NURS 480 Exam 2 V1 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 2) | West Coast University
1. A patient in the Intensive Care Unit (ICU) is diagnosed with Acute Respiratory Distress
Syndrome (ARDS). Which clinical finding is most characteristic of the early stages of this
condition?
A. Hypercapnia and respiratory acidosis
B. Right-sided heart failure and peripheral edema
C. Presence of diffuse rales and rhonchi
D. Refractory hypoxemia despite increasing FiO2
Answer: D
Rationale: ARDS is characterized by refractory hypoxemia, which is a condition where the
arterial oxygen levels remain low despite the administration of high concentrations of
oxygen. This occurs due to the severe shunting and alveolar collapse associated with the
inflammatory response in the lungs. In the early stages, patients typically exhibit tachypnea
and respiratory alkalosis before progressing to respiratory failure.
,2. A nurse is caring for a patient who sustained full-thickness burns over 40% of their body.
According to the Parkland formula, how should the nurse plan the fluid resuscitation for the
first 24 hours?
A. Give the entire calculated volume over the first 8 hours
B. Give 25% of the volume in the first 8 hours
C. Divide the volume into three equal parts every 8 hours
D. Administer half of the total volume in the first 8 hours
Answer: D
Rationale: The Parkland (Baxter) formula is used to calculate fluid resuscitation
requirements, typically 4 mL/kg/%TBSA. Half of the total calculated volume must be
administered within the first 8 hours following the actual time of the burn injury. The
remaining half is administered over the subsequent 16 hours to prevent hypovolemic
shock and maintain organ perfusion.
3. The nurse is monitoring a patient’s Central Venous Pressure (CVP). The reading is 12
mmHg. Which interpretation by the nurse is most accurate?
A. The patient is likely experiencing fluid volume overload
B. The patient has a normal hemodynamic status
C. The patient is experiencing severe dehydration
D. The patient is in the early stages of hypovolemic shock
,Answer: A
Rationale: Normal CVP ranges from 2 to 8 mmHg, and a value of 12 mmHg indicates an
elevation in right atrial pressure. This elevation often points to fluid volume excess, right-
sided heart failure, or pulmonary hypertension. The nurse must correlate this finding with
clinical signs such as jugular venous distention and peripheral edema.
4. A patient with a T6 spinal cord injury reports a sudden, pounding headache and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Perform a bladder scan to check for urinary retention
B. Administer the prescribed PRN antihypertensive medication
C. Elevate the head of the bed to 45 degrees or higher
D. Notify the healthcare provider immediately
Answer: C
Rationale: The patient is exhibiting signs of Autonomic Dysreflexia, a medical emergency
common in patients with spinal cord injuries at or above T6. The immediate priority is to
elevate the head of the bed to promote venous drainage from the brain and lower blood
pressure through orthostatic changes. After repositioning, the nurse should identify and
remove the triggering stimulus, such as a distended bladder or impacted bowel.
5. A patient in septic shock has a mean arterial pressure (MAP) of 55 mmHg. Which
pharmacological intervention is most appropriate to maintain perfusion?
A. Intravenous Nitroglycerin infusion
, B. Atenolol (Tenormin) oral dose
C. Furosemide (Lasix) IV push
D. Norepinephrine (Levophed) infusion
Answer: D
Rationale: In septic shock, vasopressors such as Norepinephrine are the first-line agents
used when fluid resuscitation fails to maintain an adequate MAP of at least 65 mmHg.
Norepinephrine works by increasing systemic vascular resistance through alpha-
adrenergic stimulation. The goal is to restore tissue perfusion and prevent multi-organ
dysfunction syndrome (MODS).
6. The nurse notes frequent premature ventricular contractions (PVCs) on the cardiac monitor
of a patient post-myocardial infarction. Which laboratory value should the nurse check first?
A. Serum potassium level
B. Serum glucose level
C. Blood Urea Nitrogen (BUN)
D. Hemoglobin and Hematocrit
Answer: A
Rationale: Electrolyte imbalances, particularly hypokalemia or hyperkalemia, are common
causes of ventricular irritability and PVCs. Following a myocardial infarction, the heart
muscle is already sensitized, making it more prone to dysrhythmias if potassium or
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 2) | West Coast University
1. A patient in the Intensive Care Unit (ICU) is diagnosed with Acute Respiratory Distress
Syndrome (ARDS). Which clinical finding is most characteristic of the early stages of this
condition?
