NUR 265 Exam 2 V1 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 2) |
Galen
1. A 24-year-old male with Type 1 Diabetes is admitted to the ICU with Diabetic Ketoacidosis
(DKA). His initial labs show a glucose of 580 mg/dL, pH 7.20, and a potassium level of 3.3
mEq/L. Which provider order should the nurse prioritize first?
A. Initiate a Regular Insulin drip at 0.1 units/kg/hr
B. Administer 40 mEq of Potassium Chloride IV piggyback
C. Administer a 1-liter bolus of 0.9% Normal Saline
D. Obtain an arterial blood gas (ABG) every 2 hours
Answer: C
Rationale: In the management of DKA, the immediate priority is fluid resuscitation to
restore circulatory volume and renal perfusion. While insulin is necessary to correct the
acidosis, it should be delayed if the potassium is dangerously low or until initial volume is
replaced. Following the bolus, potassium replacement often takes precedence over insulin
because insulin will further shift potassium into the cells, potentially causing life-
threatening arrhythmias.
2. A patient with a history of cirrhosis is admitted with suspected Hepatic Encephalopathy.
The nurse notes the patient is confused and has a flapping tremor of the hands. Which
medication does the nurse anticipate administering to reduce the serum ammonia level?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
Answer: C
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it promotes
the excretion of ammonia via the stool. It works by creating an acidic environment in the
bowel that converts ammonia to ammonium, which is non-absorbable. The nurse should
monitor for 2-3 soft stools per day to evaluate the effectiveness of the therapy.
3. A patient is being treated for Acute Kidney Injury (AKI) and enters the diuretic phase.
Which clinical manifestation is the nurse’s primary concern during this phase?
A. Hypervolemia and pulmonary edema
B. Hypovolemia and electrolyte imbalances
,C. Metabolic acidosis and Kussmaul respirations
D. Elevated serum creatinine and BUN
Answer: B
Rationale: The diuretic phase of AKI is characterized by a high volume of urine output
because the nephrons are not yet fully functional at concentrating urine. This puts the
patient at significant risk for dehydration, hypovolemia, and the loss of electrolytes such as
sodium and potassium. Nursing care must focus on strict intake and output, daily weights,
and monitoring blood pressure.
4. An adult patient sustained partial and full-thickness burns to the entire left arm and the
anterior trunk. Using the Rule of Nines, what is the estimated Total Body Surface Area (TBSA)
affected?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Rationale: According to the Rule of Nines, the entire arm accounts for 9% and the anterior
trunk accounts for 18%. Adding 9% and 18% results in a total of 27% TBSA. Accurate
calculation of TBSA is critical for determining the appropriate volume for fluid
resuscitation using the Parkland formula.
5. A patient with Small Cell Lung Cancer develops Syndrome of Inappropriate Antidiuretic
Hormone (SIADH). Which laboratory finding is most consistent with this diagnosis?
A. Serum Osmolality 310 mOsm/kg
B. Serum Sodium 122 mEq/L
C. Urine Specific Gravity 1.002
D. Hematocrit 55%
Answer: B
Rationale: SIADH results in excessive water retention, which causes dilutional
hyponatremia; therefore, a serum sodium of 122 mEq/L is a hallmark finding. In contrast
to Diabetes Insipidus, SIADH presents with low serum osmolality and high urine specific
gravity. Management focuses on fluid restriction and, in severe cases, the administration of
hypertonic saline.
, 6. Which assessment finding in a patient with an Arteriovenous (AV) Fistula in the left arm
requires immediate notification to the provider?
A. A palpable thrill over the site
B. An audible bruit upon auscultation
C. Absence of a radial pulse in the left arm
D. Small amount of bruising at the needle puncture site
Answer: C
Rationale: The absence of a distal pulse or a change in the neurovascular status of the
extremity indicates potential ‘steal syndrome’ or thrombosis, which is a surgical
emergency. Normal findings for a functional AV fistula include a palpable thrill and an
audible bruit. The nurse must also ensure that no blood pressures or venipunctures are
performed on the affected arm to protect the access.
7. A patient is admitted in Septic Shock. The nurse notes the patient’s blood pressure is 82/40
mmHg, heart rate is 124 bpm, and the serum lactate is 5.2 mmol/L. What is the priority
nursing intervention?
A. Administer 30 mL/kg of IV crystalloids
B. Start a Norepinephrine infusion
C. Obtain blood cultures x 2
D. Administer broad-spectrum antibiotics
Answer: A
Rationale: The Surviving Sepsis Bundle mandates that for hypotension or a lactate level >
4 mmol/L, a rapid bolus of 30 mL/kg of crystalloid fluid should be initiated. While cultures
and antibiotics are essential, restoring perfusion via volume is the immediate priority.
Vasopressors like norepinephrine are indicated only if the patient remains hypotensive
after adequate fluid resuscitation.
8. A patient with Acute Pancreatitis is being monitored for complications. The nurse notes a
positive Trousseau’s sign. Which electrolyte imbalance does this indicate?
