NSG223/NSG 223 Exam 4 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with a spinal cord injury at the T4 level reports a sudden, severe pounding
headache and is found to have a blood pressure of 190/110 mmHg. What is the priority
nursing action?
A. Administer the prescribed PRN antihypertensive medication.
B. Check the patient’s bladder for distension or a blocked catheter.
C. Place the patient in a flat, supine position immediately.
D. Elevate the head of the bed to 45 degrees or higher.
Correct Answer: D
Rationale: The patient is exhibiting signs of autonomic dysreflexia, which is a medical
emergency in spinal cord injury patients. The first nursing action is to elevate the head of
the bed to use gravity to help lower the blood pressure. After positioning, the nurse should
then assess for the cause, such as bladder distension or fecal impaction.
2. A nurse is caring for a patient who suffered partial-thickness burns to the anterior trunk
and both anterior legs. Using the Rule of Nines, what is the estimated Percentage of Total
Body Surface Area (TBSA) affected?
A. 36%
,B. 27%
C. 45%
D. 54%
Correct Answer: A
Rationale: According to the Rule of Nines, the anterior trunk accounts for 18% of the
TBSA. Each whole leg accounts for 18%, so both anterior legs together account for another
18%. Adding 18% for the trunk and 18% for the legs results in a total of 36% TBSA.
3. Which clinical manifestation should the nurse expect to find in a patient during the oliguric
phase of Acute Kidney Injury (AKI)?
A. Hypokalemia and hypotension.
B. Elevated blood urea nitrogen (BUN) and creatinine.
C. Metabolic alkalosis and hypovolemia.
D. Increased urine output and hypernatremia.
Correct Answer: B
Rationale: During the oliguric phase of AKI, the kidneys are unable to excrete nitrogenous
waste products efficiently. This leads to a significant rise in serum BUN and creatinine
levels due to the decreased glomerular filtration rate. Other common findings in this phase
include hyperkalemia, fluid volume excess, and metabolic acidosis.
,4. A patient with a traumatic brain injury (TBI) has a Glasgow Coma Scale (GCS) score of 7.
What is the priority nursing intervention for this patient?
A. Monitor the patient’s temperature every 4 hours.
B. Prepare the patient for immediate endotracheal intubation.
C. Assess the patient’s pupillary response to light.
D. Perform a comprehensive neurological assessment every hour.
Correct Answer: B
Rationale: A GCS score of 8 or less typically indicates that the patient is in a coma and
cannot maintain their own airway. Airway protection is the absolute priority to prevent
aspiration and ensure adequate oxygenation to the brain. Once the airway is secured, the
nurse can proceed with secondary assessments like pupillary responses.
5. A nurse is managing the fluid resuscitation of a 70 kg patient with 40% TBSA burns. Using
the Parkland Formula (4mL/kg/%TBSA), how much fluid should be administered in the first 8
hours?
A. 2,800 mL
B. 11,200 mL
C. 5,600 mL
D. 7,000 mL
Correct Answer: C
, Rationale: The Parkland formula calculates total fluid for 24 hours: 4 mL x 70 kg x 40 =
11,200 mL. Half of this total volume must be administered within the first 8 hours
following the injury. Therefore, 11,200 mL divided by 2 equals 5,600 mL to be infused in
the first 8 hours.
6. A patient is admitted with a suspected stroke. Which diagnostic test is the priority to
differentiate between an ischemic and a hemorrhagic stroke?
A. Magnetic Resonance Imaging (MRI).
B. Carotid duplex ultrasound.
C. Lumbar puncture for cerebral spinal fluid analysis.
D. Non-contrast Computed Tomography (CT) scan.
Correct Answer: D
Rationale: A non-contrast CT scan is the gold standard for initial stroke assessment
because it quickly identifies the presence of intracranial hemorrhage. This distinction is
critical because the treatments for ischemic and hemorrhagic strokes are fundamentally
different. MRI provides more detail but takes significantly longer, which can delay life-
saving interventions like tPA.
7. A patient with Type 1 Diabetes is admitted with Diabetic Ketoacidosis (DKA). Which of the
following laboratory results is most consistent with this diagnosis?
