NSG223/NSG 223 Final Exam V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with a spinal cord injury at the T4 level reports a severe, throbbing headache and
has a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer prescribed analgesic for the headache
B. Perform a neurological assessment to check for motor changes
C. Check the patient’s temperature for signs of infection
D. Place the patient in a high-Fowler’s position
Correct Answer: D
Rationale: The patient is exhibiting signs of autonomic dysreflexia, which is a medical
emergency common in injuries at T6 or above. Elevating the head of the bed to a high-
Fowler’s position is the first action to help lower the blood pressure through orthostatic
changes. After repositioning, the nurse should assess for triggers such as a distended
bladder or fecal impaction.
2. A nurse is reviewing the lab results for a patient with Acute Kidney Injury (AKI). Which
finding is most indicative of a prerenal cause of AKI?
A. Urine specific gravity of 1.010
B. Presence of tubular casts in the urine
,C. BUN-to-creatinine ratio of 25:1
D. History of nephrotoxic medication use
Correct Answer: C
Rationale: A BUN-to-creatinine ratio greater than 20:1 typically indicates prerenal causes
such as dehydration or decreased renal perfusion. In prerenal AKI, the kidneys are
structurally sound but lack adequate blood flow to filter waste effectively. This ratio helps
differentiate it from intrarenal causes where the ratio remains closer to 10:1 or 15:1.
3. The nurse is caring for a patient on a ventilator who is experiencing high-pressure alarms.
Which action should the nurse take first?
A. Suction the patient to clear the airway of secretions
B. Call the respiratory therapist to adjust the settings
C. Increase the fraction of inspired oxygen (FiO2)
D. Check the tubing for any kinks or obstructions
Correct Answer: D
Rationale: High-pressure alarms indicate that the ventilator is meeting resistance when
delivering a breath. Common causes include the patient biting the tube, tubing kinks, or
excessive secretions. The nurse should quickly assess for physical obstructions in the
circuit before proceeding to suctioning or calling for assistance.
,4. A patient in the Intensive Care Unit is diagnosed with Septic Shock. Which of the following
hemodynamic parameters is the nurse most likely to observe?
A. Decreased Systemic Vascular Resistance (SVR)
B. Decreased Cardiac Output (CO)
C. Increased Systemic Vascular Resistance (SVR)
D. Increased Pulmonary Artery Wedge Pressure (PAWP)
Correct Answer: A
Rationale: Septic shock is characterized by massive vasodilation due to the inflammatory
response to infection. This results in a significantly decreased Systemic Vascular
Resistance, which is a hallmark of distributive shock. Despite a low SVR, the cardiac output
may initially be high as a compensatory mechanism to maintain perfusion.
5. Which clinical manifestation should the nurse prioritize when assessing a patient with a
suspected tension pneumothorax?
A. Tracheal deviation toward the unaffected side
B. Muffled heart sounds and jugular venous distension
C. Decreased breath sounds on the affected side
D. Sharp chest pain that increases with inspiration
Correct Answer: A
, Rationale: Tracheal deviation is a late and critical sign of tension pneumothorax, indicating
a significant shift in mediastinal structures. This condition requires immediate
decompression to prevent cardiovascular collapse from increased intrathoracic pressure.
While decreased breath sounds occur, the tracheal shift identifies the emergency as a
tension-type pneumothorax.
6. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation with PEEP. What is the primary purpose of PEEP in this patient?
A. To increase the patient’s respiratory rate
B. To decrease the workload of the right ventricle
C. To reduce the risk of barotrauma from high tidal volumes
D. To prevent alveolar collapse and improve oxygenation
Correct Answer: D
Rationale: PEEP stands for Positive End-Expiratory Pressure and is essential for managing
ARDS by keeping alveoli open during expiration. This recruitment of alveoli increases the
surface area for gas exchange and helps reverse refractory hypoxemia. However, the nurse
must monitor for decreased cardiac output as high PEEP levels can impede venous return.
7. When calculating the total body surface area (TBSA) burned using the Rule of Nines, how
would the nurse record burns involving the entire right arm and the anterior trunk?
