NUR 265 Final Exam V1 | NUR 265 Advanced
Concepts of Medical–Surgical Nursing | Actual Q&A
with Rationale (NUR 265 Final Exam) | Galen
1. A 68-year-old male patient, Mr. Rodriguez, is admitted to the ICU with a diagnosis of septic
shock. His blood pressure is 82/44 mmHg, heart rate 126 bpm, and central venous pressure
(CVP) is 3 mmHg. Which of the following interventions should the nurse prioritize first?
A. Administer a 30 mL/kg bolus of 0.9% normal saline.
B. Start a norepinephrine infusion at 5 mcg/min.
C. Obtain blood cultures from two different sites.
D. Insert an indwelling urinary catheter to monitor output.
Correct Answer: A
Explanation: The initial management of septic shock focuses on aggressive fluid
resuscitation to restore intravascular volume and improve tissue perfusion. A low CVP of 3
mmHg indicates a significant fluid volume deficit, making a crystalloid bolus the priority
intervention. Once the patient is fluid-resuscitated, vasopressors like norepinephrine may
be considered if hypotension persists.
2. Ms. Thompson is being treated for Acute Respiratory Distress Syndrome (ARDS). The
ventilator settings include a high Level of Positive End-Expiratory Pressure (PEEP). What is the
primary physiological rationale for using high PEEP in this patient?
A. To increase the fraction of inspired oxygen (FiO2).
,B. To prevent barotrauma by decreasing peak airway pressure.
C. To decrease the patient’s work of breathing.
D. To keep the alveoli open and improve gas exchange.
Correct Answer: D
Explanation: In ARDS, alveoli tend to collapse, leading to significant shunting and
hypoxemia. PEEP provides pressure at the end of expiration to prevent alveolar collapse
and recruit previously closed alveoli, thereby increasing the surface area for gas exchange.
While it helps improve oxygenation, it does not directly change the FiO2 setting or
necessarily decrease peak airway pressures.
3. Mr. Jenkins is admitted with a traumatic brain injury (TBI). His current intracranial pressure
(ICP) is 22 mmHg and his mean arterial pressure (MAP) is 70 mmHg. Which action by the
nurse is most appropriate?
A. Maintain the head of the bed at 10 degrees.
B. Increase the intravenous sedation as prescribed.
C. Perform vigorous endotracheal suctioning every hour.
D. Notify the provider of a low cerebral perfusion pressure (CPP).
Correct Answer: D
Explanation: Cerebral Perfusion Pressure (CPP) is calculated as MAP minus ICP. In this
case, 70 minus 22 equals 48 mmHg, which is below the recommended range of 60-70
,mmHg for TBI patients. Maintaining adequate CPP is critical to prevent secondary brain
injury from ischemia.
4. A 45-year-old female patient, Mrs. Lee, has sustained partial and full-thickness burns to her
entire right arm, her entire chest, and her entire abdomen. Using the Rule of Nines, what is
the estimated total body surface area (TBSA) burned?
A. 27%
B. 18%
C. 36%
D. 45%
Correct Answer: A
Explanation: According to the Rule of Nines, the entire arm is 9%, the entire chest is 9%,
and the entire abdomen is 9%. Summing these values (9 + 9 + 9) results in a total of 27%
TBSA. Accurate calculation of TBSA is vital for determining fluid resuscitation needs using
formulas like the Parkland Formula.
5. Mr. Baker, who has a history of chronic kidney disease (CKD), presents with a serum
potassium level of 6.8 mEq/L and peaked T-waves on the ECG. Which medication should the
nurse expect to administer first to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Calcium gluconate
C. Regular insulin and 50% Dextrose
, D. Furosemide (Lasix)
Correct Answer: B
Explanation: Calcium gluconate is administered in the setting of severe hyperkalemia with
ECG changes to stabilize the myocardial cell membrane. It does not lower the potassium
level but prevents life-threatening arrhythmias while other treatments are initiated to shift
or remove potassium. Insulin and Kayexalate will work later to actually lower the serum
potassium concentration.
6. A patient with a T6 spinal cord injury reports a sudden, throbbing headache and has a
blood pressure of 190/110 mmHg. What should be the nurse’s immediate action?
A. Administer a PRN dose of hydralazine.
B. Assess the patient’s heart rate for tachycardia.
C. Lower the head of the bed to a flat position.
D. Check the patient’s bladder for distension.
Correct Answer: D
Explanation: These symptoms are indicative of autonomic dysreflexia, a medical
emergency occurring in patients with spinal cord injuries at T6 or above. The most
common cause is a noxious stimulus, such as a distended bladder or fecal impaction. The
nurse should immediately sit the patient up and then identify and remove the cause,
starting with the bladder.
