fluid resuscitation with Ringers Lactate
D. Inadequate aldosterone secretion
Correct Answer: A
Explanation: During the emergent phase of a burn, massive cellular destruction causes the
release of intracellular potassium into the extracellular space, resulting in hyperkalemia.
Simultaneously, increased capillary permeability allows sodium and water to shift from the
vascular space into the interstitial space, leading to hyponatremia. These electrolyte shifts
are characteristic of the first 24 to 48 hours following a major burn injury.
6. A patient with a T4 spinal cord injury reports a severe, throbbing headache and nasal
congestion. The nurse notes the patient is flushed above the level of injury and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer a prescribed PRN antihypertensive.
B. Place the patient in a high-Fowler’s position.
C. Assess the patient for a full bladder or fecal impaction.
D. Notify the rapid response team immediately.
Correct Answer: B
Explanation: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
triggered by noxious stimuli below the level of injury. The immediate priority is to sit the