A. 18%
B. 36%
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with a spinal cord injury at the T4 level reports a severe, throbbing headache and
has a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer prescribed analgesic for the headache
B. Perform a neurological assessment to check for motor changes
C. Check the patient’s temperature for signs of infection
D. Place the patient in a high-Fowler’s position
Correct Answer: D
Rationale: The patient is exhibiting signs of autonomic dysreflexia, which is a medical
emergency common in injuries at T6 or above. Elevating the head of the bed to a high-
Fowler’s position is the first action to help lower the blood pressure through orthostatic
changes. After repositioning, the nurse should assess for triggers such as a distended
bladder or fecal impaction.
2. A nurse is reviewing the lab results for a patient with Acute Kidney Injury (AKI). Which
finding is most indicative of a prerenal cause of AKI?
A. Urine specific gravity of 1.010
B. Presence of tubular casts in the urine
,C. BUN-to-creatinine ratio of 25:1
D. History of nephrotoxic medication use
Correct Answer: C
Rationale: A BUN-to-creatinine ratio greater than 20:1 typically indicates prerenal causes
such as dehydration or decreased renal perfusion. In prerenal AKI, the kidneys are
structurally sound but lack adequate blood flow to filter waste effectively. This ratio helps
differentiate it from intrarenal causes where the ratio remains closer to 10:1 or 15:1.
3. The nurse is caring for a patient on a ventilator who is experiencing high-pressure alarms.
Which action should the nurse take first?
A. Suction the patient to clear the airway of secretions
B. Call the respiratory therapist to adjust the settings
C. Increase the fraction of inspired oxygen (FiO2)
D. Check the tubing for any kinks or obstructions
Correct Answer: D
Rationale: High-pressure alarms indicate that the ventilator is meeting resistance when
delivering a breath. Common causes include the patient biting the tube, tubing kinks, or
excessive secretions. The nurse should quickly assess for physical obstructions in the
circuit before proceeding to suctioning or calling for assistance.
,4. A patient in the Intensive Care Unit is diagnosed with Septic Shock. Which of the following
hemodynamic parameters is the nurse most likely to observe?
A. Decreased Systemic Vascular Resistance (SVR)
B. Decreased Cardiac Output (CO)
C. Increased Systemic Vascular Resistance (SVR)
D. Increased Pulmonary Artery Wedge Pressure (PAWP)
Correct Answer: A
Rationale: Septic shock is characterized by massive vasodilation due to the inflammatory
response to infection. This results in a significantly decreased Systemic Vascular
Resistance, which is a hallmark of distributive shock. Despite a low SVR, the cardiac output
may initially be high as a compensatory mechanism to maintain perfusion.
5. Which clinical manifestation should the nurse prioritize when assessing a patient with a
suspected tension pneumothorax?
A. Tracheal deviation toward the unaffected side
B. Muffled heart sounds and jugular venous distension
C. Decreased breath sounds on the affected side
D. Sharp chest pain that increases with inspiration
Correct Answer: A
, Rationale: Tracheal deviation is a late and critical sign of tension pneumothorax, indicating
a significant shift in mediastinal structures. This condition requires immediate
decompression to prevent cardiovascular collapse from increased intrathoracic pressure.
While decreased breath sounds occur, the tracheal shift identifies the emergency as a
tension-type pneumothorax.
6. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation with PEEP. What is the primary purpose of PEEP in this patient?
A. To increase the patient’s respiratory rate
B. To decrease the workload of the right ventricle
C. To reduce the risk of barotrauma from high tidal volumes
D. To prevent alveolar collapse and improve oxygenation
Correct Answer: D
Rationale: PEEP stands for Positive End-Expiratory Pressure and is essential for managing
ARDS by keeping alveoli open during expiration. This recruitment of alveoli increases the
surface area for gas exchange and helps reverse refractory hypoxemia. However, the nurse
must monitor for decreased cardiac output as high PEEP levels can impede venous return.
7. When calculating the total body surface area (TBSA) burned using the Rule of Nines, how
would the nurse record burns involving the entire right arm and the anterior trunk?
A. 18%
B. 36%
