NUR 265 Exams 1-3 & Final Medical-Surgical
Nursing (2026/2027) PDF | Nursing | Galen College
1. A patient with acute decompensated heart failure is on a nitroprusside drip. The nurse
notes a drop in mean arterial pressure (MAP) from 70 to 55 mm Hg and a rise in
pulmonary artery wedge pressure (PAWP) from 18 to 24 mm Hg. What is the most likely
cause?
A. Excessive preload reduction
B. Inadequate afterload reduction
C. Left ventricular pump failure
D. Nitroprusside-induced coronary steal
Answer: C
Rationale: The combination of decreasing MAP and increasing PAWP indicates worsening left
ventricular function despite vasodilator therapy. Excessive preload reduction would decrease
PAWP, not increase. Inadequate afterload reduction would not explain rising PAWP. Coronary
steal is not typical with nitroprusside.
2. A patient with ARDS has a PaO2 of 60 mm Hg on FiO2 0.8 with PEEP 10 cm H2O.
PaCO2 35, pH 7.42. The nurse calculates the PaO2/FiO2 ratio. Which intervention is most
appropriate based on this data?
A. Increase PEEP to 15 cm H2O and reassess
B. Decrease FiO2 to 0.6
C. Initiate prone positioning
D. Prepare for extracorporeal membrane oxygenation (ECMO)
Answer: C
Rationale: PaO2/FiO2 ratio = 60/0.8 = 75, indicating severe ARDS (ratio < 100). Prone
positioning is recommended for moderate to severe ARDS to improve oxygenation. Increasing
PEEP may be considered but requires assessment of plateau pressure. Decreasing FiO2 is not
appropriate due to severe hypoxemia. ECMO is a rescue therapy after prone positioning fails.
3. A patient with traumatic brain injury has an intraventricular drain. The nurse observes
a flat ICP waveform with no respiratory variation and a mean ICP of 5 mm Hg. The
patient is sedated and paralyzed. What should the nurse do first?
A. Administer a 500 mL bolus of normal saline
B. Check the drainage system for obstruction or kinking
C. Increase the sedation infusion rate
D. Notify the physician immediately for possible brain death
Page 1
,Answer: B
Rationale: A flat waveform with low ICP suggests overdrainage or obstruction. The first action is
to assess the system patency. Saline bolus is not indicated without signs of hypovolemia.
Increasing sedation would lower ICP further. Notifying the physician can wait until a
mechanical issue is ruled out.
4. A patient with sepsis develops oliguria. Labs: serum creatinine 2.5 mg/dL (baseline 1.0),
BUN 45 mg/dL, urine sodium 10 mEq/L, urine osmolality 450 mOsm/kg. What is the most
likely etiology of the acute kidney injury?
A. Acute tubular necrosis (ATN)
B. Prerenal azotemia
C. Postrenal obstruction
D. Acute interstitial nephritis
Answer: B
Rationale: Low urine sodium (<20 mEq/L) and high urine osmolality (>400 mOsm/kg) indicate
intact tubular function, consistent with prerenal azotemia. ATN typically shows high urine
sodium and low osmolality. Postrenal causes may initially have variable urine sodium.
Interstitial nephritis often presents with pyuria and eosinophiluria.
5. See table above.
A. Anticipated for fluid, insulin bolus, insulin infusion, and urine output; Contraindicated for
potassium and bicarbonate.
B. Anticipated for all except bicarbonate; Contraindicated for bicarbonate.
C. Nonessential for fluid and urine output; Contraindicated for potassium and bicarbonate.
D. Anticipated for fluid and insulin bolus; Contraindicated for potassium, bicarbonate, and insulin
infusion.
Answer: A
Rationale: IV fluids correct hypovolemia; insulin bolus and infusion lower glucose; urine output
monitoring is essential. Potassium is contraindicated due to hyperkalemia; bicarbonate is
reserved for pH <6.9 (current pH 7.20).
6. A patient with acute pancreatitis on day 3 develops sudden worsening of abdominal pain,
hypotension, and a drop in hematocrit from 38% to 28%. The nurse assesses for which
complication?
A. Pancreatic pseudocyst
B. Acute respiratory distress syndrome (ARDS)
C. Hemorrhagic pancreatitis
D. Pancreatic abscess
Answer: C
Rationale: The acute drop in hematocrit with hypotension suggests bleeding, characteristic of
hemorrhagic pancreatitis. Pseudocyst develops weeks later; ARDS presents with respiratory
Page 2
,distress; abscess presents with fever and toxic appearance later in the course.
7. A patient with sepsis has labs: platelets 45,000/mm3, PT 16 sec (control 12), aPTT 45 sec
(control 30), fibrinogen 120 mg/dL, D-dimer elevated. The nurse prepares to administer
blood products. Which combination is most appropriate?
