Exam 1: NUR 209 Medical-Surgical Nursing II
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Study Guide
Guaranteed Pass
Q1. A 42-year-old male is brought to the emergency department following a house fire. He
has partial-thickness burns covering the anterior torso, both entire arms, and the entire
head and neck. Using the Rule of Nines, what is his estimated total body surface area
(TBSA) burned?
A. 27%
B. 36%
C. 45%
D. 54%
Correct Answer: C
Rationale: Correct because the Rule of Nines assigns 18% to the anterior torso, 9% to each
entire arm (18% total for both arms), and 9% to the entire head and neck, which sums to
45% TBSA burned. The posterior torso is unburned and therefore not included in the
calculation, as TBSA for fluid resuscitation only counts partial-thickness and full-thickness
burns. The nurse must immediately initiate fluid resuscitation using the Parkland Formula
and establish two large-bore IV lines, as burns exceeding 20% TBSA in adults require
aggressive crystalloid replacement to prevent hypovolemic shock.
Q2. A patient with septic shock has a temperature of 38.9°C, heart rate of 112 bpm,
respiratory rate of 24 breaths/min, and WBC of 15,800/mm³. The nurse recognizes these
findings as consistent with which criteria?
,A. Systemic Inflammatory Response Syndrome (SIRS)
B. Mild sepsis without organ dysfunction
C. Compensated shock state
D. Anaphylactic reaction
Correct Answer: A
Rationale: Correct because this patient meets at least three SIRS criteria: temperature
>38°C, heart rate >90 bpm, respiratory rate >20 breaths/min, and WBC >12,000/mm³,
which together indicate a systemic inflammatory response to infection. SIRS is the
foundational clinical syndrome that, when combined with a documented or suspected
infection, defines sepsis according to current guidelines. The nurse must recognize that
while SIRS criteria identify patients at risk, the priority intervention is to initiate broad -
spectrum antibiotics within one hour of recognition and begin aggressive fluid
resuscitation with 30 mL/kg of crystalloids to prevent progression to septic shock.
Q3. A 68-year-old male with chronic hypertension presents with sudden, severe, tearing
chest pain that radiates directly into his back between the scapulae. Vital signs reveal a
blood pressure of 198/110 mmHg in the left arm and 156/98 mmHg in the right arm.
Which priority intervention should the nurse anticipate?
A. Immediate surgical repair without blood pressure management
B. Administration of IV heparin for anticoagulation
C. Aggressive fluid resuscitation with normal saline
D. IV beta-blocker administration to reduce aortic wall shear stress
Correct Answer: D
Rationale: Correct because the priority medical management for aortic dissection is
immediate blood pressure and heart rate control using IV beta-blockers such as esmolol or
labetalol to reduce shear stress on the torn aortic intima and prevent further propagation
of the dissection. The vastly unequal blood pressures between arms (pulse deficit) and the
classic tearing interscapular back pain are pathognomonic for aortic dissection, and the
target parameters are heart rate <60 bpm and systolic blood pressure of 100 -120 mmHg.
The nurse must initiate continuous cardiac and hemodynamic monitoring, prepare for
,emergent surgical consultation, and avoid anticoagulation or aggressive fluid resuscitation
which could worsen bleeding or increase aortic wall stress.
Q4. A patient receiving chemotherapy for acute myeloid leukemia develops a temperature
of 38.6°C, chills, and absolute neutrophil count (ANC) of 320/mm³. Which nursing action is
the priority?
A. Administer acetaminophen and monitor temperature every 4 hours
B. Obtain blood cultures and initiate broad-spectrum antibiotics immediately
C. Place the patient in droplet precautions and restrict visitors
D. Administer granulocyte colony-stimulating factor (G-CSF) subcutaneously
Correct Answer: B
Rationale: Correct because febrile neutropenia (temperature >38.3°C with ANC
<500/mm³) is a life-threatening oncologic emergency requiring immediate blood cultures
from all lumens and initiation of broad-spectrum antibiotics within one hour to prevent
sepsis and death. The nurse must recognize that infection is the most common cause of
chemotherapy-related mortality, and delays in antibiotic administration significantly
increase mortality rates. While G-CSF may be part of the long-term management plan, it
does not address the acute bacterial infection, and droplet precautions are inappropriate as
the source is typically endogenous bacterial translocation rather than respiratory
transmission.
