NSG233/NSG 233 Exam 3 V1 | Medical-
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A nurse is caring for a patient in the ICU who is receiving mechanical ventilation. The low-
pressure alarm on the ventilator sounds. What is the priority nursing action?
A. Check for a disconnection in the ventilator circuit
B. Suction the patient’s airway
C. Increase the PEEP setting
D. Administer a sedative to the patient
Correct Answer: A
Rationale: A low-pressure alarm typically indicates a leak or a disconnection within the
ventilator system or the patient’s artificial airway. The nurse must immediately inspect all
tubing connections and the endotracheal tube cuff to ensure integrity. If the source of the
leak cannot be quickly identified and corrected, the nurse should manually ventilate the
patient using a bag-valve mask.
2. A patient with Acute Respiratory Distress Syndrome (ARDS) is placed in the prone position.
What is the primary rationale for this intervention?
A. To improve drainage of oral secretions
B. To prevent the development of pressure ulcers
,C. To improve oxygenation by recruiting collapsed alveoli
D. To reduce the risk of ventilator-associated pneumonia
Correct Answer: C
Rationale: Prone positioning is utilized in ARDS patients to improve gas exchange and
oxygenation by redistributing pulmonary blood flow and recruiting dorsal lung regions.
This position helps to reduce the weight of the heart and abdominal contents on the lungs,
allowing for better alveolar expansion. The nurse must carefully monitor the patient’s
hemodynamic stability and skin integrity during the repositioning process.
3. The nurse is interpreting ABG results for a patient: pH 7.30, PaCO2 52 mmHg, and HCO3 24
mEq/L. Which acid-base imbalance does this reflect?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Rationale: The pH of 7.30 indicates acidosis as it is below the normal range of 7.35 to 7.45.
The PaCO2 of 52 mmHg is elevated, which is the primary cause of the acidic pH in
respiratory acidosis. Since the HCO3 is within the normal range, the compensation has not
yet occurred or is insufficient.
,4. A patient with a history of Atrial Fibrillation suddenly develops a heart rate of 150 bpm and
reports shortness of breath. Which medication should the nurse anticipate administering if
the patient is stable?
A. Atropine
B. Diltiazem
C. Epinephrine
D. Lidocaine
Correct Answer: B
Rationale: Diltiazem is a calcium channel blocker commonly used to control the heart rate
in patients with Atrial Fibrillation with rapid ventricular response. By slowing conduction
through the AV node, it helps to decrease the heart rate and improve cardiac output. The
nurse should monitor the patient’s blood pressure closely after administration as
hypotension is a common side effect.
5. Which assessment finding is most indicative of cardiac tamponade?
A. Hypertension and bradycardia
B. Widened pulse pressure and tachycardia
C. Muffled heart sounds and jugular venous distention
D. Inspiratory crackles and S3 heart sound
Correct Answer: C
, Rationale: Cardiac tamponade is characterized by Beck’s Triad, which includes muffled
heart sounds, jugular venous distention, and hypotension. These signs occur because fluid
accumulation in the pericardial sac restricts heart expansion and reduces stroke volume.
Immediate intervention, such as a pericardiocentesis, is often required to relieve the
pressure.
6. When caring for a patient with an intracranial pressure (ICP) monitoring device, which
value should the nurse report immediately?
A. ICP of 22 mmHg
B. CPP of 70 mmHg
C. ICP of 12 mmHg
D. MAP of 85 mmHg
Correct Answer: A
Rationale: A normal ICP range is typically 5 to 15 mmHg; therefore, an ICP of 22 mmHg is
elevated and requires immediate intervention to prevent brain herniation. The cerebral
perfusion pressure (CPP) is calculated as MAP minus ICP, and a value of 70 mmHg is within
the target range of 60-100 mmHg. The nurse must maintain the head of the bed at 30
degrees and minimize stimulation to help lower the ICP.
7. A patient in the resuscitative phase of a major burn injury has a blood pressure of 88/50
mmHg and a heart rate of 120 bpm. What is the priority nursing intervention?