A. Hypercapnia and respiratory acidosis
B. Right-sided heart failure and peripheral edema
C. Presence of diffuse rales and rhonchi
D. Refractory hypoxemia despite increasing FiO2
Answer: D
Rationale: ARDS is characterized by refractory hypoxemia, which is a condition where the
arterial oxygen levels remain low despite the administration of high concentrations of
oxygen. This occurs due to the severe shunting and alveolar collapse associated with the
inflammatory response in the lungs. In the early stages, patients typically exhibit tachypnea
and respiratory alkalosis before progressing to respiratory failure.
,2. A nurse is caring for a patient who sustained full-thickness burns over 40% of their body.
According to the Parkland formula, how should the nurse plan the fluid resuscitation for the
first 24 hours?
A. Give the entire calculated volume over the first 8 hours
B. Give 25% of the volume in the first 8 hours
C. Divide the volume into three equal parts every 8 hours
D. Administer half of the total volume in the first 8 hours
Answer: D
Rationale: The Parkland (Baxter) formula is used to calculate fluid resuscitation
requirements, typically 4 mL/kg/%TBSA. Half of the total calculated volume must be
administered within the first 8 hours following the actual time of the burn injury. The
remaining half is administered over the subsequent 16 hours to prevent hypovolemic
shock and maintain organ perfusion.
3. The nurse is monitoring a patient’s Central Venous Pressure (CVP). The reading is 12
mmHg. Which interpretation by the nurse is most accurate?
A. The patient is likely experiencing fluid volume overload
B. The patient has a normal hemodynamic status
C. The patient is experiencing severe dehydration
D. The patient is in the early stages of hypovolemic shock
,Answer: A
Rationale: Normal CVP ranges from 2 to 8 mmHg, and a value of 12 mmHg indicates an
elevation in right atrial pressure. This elevation often points to fluid volume excess, right-
sided heart failure, or pulmonary hypertension. The nurse must correlate this finding with
clinical signs such as jugular venous distention and peripheral edema.
4. A patient with a T6 spinal cord injury reports a sudden, pounding headache and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Perform a bladder scan to check for urinary retention
B. Administer the prescribed PRN antihypertensive medication
C. Elevate the head of the bed to 45 degrees or higher
D. Notify the healthcare provider immediately
Answer: C
Rationale: The patient is exhibiting signs of Autonomic Dysreflexia, a medical emergency
common in patients with spinal cord injuries at or above T6. The immediate priority is to
elevate the head of the bed to promote venous drainage from the brain and lower blood
pressure through orthostatic changes. After repositioning, the nurse should identify and
remove the triggering stimulus, such as a distended bladder or impacted bowel.
5. A patient in septic shock has a mean arterial pressure (MAP) of 55 mmHg. Which
pharmacological intervention is most appropriate to maintain perfusion?
A. Intravenous Nitroglycerin infusion
, B. Atenolol (Tenormin) oral dose
C. Furosemide (Lasix) IV push
D. Norepinephrine (Levophed) infusion
Answer: D
Rationale: In septic shock, vasopressors such as Norepinephrine are the first-line agents
used when fluid resuscitation fails to maintain an adequate MAP of at least 65 mmHg.
Norepinephrine works by increasing systemic vascular resistance through alpha-
adrenergic stimulation. The goal is to restore tissue perfusion and prevent multi-organ
dysfunction syndrome (MODS).
6. The nurse notes frequent premature ventricular contractions (PVCs) on the cardiac monitor
of a patient post-myocardial infarction. Which laboratory value should the nurse check first?
A. Serum potassium level
B. Serum glucose level
C. Blood Urea Nitrogen (BUN)
D. Hemoglobin and Hematocrit
Answer: A
Rationale: Electrolyte imbalances, particularly hypokalemia or hyperkalemia, are common
causes of ventricular irritability and PVCs. Following a myocardial infarction, the heart
muscle is already sensitized, making it more prone to dysrhythmias if potassium or
