NUR 265 Exam 4 V3 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. A 62-year-old male patient with a history of heart failure is admitted to the ICU with a
diagnosis of cardiogenic shock. The nurse notes a pulmonary artery occlusion pressure
(PAOP) of 22 mmHg and a cardiac index of 1.8 L/min/m². Which medication order should the
nurse prioritize?
A. 0.9% Normal Saline bolus 500 mL
B. Furosemide 40 mg IV push
C. Dobutamine infusion at 5 mcg/kg/min
D. Norepinephrine infusion at 0.1 mcg/kg/min
Correct Answer: C
Explanation: In cardiogenic shock, the heart fails to pump effectively, resulting in a low
cardiac index and elevated PAOP due to fluid backing up. Dobutamine is an inotropic agent
that increases myocardial contractility and cardiac output, which is the primary goal of
treatment. Normal saline would worsen the fluid overload, and while diuretics may be used
later, increasing pump efficiency is the priority.
,2. Following a multi-vehicle accident, a 28-year-old female is brought to the Emergency
Department. She has paradoxical chest wall movement and is in respiratory distress. The
nurse suspects a flail chest. What is the priority nursing action?
A. Prepare for immediate chest tube insertion
B. Administer intravenous morphine for pain control
C. Provide supplemental oxygen and prepare for intubation
D. Apply a pressure dressing to the affected side
Correct Answer: C
Explanation: Flail chest occurs when multiple ribs are fractured in two or more places,
causing the segment to move independently. This leads to severe respiratory compromise
and hypoxemia. The priority is to ensure adequate oxygenation and ventilation, often
requiring positive pressure ventilation to stabilize the chest wall. Pain control and chest
tubes are secondary to airway and ventilation management.
3. A patient in the hypermetabolic phase of a major burn injury (45% Total Body Surface
Area) requires nutritional support. Which dietary prescription should the nurse expect to
implement?
A. Low-sodium, fluid-restricted diet
B. High-calorie, high-protein diet
C. Low-carbohydrate, high-fat diet
D. Standard 2,000 calorie diet
,Correct Answer: B
Explanation: Major burn injuries trigger a massive hypermetabolic state that can double
the patient’s resting energy expenditure. A high-protein diet is essential to promote wound
healing and prevent the breakdown of lean body mass. High-calorie intake is necessary to
meet the increased energy demands during the long recovery process.
4. The nurse is caring for a patient who was rescued from a burning house and presents with
soot around the nose, singed nasal hairs, and a hoarse voice. What is the most critical
complication for which the nurse must monitor?
A. Hypovolemic shock
B. Carbon monoxide poisoning
C. Upper airway edema and obstruction
D. Systemic infection
Correct Answer: C
Explanation: Singed nasal hairs and soot in the airway are classic signs of inhalation injury
above the glottis. This can lead to rapid onset of laryngeal edema and complete airway
obstruction within minutes to hours. The nurse must prioritize monitoring the airway and
prepare for early intubation before the edema makes it impossible.
, 5. During a mass casualty incident, a nurse is performing triage using the START (Simple
Triage and Rapid Treatment) method. A victim is found who is not breathing; after
repositioning the airway, the victim remains apneic. Which color tag should the nurse assign?
A. Red
B. Yellow
C. Black
D. Green
Correct Answer: C
Explanation: According to the START triage protocol, if a patient is not breathing, the
nurse should attempt to open the airway once. If the patient does not begin breathing after
this maneuver, they are classified as deceased or expectant and given a black tag. This
allows resources to be focused on victims who have a chance of survival.
6. A patient with Acute Respiratory Distress Syndrome (ARDS) is being ventilated with a PEEP
of 15 cm H2O. The nurse notes a sudden drop in blood pressure and absent breath sounds on
the right side. What is the most likely cause?
