NUR 242 Med-Surg Nursing Exam 3 Galen College 2026/2027 -
Questions and Answers 100% Verified Detailed Rationales -
Pass Guaranteed - A+ Graded
NUR 242 Medical-Surgical Nursing Exam 3 is a Galen College of Nursing unit exam assessing clinical judgment
across adult health disorders, with emphasis on perioperative care, cardiovascular and hematologic emergencies,
respiratory failure, neurologic dysfunction, renal/GI/endocrine imbalances, and oncologic emergencies.
Questions align with the NCSBN Clinical Judgment Measurement Model and 2026 NCLEX-RN Test Plan,
requiring multi-step analysis, priority setting, and evidence-based decision-making. It contains 98 multiple-choice
questions, each with four distractors and a fully worked rationale that explains why the keyed answer is correct.
Questions are organized into clearly labelled sections that mirror the major content areas of the course. Targeted
learning outcomes include: Apply the NCSBN Clinical Judgment Measurement Model to prioritize assessment and
intervention in complex medical-surgical scenarios.; Analyze laboratory, hemodynamic, and diagnostic data to
identify life-threatening complications and evaluate treatment response.; Synthesize evidence-based guidelines
(AHA, AACN, CDC, KDIGO, Surviving Sepsis) to formulate safe nursing and interprofessional management
plans.. Every item has been reviewed for clinical accuracy, current guidelines, and clarity so that students can
study with confidence and self-correct as they work through the bank. Use it as a high-yield review immediately
before the exam, or as a structured practice tool during the unit - the rationales double as concise teaching notes.
The recommended writing time is 2 hours, with a passing score of 75% (minimum 38/50 correct). Aligned with
Section 1: General (Questions 1-98)
1 Which assessment finding most specifically indicates impending local anesthetic
systemic toxicity after peripheral nerve block?
A) Circumoral paresthesia with metallic taste and tinnitus
B) Hypertension with reflex tachycardia and diaphoresis
C) Bradycardia with warm flushed extremities
D) Localized erythema at the injection site
Answer: A
Rationale: Local anesthetic systemic toxicity (LAST) classically begins with CNS
excitation signs-perioral numbness, metallic taste, and tinnitus-before progressing to
seizures and cardiovascular collapse. Hypertension/tachycardia are nonspecific
sympathetic responses, bradycardia with flushing suggests anaphylaxis or vasovagal
response, and local erythema is an expected injection-site finding. Early recognition
of neurologic prodromes is critical because lipid emulsion therapy must be initiated
before cardiovascular decompensation.
2 Which ECG change most reliably signals hyperkalemia-induced cardiac
membrane instability in acute kidney injury?
A) Peaked T waves with widened QRS and flattened P waves
B) Prominent U waves with ST depression
C) ST elevation in contiguous leads with reciprocal changes
,D) Prolonged QT interval with torsades risk
Answer: A
Rationale: Hyperkalemia produces progressive conduction slowing: tall peaked T
waves, PR prolongation, P-wave flattening, and QRS widening that can degenerate
into a sine-wave pattern and ventricular fibrillation. U waves with ST depression
reflect hypokalemia, ST elevation with reciprocal change indicates STEMI, and QT
prolongation with torsades is characteristic of hypokalemia or hypomagnesemia.
Recognizing the peaked-T-to-widened-QRS progression drives emergent calcium
and insulin-dextrose administration.
3 Which intervention takes priority for a patient with acute respiratory distress
syndrome exhibiting plateau pressure 36 cm H2O?
A) Reduce tidal volume to 4-6 mL/kg predicted body weight
B) Increase PEEP to 20 cm H2O to recruit alveoli
C) Administer a 500-mL normal saline fluid bolus
D) Place in high-Fowler's and increase tidal volume
Answer: A
Rationale: Lung-protective ventilation targeting tidal volumes of 4–6 mL/kg
predicted body weight and plateau pressures 30 cm H2O reduces ventilator-induced
lung injury and mortality in ARDS. Increasing PEEP to 20 cm H2O risks
barotrauma and hemodynamic compromise without proven mortality benefit, fluid
boluses worsen pulmonary edema in the permeability phase, and increasing tidal
volume compounds volutrauma. The elevated plateau pressure signals alveolar
overdistension requiring immediate tidal volume reduction.
4 Which finding best differentiates myasthenic crisis from cholinergic crisis in a
patient on pyridostigmine?