A. Hypokalemia
B. Hypermagnesemia
C. Hypernatremia
D. Hypocalcemia
Answer: D
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 2) |
Galen
1. A 24-year-old male with Type 1 Diabetes is admitted to the ICU with Diabetic Ketoacidosis
(DKA). His initial labs show a glucose of 580 mg/dL, pH 7.20, and a potassium level of 3.3
mEq/L. Which provider order should the nurse prioritize first?
A. Initiate a Regular Insulin drip at 0.1 units/kg/hr
B. Administer 40 mEq of Potassium Chloride IV piggyback
C. Administer a 1-liter bolus of 0.9% Normal Saline
D. Obtain an arterial blood gas (ABG) every 2 hours
Answer: C
Rationale: In the management of DKA, the immediate priority is fluid resuscitation to
restore circulatory volume and renal perfusion. While insulin is necessary to correct the
acidosis, it should be delayed if the potassium is dangerously low or until initial volume is
replaced. Following the bolus, potassium replacement often takes precedence over insulin
because insulin will further shift potassium into the cells, potentially causing life-
threatening arrhythmias.
2. A patient with a history of cirrhosis is admitted with suspected Hepatic Encephalopathy.
The nurse notes the patient is confused and has a flapping tremor of the hands. Which
medication does the nurse anticipate administering to reduce the serum ammonia level?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
Answer: C
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it promotes
the excretion of ammonia via the stool. It works by creating an acidic environment in the
bowel that converts ammonia to ammonium, which is non-absorbable. The nurse should
monitor for 2-3 soft stools per day to evaluate the effectiveness of the therapy.
3. A patient is being treated for Acute Kidney Injury (AKI) and enters the diuretic phase.
Which clinical manifestation is the nurse’s primary concern during this phase?
A. Hypervolemia and pulmonary edema
B. Hypovolemia and electrolyte imbalances
,C. Metabolic acidosis and Kussmaul respirations
D. Elevated serum creatinine and BUN
Answer: B
Rationale: The diuretic phase of AKI is characterized by a high volume of urine output
because the nephrons are not yet fully functional at concentrating urine. This puts the
patient at significant risk for dehydration, hypovolemia, and the loss of electrolytes such as
sodium and potassium. Nursing care must focus on strict intake and output, daily weights,
and monitoring blood pressure.
4. An adult patient sustained partial and full-thickness burns to the entire left arm and the
anterior trunk. Using the Rule of Nines, what is the estimated Total Body Surface Area (TBSA)
affected?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Rationale: According to the Rule of Nines, the entire arm accounts for 9% and the anterior
trunk accounts for 18%. Adding 9% and 18% results in a total of 27% TBSA. Accurate
calculation of TBSA is critical for determining the appropriate volume for fluid
resuscitation using the Parkland formula.
5. A patient with Small Cell Lung Cancer develops Syndrome of Inappropriate Antidiuretic
Hormone (SIADH). Which laboratory finding is most consistent with this diagnosis?
A. Serum Osmolality 310 mOsm/kg
B. Serum Sodium 122 mEq/L
C. Urine Specific Gravity 1.002
D. Hematocrit 55%
Answer: B
Rationale: SIADH results in excessive water retention, which causes dilutional
hyponatremia; therefore, a serum sodium of 122 mEq/L is a hallmark finding. In contrast
to Diabetes Insipidus, SIADH presents with low serum osmolality and high urine specific
gravity. Management focuses on fluid restriction and, in severe cases, the administration of
hypertonic saline.
, 6. Which assessment finding in a patient with an Arteriovenous (AV) Fistula in the left arm
requires immediate notification to the provider?
A. A palpable thrill over the site
B. An audible bruit upon auscultation
C. Absence of a radial pulse in the left arm
D. Small amount of bruising at the needle puncture site
Answer: C
Rationale: The absence of a distal pulse or a change in the neurovascular status of the
extremity indicates potential ‘steal syndrome’ or thrombosis, which is a surgical
emergency. Normal findings for a functional AV fistula include a palpable thrill and an
audible bruit. The nurse must also ensure that no blood pressures or venipunctures are
performed on the affected arm to protect the access.
7. A patient is admitted in Septic Shock. The nurse notes the patient’s blood pressure is 82/40
mmHg, heart rate is 124 bpm, and the serum lactate is 5.2 mmol/L. What is the priority
nursing intervention?
A. Administer 30 mL/kg of IV crystalloids
B. Start a Norepinephrine infusion
C. Obtain blood cultures x 2
D. Administer broad-spectrum antibiotics
Answer: A
Rationale: The Surviving Sepsis Bundle mandates that for hypotension or a lactate level >
4 mmol/L, a rapid bolus of 30 mL/kg of crystalloid fluid should be initiated. While cultures
and antibiotics are essential, restoring perfusion via volume is the immediate priority.
Vasopressors like norepinephrine are indicated only if the patient remains hypotensive
after adequate fluid resuscitation.
8. A patient with Acute Pancreatitis is being monitored for complications. The nurse notes a
positive Trousseau’s sign. Which electrolyte imbalance does this indicate?
A. Hypokalemia
B. Hypermagnesemia
C. Hypernatremia
D. Hypocalcemia
Answer: D