A. Endotracheal tube displacement
B. Right-sided heart failure
C. Tension pneumothorax
D. Pulmonary embolism
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. A 62-year-old male patient with a history of heart failure is admitted to the ICU with a
diagnosis of cardiogenic shock. The nurse notes a pulmonary artery occlusion pressure
(PAOP) of 22 mmHg and a cardiac index of 1.8 L/min/m². Which medication order should the
nurse prioritize?
A. 0.9% Normal Saline bolus 500 mL
B. Furosemide 40 mg IV push
C. Dobutamine infusion at 5 mcg/kg/min
D. Norepinephrine infusion at 0.1 mcg/kg/min
Correct Answer: C
Explanation: In cardiogenic shock, the heart fails to pump effectively, resulting in a low
cardiac index and elevated PAOP due to fluid backing up. Dobutamine is an inotropic agent
that increases myocardial contractility and cardiac output, which is the primary goal of
treatment. Normal saline would worsen the fluid overload, and while diuretics may be used
later, increasing pump efficiency is the priority.
,2. Following a multi-vehicle accident, a 28-year-old female is brought to the Emergency
Department. She has paradoxical chest wall movement and is in respiratory distress. The
nurse suspects a flail chest. What is the priority nursing action?
A. Prepare for immediate chest tube insertion
B. Administer intravenous morphine for pain control
C. Provide supplemental oxygen and prepare for intubation
D. Apply a pressure dressing to the affected side
Correct Answer: C
Explanation: Flail chest occurs when multiple ribs are fractured in two or more places,
causing the segment to move independently. This leads to severe respiratory compromise
and hypoxemia. The priority is to ensure adequate oxygenation and ventilation, often
requiring positive pressure ventilation to stabilize the chest wall. Pain control and chest
tubes are secondary to airway and ventilation management.
3. A patient in the hypermetabolic phase of a major burn injury (45% Total Body Surface
Area) requires nutritional support. Which dietary prescription should the nurse expect to
implement?
A. Low-sodium, fluid-restricted diet
B. High-calorie, high-protein diet
C. Low-carbohydrate, high-fat diet
D. Standard 2,000 calorie diet
,Correct Answer: B
Explanation: Major burn injuries trigger a massive hypermetabolic state that can double
the patient’s resting energy expenditure. A high-protein diet is essential to promote wound
healing and prevent the breakdown of lean body mass. High-calorie intake is necessary to
meet the increased energy demands during the long recovery process.
4. The nurse is caring for a patient who was rescued from a burning house and presents with
soot around the nose, singed nasal hairs, and a hoarse voice. What is the most critical
complication for which the nurse must monitor?
A. Hypovolemic shock
B. Carbon monoxide poisoning
C. Upper airway edema and obstruction
D. Systemic infection
Correct Answer: C
Explanation: Singed nasal hairs and soot in the airway are classic signs of inhalation injury
above the glottis. This can lead to rapid onset of laryngeal edema and complete airway
obstruction within minutes to hours. The nurse must prioritize monitoring the airway and
prepare for early intubation before the edema makes it impossible.
, 5. During a mass casualty incident, a nurse is performing triage using the START (Simple
Triage and Rapid Treatment) method. A victim is found who is not breathing; after
repositioning the airway, the victim remains apneic. Which color tag should the nurse assign?
A. Red
B. Yellow
C. Black
D. Green
Correct Answer: C
Explanation: According to the START triage protocol, if a patient is not breathing, the
nurse should attempt to open the airway once. If the patient does not begin breathing after
this maneuver, they are classified as deceased or expectant and given a black tag. This
allows resources to be focused on victims who have a chance of survival.
6. A patient with Acute Respiratory Distress Syndrome (ARDS) is being ventilated with a PEEP
of 15 cm H2O. The nurse notes a sudden drop in blood pressure and absent breath sounds on
the right side. What is the most likely cause?
A. Endotracheal tube displacement
B. Right-sided heart failure
C. Tension pneumothorax
D. Pulmonary embolism