A) Worsening weakness with increased secretions and miosis after dose
B) Improved strength after edrophonium with no muscarinic symptoms
C) Unilateral ptosis with spared respiratory muscles
D) Ascending symmetric paralysis with areflexia
Answer: A
Rationale: Cholinergic crisis results from excessive acetylcholinesterase inhibition,
producing worsening weakness plus muscarinic excess-secretions, miosis,
bradycardia, and diarrhea-that worsens after medication; myasthenic crisis improves
with additional cholinesterase inhibitor. Edrophonium improvement without
muscarinic signs suggests myasthenic crisis, unilateral ptosis suggests a structural
lesion, and ascending areflexic paralysis describes Guillain-Barré syndrome.
,Distinguishing these crises dictates whether pyridostigmine is held or given.
5 Which parameter best guides fluid resuscitation in sepsis-induced hypoperfusion
per Surviving Sepsis Campaign 2024?
A) Serum lactate clearance combined with capillary refill time
B) Central venous pressure target of 12 mm Hg
C) Urine output alone at 0.3 mL/kg/hr
D) Mean arterial pressure of 55 mm Hg
Answer: A
Rationale: Current Surviving Sepsis Campaign guidance emphasizes dynamic
measures-lactate clearance and capillary refill time-over static CVP targets, which
poorly predict fluid responsiveness. Urine output <0.5 mL/kg/hr suggests
hypoperfusion but is a lagging indicator, and an MAP target of 65 mm Hg (not 55)
is standard. Lactate normalization within 2-4 hours correlates with improved
outcomes and guides resuscitation endpoints.
6 Which manifestation most specifically indicates tumor lysis syndrome within 24
hours of chemotherapy initiation?
A) Hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia
B) Hypernatremia with hyperchloremic metabolic acidosis
C) Hypokalemia with hypophosphatemia and hypercalcemia
D) Hypoglycemia with lactic acidosis and ketonuria
Answer: A
Rationale: Tumor lysis syndrome results from rapid malignant cell breakdown
releasing intracellular contents, producing the classic tetrad of hyperkalemia,
hyperuricemia, hyperphosphatemia, and secondary hypocalcemia that can precipitate
acute kidney injury and dysrhythmias. The other electrolyte patterns do not match
TLS pathophysiology; hypokalemia/hypophosphatemia suggest refeeding syndrome,
and hypoglycemia with ketonuria suggests metabolic derangement unrelated to TLS.
Prophylactic allopurinol or rasburicase plus aggressive hydration is the cornerstone
of prevention.
7 Which finding most strongly suggests upper GI bleeding rather than lower GI
bleeding?
A) Elevated BUN-to-creatinine ratio with hematemesis
B) Bright red blood per rectum with normal BUN
C) Positive fecal occult blood with iron deficiency
D) Hematochezia with hemodynamic stability
, Answer: A
Rationale: Upper GI bleeding often produces hematemesis and an elevated
BUN-to-creatinine ratio >30:1 due to absorbed blood protein, whereas lower GI
bleeding typically presents with hematochezia and a normal BUN. Occult blood
with iron deficiency suggests chronic slow loss, not acute localization. Recognizing
this pattern guides urgency of endoscopy versus colonoscopy.
8 Which arterial blood gas pattern indicates compensated respiratory acidosis in
advanced COPD?
A) pH 7.36, PaCO2 58, HCO3 32
B) pH 7.48, PaCO2 30, HCO3 22
C) pH 7.30, PaCO2 50, HCO3 24
D) pH 7.28, PaCO2 30, HCO3 14
Answer: A
Rationale: Compensated respiratory acidosis shows a near-normal pH with elevated
PaCO2 and a compensatory elevated bicarbonate from renal retention. Option B
represents respiratory alkalosis, C is uncompensated respiratory acidosis, and D is
metabolic acidosis with respiratory compensation. Chronic CO2 retention in COPD
should be managed with controlled oxygen targeting SpO2 88-92% to avoid losing
hypoxic drive.
9 Which laboratory trend most strongly predicts impending acute kidney injury after
major abdominal surgery?
A) Rising creatinine with oliguria unresponsive to fluid challenge
B) Transient hemoglobin drop with stable urine output
C) Elevated BUN with normal creatinine and urine output
D) Isolated hyperkalemia with preserved glomerular filtration
Answer: A
Rationale: AKI diagnosis per KDIGO requires a creatinine rise "e0.3 mg/dL within 48
hours or 1.5× baseline within 7 days, often accompanied by oliguria <0.5 mL/kg/hr
unresponsive to volume. Isolated hemoglobin drops or BUN elevation with normal
creatinine do not meet criteria, and isolated hyperkalemia may reflect nonrenal
causes. Early recognition triggers nephrology consultation and avoidance of
nephrotoxins.
10 Which action is most appropriate when a patient with a new below-knee cast
reports unrelieved pain and numbness?
