NURS 480 Exam 1 V3 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 1) | West Coast University
1. A nurse is caring for a patient in septic shock. Which of the following is the priority
intervention to be completed within the first hour of treatment according to the Surviving
Sepsis Campaign?
A. Initiating vasopressors if MAP remains below 70 mmHg
B. Inserting a foley catheter to monitor hourly urine output
C. Administering a 30 mL/kg crystalloid bolus for hypotension or lactate ≥ 4 mmol/L
D. Administering broad-spectrum antibiotics after blood cultures are drawn
Answer: C
Rationale: The Surviving Sepsis Bundle emphasizes rapid fluid resuscitation as a primary
intervention for hypoperfusion. A 30 mL/kg isotonic crystalloid bolus is required for
patients with hypotension or a serum lactate level of 4 mmol/L or higher. This intervention
is critical to restoring mean arterial pressure and ensuring adequate tissue oxygenation
during the initial stages of shock.
2. Which assessment finding in a patient with Acute Respiratory Distress Syndrome (ARDS)
indicates that the condition is progressing to the fibrotic phase?
A. Respiratory alkalosis due to compensatory hyperventilation
,B. Pink frothy sputum and crackles throughout all lung fields
C. Increased pulmonary vascular resistance and decreased lung compliance
D. Improved PaO2/FiO2 ratio following prone positioning
Answer: C
Rationale: The fibrotic phase of ARDS occurs approximately 2 to 3 weeks after the initial
lung injury. During this stage, the lung tissue is remodeled by collagen and fibrous tissue,
which significantly reduces lung compliance. This lead to increased work of breathing and
high pulmonary vascular resistance as the alveolar structures are permanently altered.
3. The nurse is monitoring a patient with an arterial line. The monitor shows a mean arterial
pressure (MAP) of 58 mmHg. What is the nurse’s priority action?
A. Re-level the transducer to the phlebostatic axis
B. Notify the physician immediately to request a vasopressor bolus
C. Perform a square-wave test to ensure equipment accuracy
D. Assess the patient’s level of consciousness and check for a pulse
Answer: D
Rationale: The first step when an abnormal reading appears on a monitor is to assess the
patient’s clinical status. A MAP below 65 mmHg indicates inadequate organ perfusion and
requires immediate intervention. Assessing the patient’s physical state ensures that the
nurse is treating the patient rather than an equipment malfunction.
, 4. A patient with a thermal burn injury to 40% of their body surface area is in the emergent
phase. Which laboratory value should the nurse anticipate?
A. Hypernatremia due to fluid shifts into the interstitial space
B. Hyperkalemia due to massive cell destruction and release of intracellular potassium
C. Decreased hematocrit due to hemodilution from fluid resuscitation
D. Increased serum albumin levels because of inflammatory response
Answer: B
Rationale: During the emergent phase of a burn, cells are destroyed, releasing large
amounts of potassium into the extracellular fluid. This leads to hyperkalemia, which carries
a high risk for cardiac dysrhythmias. The nurse must monitor the patient’s EKG and
electrolyte levels closely during this 24- to 48-hour window.
5. A patient is being treated for cardiogenic shock. Which hemodynamic measurement would
the nurse expect to find?
A. Cardiac Index of 3.5 L/min/m2
B. Central Venous Pressure (CVP) of 2 mmHg
C. Systemic Vascular Resistance (SVR) of 800 dynes/sec/cm-5
D. Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg
Answer: D
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 1) | West Coast University
1. A nurse is caring for a patient in septic shock. Which of the following is the priority
intervention to be completed within the first hour of treatment according to the Surviving
Sepsis Campaign?
A. Initiating vasopressors if MAP remains below 70 mmHg
B. Inserting a foley catheter to monitor hourly urine output
C. Administering a 30 mL/kg crystalloid bolus for hypotension or lactate ≥ 4 mmol/L
D. Administering broad-spectrum antibiotics after blood cultures are drawn
Answer: C
Rationale: The Surviving Sepsis Bundle emphasizes rapid fluid resuscitation as a primary
intervention for hypoperfusion. A 30 mL/kg isotonic crystalloid bolus is required for
patients with hypotension or a serum lactate level of 4 mmol/L or higher. This intervention
is critical to restoring mean arterial pressure and ensuring adequate tissue oxygenation
during the initial stages of shock.
2. Which assessment finding in a patient with Acute Respiratory Distress Syndrome (ARDS)
indicates that the condition is progressing to the fibrotic phase?
A. Respiratory alkalosis due to compensatory hyperventilation
,B. Pink frothy sputum and crackles throughout all lung fields
C. Increased pulmonary vascular resistance and decreased lung compliance
D. Improved PaO2/FiO2 ratio following prone positioning
Answer: C
Rationale: The fibrotic phase of ARDS occurs approximately 2 to 3 weeks after the initial
lung injury. During this stage, the lung tissue is remodeled by collagen and fibrous tissue,
which significantly reduces lung compliance. This lead to increased work of breathing and
high pulmonary vascular resistance as the alveolar structures are permanently altered.
3. The nurse is monitoring a patient with an arterial line. The monitor shows a mean arterial
pressure (MAP) of 58 mmHg. What is the nurse’s priority action?
A. Re-level the transducer to the phlebostatic axis
B. Notify the physician immediately to request a vasopressor bolus
C. Perform a square-wave test to ensure equipment accuracy
D. Assess the patient’s level of consciousness and check for a pulse
Answer: D
Rationale: The first step when an abnormal reading appears on a monitor is to assess the
patient’s clinical status. A MAP below 65 mmHg indicates inadequate organ perfusion and
requires immediate intervention. Assessing the patient’s physical state ensures that the
nurse is treating the patient rather than an equipment malfunction.
, 4. A patient with a thermal burn injury to 40% of their body surface area is in the emergent
phase. Which laboratory value should the nurse anticipate?
A. Hypernatremia due to fluid shifts into the interstitial space
B. Hyperkalemia due to massive cell destruction and release of intracellular potassium
C. Decreased hematocrit due to hemodilution from fluid resuscitation
D. Increased serum albumin levels because of inflammatory response
Answer: B
Rationale: During the emergent phase of a burn, cells are destroyed, releasing large
amounts of potassium into the extracellular fluid. This leads to hyperkalemia, which carries
a high risk for cardiac dysrhythmias. The nurse must monitor the patient’s EKG and
electrolyte levels closely during this 24- to 48-hour window.
5. A patient is being treated for cardiogenic shock. Which hemodynamic measurement would
the nurse expect to find?
A. Cardiac Index of 3.5 L/min/m2
B. Central Venous Pressure (CVP) of 2 mmHg
C. Systemic Vascular Resistance (SVR) of 800 dynes/sec/cm-5
D. Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg
Answer: D