A. Platelets and fresh frozen plasma (FFP)
B. Cryoprecipitate and packed red cells
C. Platelets and cryoprecipitate
D. FFP and cryoprecipitate
Answer: A
Rationale: In DIC with active bleeding and thrombocytopenia, the priority is to replace platelets
and clotting factors. FFP provides multiple coagulation factors; cryoprecipitate mainly
fibrinogen, but fibrinogen is 120 (low but not critical unless <100). Platelets and FFP address
both deficits. Packed red cells are given for significant anemia (not indicated here).
8. See table above.
A. Continue norepinephrine and repeat lactate; Initiate fluid bolus; Discontinue vasopressin and
transfusion.
B. Continue all except vasopressin; Initiate transfusion; Discontinue fluid.
C. Continue norepinephrine and transfusion; Initiate vasopressin; Discontinue fluid and repeat lactate.
D. Initiate all; Continue none; Discontinue repeat lactate.
Answer: A
Rationale: MAP at goal on current norepinephrine, so continue. Lactate still elevated (>2) with
ScvO2 70% suggests ongoing tissue hypoperfusion, so additional fluid bolus is appropriate.
Vasopressin not indicated with MAP at goal on low-dose norepinephrine. Transfusion not
indicated because ScvO2 is at 70% (target 70%). Repeat lactate is standard monitoring.
9. A patient with renal failure on hemodialysis has ECG changes: peaked T waves, loss of P
wave, widened QRS. Serum potassium is 7.2 mEq/L. The nurse prepares to administer
calcium gluconate. Which statement accurately describes the mechanism of action?
A. Calcium shifts potassium into cells via Na-K ATPase activation
B. Calcium antagonizes the cardiac effects of hyperkalemia by stabilizing the sarcolemma
C. Calcium binds to potassium and enhances renal excretion
D. Calcium increases insulin secretion which promotes cellular uptake of potassium
Answer: B
Rationale: Calcium gluconate protects the heart by raising the threshold potential, counteracting
the excitability caused by hyperkalemia. It does not lower serum potassium. Options A and D
describe shifting potassium into cells (e.g., insulin, albuterol). Option C is false; calcium does
not enhance renal excretion.
Page 3
, 10. A patient with chronic back pain on high-dose opioids for months reports increased
pain despite dose escalation. The nurse suspects opioid-induced hyperalgesia (OIH) versus
tolerance. Which finding best supports OIH?
A. Pain is relieved by additional opioid doses
B. Pain is localized to the original site only
C. Pain is diffuse and non-anatomic, with hyperalgesia to light touch
D. Pain worsens after opioid dose reduction
Answer: C
Rationale: OIH presents as increased pain sensitivity, often diffuse and spreading beyond the
original site, with hyperalgesia (increased pain from normally painful stimuli) and allodynia
(pain from light touch). Tolerance requires higher doses for same effect and pain is relieved by
dose increase. Pain worsening after dose reduction is more typical of physical dependence.
11. A patient with sepsis develops tachypnea. Arterial blood gas results: pH 7.31, PaCO2 30
mm Hg, HCO3 16 mEq/L. Which interpretation is correct?
A. Respiratory alkalosis with metabolic compensation
B. Metabolic acidosis with respiratory compensation
C. Metabolic alkalosis with respiratory compensation
D. Mixed metabolic acidosis and respiratory acidosis
Answer: B
Rationale: The pH is acidic (7.31), indicating acidosis. The HCO3 is low (16), pointing to
metabolic acidosis. The PaCO2 is low (30), which is compensatory respiratory alkalosis. Thus,
partially compensated metabolic acidosis.
12. A patient under general anesthesia develops masseter spasm after succinylcholine, then
rigidity, hyperthermia, and tachydysrhythmias. Stat arterial blood gas shows hypercapnia
and metabolic acidosis. What is the priority nursing intervention?
A. Administer dantrolene sodium 2.5 mg/kg IV
B. Discontinue volatile anesthetic agents and succinylcholine
C. Apply cooling blankets and administer ice IV fluids
D. Administer sodium bicarbonate 1 mEq/kg IV
Answer: B
Rationale: The first and most critical step in malignant hyperthermia is to discontinue the
triggering agents (volatile anesthetics and succinylcholine) to stop further calcium release.
Dantrolene is given thereafter, and cooling and bicarbonate are supportive.
13. A patient has been taking oxycodone 40 mg daily for chronic back pain for two years
and is now postoperative after a colectomy. Which pain management plan is most
appropriate?