A) Notify the provider immediately and prepare for cast bivalving
Questions and Answers 100% Verified Detailed Rationales -
Pass Guaranteed - A+ Graded
NUR 242 Medical-Surgical Nursing Exam 3 is a Galen College of Nursing unit exam assessing clinical judgment
across adult health disorders, with emphasis on perioperative care, cardiovascular and hematologic emergencies,
respiratory failure, neurologic dysfunction, renal/GI/endocrine imbalances, and oncologic emergencies.
Questions align with the NCSBN Clinical Judgment Measurement Model and 2026 NCLEX-RN Test Plan,
requiring multi-step analysis, priority setting, and evidence-based decision-making. It contains 98 multiple-choice
questions, each with four distractors and a fully worked rationale that explains why the keyed answer is correct.
Questions are organized into clearly labelled sections that mirror the major content areas of the course. Targeted
learning outcomes include: Apply the NCSBN Clinical Judgment Measurement Model to prioritize assessment and
intervention in complex medical-surgical scenarios.; Analyze laboratory, hemodynamic, and diagnostic data to
identify life-threatening complications and evaluate treatment response.; Synthesize evidence-based guidelines
(AHA, AACN, CDC, KDIGO, Surviving Sepsis) to formulate safe nursing and interprofessional management
plans.. Every item has been reviewed for clinical accuracy, current guidelines, and clarity so that students can
study with confidence and self-correct as they work through the bank. Use it as a high-yield review immediately
before the exam, or as a structured practice tool during the unit - the rationales double as concise teaching notes.
The recommended writing time is 2 hours, with a passing score of 75% (minimum 38/50 correct). Aligned with
Section 1: General (Questions 1-98)
1 Which assessment finding most specifically indicates impending local anesthetic
systemic toxicity after peripheral nerve block?
A) Circumoral paresthesia with metallic taste and tinnitus
B) Hypertension with reflex tachycardia and diaphoresis
C) Bradycardia with warm flushed extremities
D) Localized erythema at the injection site
Answer: A
Rationale: Local anesthetic systemic toxicity (LAST) classically begins with CNS
excitation signs-perioral numbness, metallic taste, and tinnitus-before progressing to
seizures and cardiovascular collapse. Hypertension/tachycardia are nonspecific
sympathetic responses, bradycardia with flushing suggests anaphylaxis or vasovagal
response, and local erythema is an expected injection-site finding. Early recognition
of neurologic prodromes is critical because lipid emulsion therapy must be initiated
before cardiovascular decompensation.
2 Which ECG change most reliably signals hyperkalemia-induced cardiac
membrane instability in acute kidney injury?
A) Peaked T waves with widened QRS and flattened P waves
B) Prominent U waves with ST depression
C) ST elevation in contiguous leads with reciprocal changes
,D) Prolonged QT interval with torsades risk
Answer: A
Rationale: Hyperkalemia produces progressive conduction slowing: tall peaked T
waves, PR prolongation, P-wave flattening, and QRS widening that can degenerate
into a sine-wave pattern and ventricular fibrillation. U waves with ST depression
reflect hypokalemia, ST elevation with reciprocal change indicates STEMI, and QT
prolongation with torsades is characteristic of hypokalemia or hypomagnesemia.
Recognizing the peaked-T-to-widened-QRS progression drives emergent calcium
and insulin-dextrose administration.
3 Which intervention takes priority for a patient with acute respiratory distress
syndrome exhibiting plateau pressure 36 cm H2O?
A) Reduce tidal volume to 4-6 mL/kg predicted body weight
B) Increase PEEP to 20 cm H2O to recruit alveoli
C) Administer a 500-mL normal saline fluid bolus
D) Place in high-Fowler's and increase tidal volume
Answer: A
Rationale: Lung-protective ventilation targeting tidal volumes of 4–6 mL/kg
predicted body weight and plateau pressures 30 cm H2O reduces ventilator-induced
lung injury and mortality in ARDS. Increasing PEEP to 20 cm H2O risks
barotrauma and hemodynamic compromise without proven mortality benefit, fluid
boluses worsen pulmonary edema in the permeability phase, and increasing tidal
volume compounds volutrauma. The elevated plateau pressure signals alveolar
overdistension requiring immediate tidal volume reduction.
4 Which finding best differentiates myasthenic crisis from cholinergic crisis in a
patient on pyridostigmine?