Concepts of Medical–Surgical Nursing | Actual Q&A
with Rationale (NUR 265 Final Exam) | Galen
1. A 68-year-old male patient, Mr. Rodriguez, is admitted to the ICU with a diagnosis of septic
shock. His blood pressure is 82/44 mmHg, heart rate 126 bpm, and central venous pressure
(CVP) is 3 mmHg. Which of the following interventions should the nurse prioritize first?
A. Administer a 30 mL/kg bolus of 0.9% normal saline.
B. Start a norepinephrine infusion at 5 mcg/min.
C. Obtain blood cultures from two different sites.
D. Insert an indwelling urinary catheter to monitor output.
Correct Answer: A
Explanation: The initial management of septic shock focuses on aggressive fluid
resuscitation to restore intravascular volume and improve tissue perfusion. A low CVP of 3
mmHg indicates a significant fluid volume deficit, making a crystalloid bolus the priority
intervention. Once the patient is fluid-resuscitated, vasopressors like norepinephrine may
be considered if hypotension persists.
2. Ms. Thompson is being treated for Acute Respiratory Distress Syndrome (ARDS). The
ventilator settings include a high Level of Positive End-Expiratory Pressure (PEEP). What is the
primary physiological rationale for using high PEEP in this patient?
A. To increase the fraction of inspired oxygen (FiO2).
,B. To prevent barotrauma by decreasing peak airway pressure.
C. To decrease the patient’s work of breathing.
D. To keep the alveoli open and improve gas exchange.
Correct Answer: D
Explanation: In ARDS, alveoli tend to collapse, leading to significant shunting and
hypoxemia. PEEP provides pressure at the end of expiration to prevent alveolar collapse
and recruit previously closed alveoli, thereby increasing the surface area for gas exchange.
While it helps improve oxygenation, it does not directly change the FiO2 setting or
necessarily decrease peak airway pressures.
3. Mr. Jenkins is admitted with a traumatic brain injury (TBI). His current intracranial pressure
(ICP) is 22 mmHg and his mean arterial pressure (MAP) is 70 mmHg. Which action by the
nurse is most appropriate?
A. Maintain the head of the bed at 10 degrees.
B. Increase the intravenous sedation as prescribed.
C. Perform vigorous endotracheal suctioning every hour.
D. Notify the provider of a low cerebral perfusion pressure (CPP).
Correct Answer: D
Explanation: Cerebral Perfusion Pressure (CPP) is calculated as MAP minus ICP. In this
case, 70 minus 22 equals 48 mmHg, which is below the recommended range of 60-70
,mmHg for TBI patients. Maintaining adequate CPP is critical to prevent secondary brain
injury from ischemia.
4. A 45-year-old female patient, Mrs. Lee, has sustained partial and full-thickness burns to her
entire right arm, her entire chest, and her entire abdomen. Using the Rule of Nines, what is
the estimated total body surface area (TBSA) burned?
A. 27%
B. 18%
C. 36%
D. 45%
Correct Answer: A
Explanation: According to the Rule of Nines, the entire arm is 9%, the entire chest is 9%,
and the entire abdomen is 9%. Summing these values (9 + 9 + 9) results in a total of 27%
TBSA. Accurate calculation of TBSA is vital for determining fluid resuscitation needs using
formulas like the Parkland Formula.
5. Mr. Baker, who has a history of chronic kidney disease (CKD), presents with a serum
potassium level of 6.8 mEq/L and peaked T-waves on the ECG. Which medication should the
nurse expect to administer first to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Calcium gluconate
C. Regular insulin and 50% Dextrose
, D. Furosemide (Lasix)
Correct Answer: B
Explanation: Calcium gluconate is administered in the setting of severe hyperkalemia with
ECG changes to stabilize the myocardial cell membrane. It does not lower the potassium
level but prevents life-threatening arrhythmias while other treatments are initiated to shift
or remove potassium. Insulin and Kayexalate will work later to actually lower the serum
potassium concentration.
6. A patient with a T6 spinal cord injury reports a sudden, throbbing headache and has a
blood pressure of 190/110 mmHg. What should be the nurse’s immediate action?
A. Administer a PRN dose of hydralazine.
B. Assess the patient’s heart rate for tachycardia.
C. Lower the head of the bed to a flat position.
D. Check the patient’s bladder for distension.
Correct Answer: D
Explanation: These symptoms are indicative of autonomic dysreflexia, a medical
emergency occurring in patients with spinal cord injuries at T6 or above. The most
common cause is a noxious stimulus, such as a distended bladder or fecal impaction. The
nurse should immediately sit the patient up and then identify and remove the cause,
starting with the bladder.