A. Discontinue chronic opioids and start IV morphine patient-controlled analgesia
Page 4
Nursing (2026/2027) PDF | Nursing | Galen College
1. A patient with acute decompensated heart failure is on a nitroprusside drip. The nurse
notes a drop in mean arterial pressure (MAP) from 70 to 55 mm Hg and a rise in
pulmonary artery wedge pressure (PAWP) from 18 to 24 mm Hg. What is the most likely
cause?
A. Excessive preload reduction
B. Inadequate afterload reduction
C. Left ventricular pump failure
D. Nitroprusside-induced coronary steal
Answer: C
Rationale: The combination of decreasing MAP and increasing PAWP indicates worsening left
ventricular function despite vasodilator therapy. Excessive preload reduction would decrease
PAWP, not increase. Inadequate afterload reduction would not explain rising PAWP. Coronary
steal is not typical with nitroprusside.
2. A patient with ARDS has a PaO2 of 60 mm Hg on FiO2 0.8 with PEEP 10 cm H2O.
PaCO2 35, pH 7.42. The nurse calculates the PaO2/FiO2 ratio. Which intervention is most
appropriate based on this data?
A. Increase PEEP to 15 cm H2O and reassess
B. Decrease FiO2 to 0.6
C. Initiate prone positioning
D. Prepare for extracorporeal membrane oxygenation (ECMO)
Answer: C
Rationale: PaO2/FiO2 ratio = 60/0.8 = 75, indicating severe ARDS (ratio < 100). Prone
positioning is recommended for moderate to severe ARDS to improve oxygenation. Increasing
PEEP may be considered but requires assessment of plateau pressure. Decreasing FiO2 is not
appropriate due to severe hypoxemia. ECMO is a rescue therapy after prone positioning fails.
3. A patient with traumatic brain injury has an intraventricular drain. The nurse observes
a flat ICP waveform with no respiratory variation and a mean ICP of 5 mm Hg. The
patient is sedated and paralyzed. What should the nurse do first?
A. Administer a 500 mL bolus of normal saline
B. Check the drainage system for obstruction or kinking
C. Increase the sedation infusion rate
D. Notify the physician immediately for possible brain death
Page 1
,Answer: B
Rationale: A flat waveform with low ICP suggests overdrainage or obstruction. The first action is
to assess the system patency. Saline bolus is not indicated without signs of hypovolemia.
Increasing sedation would lower ICP further. Notifying the physician can wait until a
mechanical issue is ruled out.
4. A patient with sepsis develops oliguria. Labs: serum creatinine 2.5 mg/dL (baseline 1.0),
BUN 45 mg/dL, urine sodium 10 mEq/L, urine osmolality 450 mOsm/kg. What is the most
likely etiology of the acute kidney injury?
A. Acute tubular necrosis (ATN)
B. Prerenal azotemia
C. Postrenal obstruction
D. Acute interstitial nephritis
Answer: B
Rationale: Low urine sodium (<20 mEq/L) and high urine osmolality (>400 mOsm/kg) indicate
intact tubular function, consistent with prerenal azotemia. ATN typically shows high urine
sodium and low osmolality. Postrenal causes may initially have variable urine sodium.
Interstitial nephritis often presents with pyuria and eosinophiluria.
5. See table above.
A. Anticipated for fluid, insulin bolus, insulin infusion, and urine output; Contraindicated for
potassium and bicarbonate.
B. Anticipated for all except bicarbonate; Contraindicated for bicarbonate.
C. Nonessential for fluid and urine output; Contraindicated for potassium and bicarbonate.
D. Anticipated for fluid and insulin bolus; Contraindicated for potassium, bicarbonate, and insulin
infusion.
Answer: A
Rationale: IV fluids correct hypovolemia; insulin bolus and infusion lower glucose; urine output
monitoring is essential. Potassium is contraindicated due to hyperkalemia; bicarbonate is
reserved for pH <6.9 (current pH 7.20).
6. A patient with acute pancreatitis on day 3 develops sudden worsening of abdominal pain,
hypotension, and a drop in hematocrit from 38% to 28%. The nurse assesses for which
complication?
A. Pancreatic pseudocyst
B. Acute respiratory distress syndrome (ARDS)
C. Hemorrhagic pancreatitis
D. Pancreatic abscess
Answer: C
Rationale: The acute drop in hematocrit with hypotension suggests bleeding, characteristic of
hemorrhagic pancreatitis. Pseudocyst develops weeks later; ARDS presents with respiratory
Page 2
,distress; abscess presents with fever and toxic appearance later in the course.
7. A patient with sepsis has labs: platelets 45,000/mm3, PT 16 sec (control 12), aPTT 45 sec
(control 30), fibrinogen 120 mg/dL, D-dimer elevated. The nurse prepares to administer
blood products. Which combination is most appropriate?