A) Worsening weakness with increased secretions and miosis after dose
B) Improved strength after edrophonium with no muscarinic symptoms
C) Unilateral ptosis with spared respiratory muscles
D) Ascending symmetric paralysis with areflexia
Answer: A
Rationale: Cholinergic crisis results from excessive acetylcholinesterase inhibition,
producing worsening weakness plus muscarinic excess-secretions, miosis,
bradycardia, and diarrhea-that worsens after medication; myasthenic crisis improves
with additional cholinesterase inhibitor. Edrophonium improvement without
muscarinic signs suggests myasthenic crisis, unilateral ptosis suggests a structural
lesion, and ascending areflexic paralysis describes Guillain-Barré syndrome.
,Distinguishing these crises dictates whether pyridostigmine is held or given.
5 Which parameter best guides fluid resuscitation in sepsis-induced hypoperfusion
per Surviving Sepsis Campaign 2024?
A) Serum lactate clearance combined with capillary refill time
B) Central venous pressure target of 12 mm Hg
C) Urine output alone at 0.3 mL/kg/hr
D) Mean arterial pressure of 55 mm Hg
Answer: A
Rationale: Current Surviving Sepsis Campaign guidance emphasizes dynamic
measures-lactate clearance and capillary refill time-over static CVP targets, which
poorly predict fluid responsiveness. Urine output <0.5 mL/kg/hr suggests
hypoperfusion but is a lagging indicator, and an MAP target of 65 mm Hg (not 55)
is standard. Lactate normalization within 2-4 hours correlates with improved
outcomes and guides resuscitation endpoints.
6 Which manifestation most specifically indicates tumor lysis syndrome within 24
hours of chemotherapy initiation?
A) Hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia
B) Hypernatremia with hyperchloremic metabolic acidosis
C) Hypokalemia with hypophosphatemia and hypercalcemia
D) Hypoglycemia with lactic acidosis and ketonuria
Answer: A
Rationale: Tumor lysis syndrome results from rapid malignant cell breakdown
releasing intracellular contents, producing the classic tetrad of hyperkalemia,
hyperuricemia, hyperphosphatemia, and secondary hypocalcemia that can precipitate
acute kidney injury and dysrhythmias. The other electrolyte patterns do not match
TLS pathophysiology; hypokalemia/hypophosphatemia suggest refeeding syndrome,
and hypoglycemia with ketonuria suggests metabolic derangement unrelated to TLS.
Prophylactic allopurinol or rasburicase plus aggressive hydration is the cornerstone
of prevention.
7 Which finding most strongly suggests upper GI bleeding rather than lower GI
bleeding?
A) Elevated BUN-to-creatinine ratio with hematemesis
B) Bright red blood per rectum with normal BUN
C) Positive fecal occult blood with iron deficiency
D) Hematochezia with hemodynamic stability
, Answer: A
Rationale: Upper GI bleeding often produces hematemesis and an elevated
BUN-to-creatinine ratio >30:1 due to absorbed blood protein, whereas lower GI
bleeding typically presents with hematochezia and a normal BUN. Occult blood
with iron deficiency suggests chronic slow loss, not acute localization. Recognizing
this pattern guides urgency of endoscopy versus colonoscopy.
8 Which arterial blood gas pattern indicates compensated respiratory acidosis in
advanced COPD?
A) pH 7.36, PaCO2 58, HCO3 32
B) pH 7.48, PaCO2 30, HCO3 22
C) pH 7.30, PaCO2 50, HCO3 24
D) pH 7.28, PaCO2 30, HCO3 14
Answer: A
Rationale: Compensated respiratory acidosis shows a near-normal pH with elevated
PaCO2 and a compensatory elevated bicarbonate from renal retention. Option B
represents respiratory alkalosis, C is uncompensated respiratory acidosis, and D is
metabolic acidosis with respiratory compensation. Chronic CO2 retention in COPD
should be managed with controlled oxygen targeting SpO2 88-92% to avoid losing
hypoxic drive.
9 Which laboratory trend most strongly predicts impending acute kidney injury after
major abdominal surgery?
A) Rising creatinine with oliguria unresponsive to fluid challenge
B) Transient hemoglobin drop with stable urine output
C) Elevated BUN with normal creatinine and urine output
D) Isolated hyperkalemia with preserved glomerular filtration
Answer: A
Rationale: AKI diagnosis per KDIGO requires a creatinine rise "e0.3 mg/dL within 48
hours or 1.5× baseline within 7 days, often accompanied by oliguria <0.5 mL/kg/hr
unresponsive to volume. Isolated hemoglobin drops or BUN elevation with normal
creatinine do not meet criteria, and isolated hyperkalemia may reflect nonrenal
causes. Early recognition triggers nephrology consultation and avoidance of
nephrotoxins.
10 Which action is most appropriate when a patient with a new below-knee cast
reports unrelieved pain and numbness?
A) Notify the provider immediately and prepare for cast bivalving
