NUR 425 Exam 1: Medical Surgical V2 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient is admitted with septic shock. Which of the following findings should the nurse prioritize as an
indicator of worsening condition?
A. Hyperactive bowel sounds
B. Blood pressure of 110/70 mmHg
C. WBC count of 11,000/mm3
D. Serum lactate level of 4.5 mmol/L
Ans: D
Explanation: Septic shock is characterized by cellular hypoxia and metabolic derangement. A serum
lactate level above 2 mmol/L indicates anaerobic metabolism due to inadequate tissue perfusion. While a
WBC count is important, it does not provide as immediate a picture of cellular dysfunction as lactate.
Maintaining a blood pressure within normal limits is a goal, but high lactate despite this suggests occult
shock. Monitoring these levels helps the nurse evaluate the effectiveness of fluid resuscitation and
oxygenation strategies.
2. When calculating the Parkland formula for a patient with burns, what is the significance of the first 8
hours of fluid resuscitation?
A. Administering 50% of the total calculated volume
B. Administering 100% of the total calculated volume
C. Administering 25% of the total calculated volume
D. Administering 75% of the total calculated volume
,Ans: A
Explanation: The Parkland formula dictates that half of the total 24-hour fluid requirement should be
given within the first 8 hours following the burn injury. This rapid infusion is critical to counteract the
massive fluid shifts and plasma loss occurring in the emergent phase. The remaining 50% is distributed
over the subsequent 16 hours to maintain hemodynamic stability. Failure to provide adequate early
volume can lead to hypovolemic shock and acute kidney injury. The nurse must track urine output closely
to ensure the calculated rate meets the patient’s physiological needs.
3. A nurse is caring for a patient in the emergent phase of a burn injury. Which electrolyte imbalance is most
commonly expected during this period?
A. Hypernatremia
B. Hypokalemia
C. Hyperkalemia
D. Hypocalcemia
Ans: C
Explanation: In the emergent phase of a burn, massive cell destruction causes the release of intracellular
potassium into the extracellular space. This results in hyperkalemia, which poses a significant risk for
cardiac dysrhythmias. Conversely, sodium is often lost through the damaged skin or moves into the
interstitial space, leading to hyponatremia. The nurse must monitor the EKG for peaked T waves which
signal dangerously high potassium levels. Correction of this imbalance is a priority to prevent cardiac
arrest in the early stages of trauma.
4. A patient is suspected of having a Pulmonary Embolism (PE). Which diagnostic test is considered the gold
standard for confirming this diagnosis?
A. Chest X-ray
, B. Electrocardiogram (ECG)
C. D-dimer assay
D. Spiral Computed Tomography (CT) Angiography
Ans: D
Explanation: Spiral CT Angiography is the most sensitive and specific non-invasive test for identifying
pulmonary emboli. It allows for direct visualization of the pulmonary vasculature to pinpoint the location
of the clot. While a D-dimer test can rule out a PE if negative, a positive result is non-specific and requires
further imaging. Chest X-rays are often normal in PE and are used primarily to rule out other respiratory
conditions. Prompt diagnosis via CT allows for the immediate initiation of anticoagulation or
thrombolytic therapy.
5. Which clinical manifestation is a hallmark sign of a tension pneumothorax?
A. Increased breath sounds on the affected side
B. Tracheal deviation to the unaffected side
C. Bradypnea and hypertension
D. Flattened neck veins
Ans: B
Explanation: A tension pneumothorax occurs when air enters the pleural space but cannot escape,
leading to increased intrathoracic pressure. This pressure causes a mediastinal shift, characterized by
tracheal deviation away from the side of the injury. Distended neck veins are commonly observed due to
the compression of the superior vena cava. Breath sounds will be absent on the affected side, not
increased, as the lung collapses. This is a medical emergency requiring immediate needle decompression
to prevent cardiovascular collapse.
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient is admitted with septic shock. Which of the following findings should the nurse prioritize as an
indicator of worsening condition?
A. Hyperactive bowel sounds
B. Blood pressure of 110/70 mmHg
C. WBC count of 11,000/mm3
D. Serum lactate level of 4.5 mmol/L
Ans: D
Explanation: Septic shock is characterized by cellular hypoxia and metabolic derangement. A serum
lactate level above 2 mmol/L indicates anaerobic metabolism due to inadequate tissue perfusion. While a
WBC count is important, it does not provide as immediate a picture of cellular dysfunction as lactate.
Maintaining a blood pressure within normal limits is a goal, but high lactate despite this suggests occult
shock. Monitoring these levels helps the nurse evaluate the effectiveness of fluid resuscitation and
oxygenation strategies.
2. When calculating the Parkland formula for a patient with burns, what is the significance of the first 8
hours of fluid resuscitation?
A. Administering 50% of the total calculated volume
B. Administering 100% of the total calculated volume
C. Administering 25% of the total calculated volume
D. Administering 75% of the total calculated volume
,Ans: A
Explanation: The Parkland formula dictates that half of the total 24-hour fluid requirement should be
given within the first 8 hours following the burn injury. This rapid infusion is critical to counteract the
massive fluid shifts and plasma loss occurring in the emergent phase. The remaining 50% is distributed
over the subsequent 16 hours to maintain hemodynamic stability. Failure to provide adequate early
volume can lead to hypovolemic shock and acute kidney injury. The nurse must track urine output closely
to ensure the calculated rate meets the patient’s physiological needs.
3. A nurse is caring for a patient in the emergent phase of a burn injury. Which electrolyte imbalance is most
commonly expected during this period?
A. Hypernatremia
B. Hypokalemia
C. Hyperkalemia
D. Hypocalcemia
Ans: C
Explanation: In the emergent phase of a burn, massive cell destruction causes the release of intracellular
potassium into the extracellular space. This results in hyperkalemia, which poses a significant risk for
cardiac dysrhythmias. Conversely, sodium is often lost through the damaged skin or moves into the
interstitial space, leading to hyponatremia. The nurse must monitor the EKG for peaked T waves which
signal dangerously high potassium levels. Correction of this imbalance is a priority to prevent cardiac
arrest in the early stages of trauma.
4. A patient is suspected of having a Pulmonary Embolism (PE). Which diagnostic test is considered the gold
standard for confirming this diagnosis?
A. Chest X-ray
, B. Electrocardiogram (ECG)
C. D-dimer assay
D. Spiral Computed Tomography (CT) Angiography
Ans: D
Explanation: Spiral CT Angiography is the most sensitive and specific non-invasive test for identifying
pulmonary emboli. It allows for direct visualization of the pulmonary vasculature to pinpoint the location
of the clot. While a D-dimer test can rule out a PE if negative, a positive result is non-specific and requires
further imaging. Chest X-rays are often normal in PE and are used primarily to rule out other respiratory
conditions. Prompt diagnosis via CT allows for the immediate initiation of anticoagulation or
thrombolytic therapy.
5. Which clinical manifestation is a hallmark sign of a tension pneumothorax?
A. Increased breath sounds on the affected side
B. Tracheal deviation to the unaffected side
C. Bradypnea and hypertension
D. Flattened neck veins
Ans: B
Explanation: A tension pneumothorax occurs when air enters the pleural space but cannot escape,
leading to increased intrathoracic pressure. This pressure causes a mediastinal shift, characterized by
tracheal deviation away from the side of the injury. Distended neck veins are commonly observed due to
the compression of the superior vena cava. Breath sounds will be absent on the affected side, not
increased, as the lung collapses. This is a medical emergency requiring immediate needle decompression
to prevent cardiovascular collapse.