A. Platelets and fresh frozen plasma (FFP)
B. Cryoprecipitate and packed red cells
C. Platelets and cryoprecipitate
D. FFP and cryoprecipitate
Answer: A
Rationale: In DIC with active bleeding and thrombocytopenia, the priority is to replace platelets
and clotting factors. FFP provides multiple coagulation factors; cryoprecipitate mainly
fibrinogen, but fibrinogen is 120 (low but not critical unless <100). Platelets and FFP address
both deficits. Packed red cells are given for significant anemia (not indicated here).
8. See table above.
A. Continue norepinephrine and repeat lactate; Initiate fluid bolus; Discontinue vasopressin and
transfusion.
B. Continue all except vasopressin; Initiate transfusion; Discontinue fluid.
C. Continue norepinephrine and transfusion; Initiate vasopressin; Discontinue fluid and repeat lactate.
D. Initiate all; Continue none; Discontinue repeat lactate.
Answer: A
Rationale: MAP at goal on current norepinephrine, so continue. Lactate still elevated (>2) with
ScvO2 70% suggests ongoing tissue hypoperfusion, so additional fluid bolus is appropriate.
Vasopressin not indicated with MAP at goal on low-dose norepinephrine. Transfusion not
indicated because ScvO2 is at 70% (target 70%). Repeat lactate is standard monitoring.
9. A patient with renal failure on hemodialysis has ECG changes: peaked T waves, loss of P
wave, widened QRS. Serum potassium is 7.2 mEq/L. The nurse prepares to administer
calcium gluconate. Which statement accurately describes the mechanism of action?
A. Calcium shifts potassium into cells via Na-K ATPase activation
B. Calcium antagonizes the cardiac effects of hyperkalemia by stabilizing the sarcolemma
C. Calcium binds to potassium and enhances renal excretion
D. Calcium increases insulin secretion which promotes cellular uptake of potassium
Answer: B
Rationale: Calcium gluconate protects the heart by raising the threshold potential, counteracting
the excitability caused by hyperkalemia. It does not lower serum potassium. Options A and D
describe shifting potassium into cells (e.g., insulin, albuterol). Option C is false; calcium does
not enhance renal excretion.
Page 3
, 10. A patient with chronic back pain on high-dose opioids for months reports increased
pain despite dose escalation. The nurse suspects opioid-induced hyperalgesia (OIH) versus
tolerance. Which finding best supports OIH?
A. Pain is relieved by additional opioid doses
B. Pain is localized to the original site only
C. Pain is diffuse and non-anatomic, with hyperalgesia to light touch
D. Pain worsens after opioid dose reduction
Answer: C
Rationale: OIH presents as increased pain sensitivity, often diffuse and spreading beyond the
original site, with hyperalgesia (increased pain from normally painful stimuli) and allodynia
(pain from light touch). Tolerance requires higher doses for same effect and pain is relieved by
dose increase. Pain worsening after dose reduction is more typical of physical dependence.
11. A patient with sepsis develops tachypnea. Arterial blood gas results: pH 7.31, PaCO2 30
mm Hg, HCO3 16 mEq/L. Which interpretation is correct?
A. Respiratory alkalosis with metabolic compensation
B. Metabolic acidosis with respiratory compensation
C. Metabolic alkalosis with respiratory compensation
D. Mixed metabolic acidosis and respiratory acidosis
Answer: B
Rationale: The pH is acidic (7.31), indicating acidosis. The HCO3 is low (16), pointing to
metabolic acidosis. The PaCO2 is low (30), which is compensatory respiratory alkalosis. Thus,
partially compensated metabolic acidosis.
12. A patient under general anesthesia develops masseter spasm after succinylcholine, then
rigidity, hyperthermia, and tachydysrhythmias. Stat arterial blood gas shows hypercapnia
and metabolic acidosis. What is the priority nursing intervention?
A. Administer dantrolene sodium 2.5 mg/kg IV
B. Discontinue volatile anesthetic agents and succinylcholine
C. Apply cooling blankets and administer ice IV fluids
D. Administer sodium bicarbonate 1 mEq/kg IV
Answer: B
Rationale: The first and most critical step in malignant hyperthermia is to discontinue the
triggering agents (volatile anesthetics and succinylcholine) to stop further calcium release.
Dantrolene is given thereafter, and cooling and bicarbonate are supportive.
13. A patient has been taking oxycodone 40 mg daily for chronic back pain for two years
and is now postoperative after a colectomy. Which pain management plan is most
appropriate?
A. Discontinue chronic opioids and start IV morphine patient-controlled analgesia
Page 4