A. Apply topical antibiotics to the burn wounds
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A nurse is caring for a patient in the ICU who is receiving mechanical ventilation. The low-
pressure alarm on the ventilator sounds. What is the priority nursing action?
A. Check for a disconnection in the ventilator circuit
B. Suction the patient’s airway
C. Increase the PEEP setting
D. Administer a sedative to the patient
Correct Answer: A
Rationale: A low-pressure alarm typically indicates a leak or a disconnection within the
ventilator system or the patient’s artificial airway. The nurse must immediately inspect all
tubing connections and the endotracheal tube cuff to ensure integrity. If the source of the
leak cannot be quickly identified and corrected, the nurse should manually ventilate the
patient using a bag-valve mask.
2. A patient with Acute Respiratory Distress Syndrome (ARDS) is placed in the prone position.
What is the primary rationale for this intervention?
A. To improve drainage of oral secretions
B. To prevent the development of pressure ulcers
,C. To improve oxygenation by recruiting collapsed alveoli
D. To reduce the risk of ventilator-associated pneumonia
Correct Answer: C
Rationale: Prone positioning is utilized in ARDS patients to improve gas exchange and
oxygenation by redistributing pulmonary blood flow and recruiting dorsal lung regions.
This position helps to reduce the weight of the heart and abdominal contents on the lungs,
allowing for better alveolar expansion. The nurse must carefully monitor the patient’s
hemodynamic stability and skin integrity during the repositioning process.
3. The nurse is interpreting ABG results for a patient: pH 7.30, PaCO2 52 mmHg, and HCO3 24
mEq/L. Which acid-base imbalance does this reflect?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Rationale: The pH of 7.30 indicates acidosis as it is below the normal range of 7.35 to 7.45.
The PaCO2 of 52 mmHg is elevated, which is the primary cause of the acidic pH in
respiratory acidosis. Since the HCO3 is within the normal range, the compensation has not
yet occurred or is insufficient.
,4. A patient with a history of Atrial Fibrillation suddenly develops a heart rate of 150 bpm and
reports shortness of breath. Which medication should the nurse anticipate administering if
the patient is stable?
A. Atropine
B. Diltiazem
C. Epinephrine
D. Lidocaine
Correct Answer: B
Rationale: Diltiazem is a calcium channel blocker commonly used to control the heart rate
in patients with Atrial Fibrillation with rapid ventricular response. By slowing conduction
through the AV node, it helps to decrease the heart rate and improve cardiac output. The
nurse should monitor the patient’s blood pressure closely after administration as
hypotension is a common side effect.
5. Which assessment finding is most indicative of cardiac tamponade?
A. Hypertension and bradycardia
B. Widened pulse pressure and tachycardia
C. Muffled heart sounds and jugular venous distention
D. Inspiratory crackles and S3 heart sound
Correct Answer: C
, Rationale: Cardiac tamponade is characterized by Beck’s Triad, which includes muffled
heart sounds, jugular venous distention, and hypotension. These signs occur because fluid
accumulation in the pericardial sac restricts heart expansion and reduces stroke volume.
Immediate intervention, such as a pericardiocentesis, is often required to relieve the
pressure.
6. When caring for a patient with an intracranial pressure (ICP) monitoring device, which
value should the nurse report immediately?
A. ICP of 22 mmHg
B. CPP of 70 mmHg
C. ICP of 12 mmHg
D. MAP of 85 mmHg
Correct Answer: A
Rationale: A normal ICP range is typically 5 to 15 mmHg; therefore, an ICP of 22 mmHg is
elevated and requires immediate intervention to prevent brain herniation. The cerebral
perfusion pressure (CPP) is calculated as MAP minus ICP, and a value of 70 mmHg is within
the target range of 60-100 mmHg. The nurse must maintain the head of the bed at 30
degrees and minimize stimulation to help lower the ICP.
7. A patient in the resuscitative phase of a major burn injury has a blood pressure of 88/50
mmHg and a heart rate of 120 bpm. What is the priority nursing intervention?
A. Apply topical antibiotics to the burn wounds