A. Blood glucose 110 mg/dL, pH 7.35, and low serum bicarbonate.
B. Blood glucose 800 mg/dL, pH 7.40, and negative ketones in urine.
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with a spinal cord injury at the T4 level reports a sudden, severe pounding
headache and is found to have a blood pressure of 190/110 mmHg. What is the priority
nursing action?
A. Administer the prescribed PRN antihypertensive medication.
B. Check the patient’s bladder for distension or a blocked catheter.
C. Place the patient in a flat, supine position immediately.
D. Elevate the head of the bed to 45 degrees or higher.
Correct Answer: D
Rationale: The patient is exhibiting signs of autonomic dysreflexia, which is a medical
emergency in spinal cord injury patients. The first nursing action is to elevate the head of
the bed to use gravity to help lower the blood pressure. After positioning, the nurse should
then assess for the cause, such as bladder distension or fecal impaction.
2. A nurse is caring for a patient who suffered partial-thickness burns to the anterior trunk
and both anterior legs. Using the Rule of Nines, what is the estimated Percentage of Total
Body Surface Area (TBSA) affected?
A. 36%
,B. 27%
C. 45%
D. 54%
Correct Answer: A
Rationale: According to the Rule of Nines, the anterior trunk accounts for 18% of the
TBSA. Each whole leg accounts for 18%, so both anterior legs together account for another
18%. Adding 18% for the trunk and 18% for the legs results in a total of 36% TBSA.
3. Which clinical manifestation should the nurse expect to find in a patient during the oliguric
phase of Acute Kidney Injury (AKI)?
A. Hypokalemia and hypotension.
B. Elevated blood urea nitrogen (BUN) and creatinine.
C. Metabolic alkalosis and hypovolemia.
D. Increased urine output and hypernatremia.
Correct Answer: B
Rationale: During the oliguric phase of AKI, the kidneys are unable to excrete nitrogenous
waste products efficiently. This leads to a significant rise in serum BUN and creatinine
levels due to the decreased glomerular filtration rate. Other common findings in this phase
include hyperkalemia, fluid volume excess, and metabolic acidosis.
,4. A patient with a traumatic brain injury (TBI) has a Glasgow Coma Scale (GCS) score of 7.
What is the priority nursing intervention for this patient?
A. Monitor the patient’s temperature every 4 hours.
B. Prepare the patient for immediate endotracheal intubation.
C. Assess the patient’s pupillary response to light.
D. Perform a comprehensive neurological assessment every hour.
Correct Answer: B
Rationale: A GCS score of 8 or less typically indicates that the patient is in a coma and
cannot maintain their own airway. Airway protection is the absolute priority to prevent
aspiration and ensure adequate oxygenation to the brain. Once the airway is secured, the
nurse can proceed with secondary assessments like pupillary responses.
5. A nurse is managing the fluid resuscitation of a 70 kg patient with 40% TBSA burns. Using
the Parkland Formula (4mL/kg/%TBSA), how much fluid should be administered in the first 8
hours?
A. 2,800 mL
B. 11,200 mL
C. 5,600 mL
D. 7,000 mL
Correct Answer: C
, Rationale: The Parkland formula calculates total fluid for 24 hours: 4 mL x 70 kg x 40 =
11,200 mL. Half of this total volume must be administered within the first 8 hours
following the injury. Therefore, 11,200 mL divided by 2 equals 5,600 mL to be infused in
the first 8 hours.
6. A patient is admitted with a suspected stroke. Which diagnostic test is the priority to
differentiate between an ischemic and a hemorrhagic stroke?
A. Magnetic Resonance Imaging (MRI).
B. Carotid duplex ultrasound.
C. Lumbar puncture for cerebral spinal fluid analysis.
D. Non-contrast Computed Tomography (CT) scan.
Correct Answer: D
Rationale: A non-contrast CT scan is the gold standard for initial stroke assessment
because it quickly identifies the presence of intracranial hemorrhage. This distinction is
critical because the treatments for ischemic and hemorrhagic strokes are fundamentally
different. MRI provides more detail but takes significantly longer, which can delay life-
saving interventions like tPA.
7. A patient with Type 1 Diabetes is admitted with Diabetic Ketoacidosis (DKA). Which of the
following laboratory results is most consistent with this diagnosis?
A. Blood glucose 110 mg/dL, pH 7.35, and low serum bicarbonate.
B. Blood glucose 800 mg/dL, pH 7.40, and negative ketones in urine.