Q5. A patient with severe diarrhea for 5 days is admitted with lethargy, dry mucous
membranes, and orthostatic hypotension. Laboratory results show sodium 138 mEq/L,
potassium 3.0 mEq/L, and bicarbonate 18 mEq/L. Which IV fluid should the nurse
anticipate as the gold standard for resuscitation?
A. 0.9% Normal Saline
B. 3% Hypertonic Saline
, C. Lactated Ringer's
D. D5W with 20 mEq KCl
Correct Answer: A
Rationale: Correct because Lactated Ringer's is the gold standard fluid for severe
dehydration from prolonged diarrhea, as it contains physiologic concentrations of sodium,
potassium, calcium, and lactate which is converted to bicarbonate in the liver to buffer the
metabolic acidosis caused by bicarbonate loss in stool. This patient's hypokalemia (3.0
mEq/L), metabolic acidosis (bicarbonate 18 mEq/L), and clinical signs of severe
dehydration indicate significant electrolyte and fluid deficits that LR addresses more
effectively than normal saline, which lacks buffering capacity and contains higher chloride
concentrations that can worsen acidosis. The nurse must initiate continuous cardiac
monitoring for hypokalemia, track strict intake and output, and prepare for potas sium
replacement once adequate urine output is established.
Q6 – Select all that apply. A 35-year-old male is admitted with full-thickness burns
covering 40% TBSA sustained in a workplace explosion 2 hours ago. Which initial
stabilization interventions should the nurse implement? (Select all that apply.)
A. Apply ice packs directly to burned areas to reduce tissue damage
B. Establish two large-bore IV lines through unburned skin if possible
C. Secure a patent airway and administer 100% humidified oxygen
D. Break blisters to assess the extent of underlying tissue damage
E. Remove all rings, watches, and constrictive clothing immediately
Correct Answer: B, C, E
Rationale: Correct because establishing two large-bore IV lines is essential for Parkland
Formula fluid resuscitation (4 mL × kg × %TBSA), securing the airway with humidified
oxygen addresses potential inhalation injury from the explosion, and removing constrictive
items prevents tourniquet effect from rapidly developing edema. Ice application is
contraindicated as it causes vasoconstriction, worsens tissue ischemia, and can induce
hypothermia in patients with large burn surface areas. Breaking blisters destroys the
protective barrier against infection and increases fluid loss, while the exact time of injury
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Study Guide
Guaranteed Pass
Q1. A 42-year-old male is brought to the emergency department following a house fire. He
has partial-thickness burns covering the anterior torso, both entire arms, and the entire
head and neck. Using the Rule of Nines, what is his estimated total body surface area
(TBSA) burned?
A. 27%
B. 36%
C. 45%
D. 54%
Correct Answer: C
Rationale: Correct because the Rule of Nines assigns 18% to the anterior torso, 9% to each
entire arm (18% total for both arms), and 9% to the entire head and neck, which sums to
45% TBSA burned. The posterior torso is unburned and therefore not included in the
calculation, as TBSA for fluid resuscitation only counts partial-thickness and full-thickness
burns. The nurse must immediately initiate fluid resuscitation using the Parkland Formula
and establish two large-bore IV lines, as burns exceeding 20% TBSA in adults require
aggressive crystalloid replacement to prevent hypovolemic shock.
Q2. A patient with septic shock has a temperature of 38.9°C, heart rate of 112 bpm,
respiratory rate of 24 breaths/min, and WBC of 15,800/mm³. The nurse recognizes these
findings as consistent with which criteria?
,A. Systemic Inflammatory Response Syndrome (SIRS)
B. Mild sepsis without organ dysfunction
C. Compensated shock state
D. Anaphylactic reaction
Correct Answer: A
Rationale: Correct because this patient meets at least three SIRS criteria: temperature
>38°C, heart rate >90 bpm, respiratory rate >20 breaths/min, and WBC >12,000/mm³,
which together indicate a systemic inflammatory response to infection. SIRS is the
foundational clinical syndrome that, when combined with a documented or suspected
infection, defines sepsis according to current guidelines. The nurse must recognize that
while SIRS criteria identify patients at risk, the priority intervention is to initiate broad -
spectrum antibiotics within one hour of recognition and begin aggressive fluid
resuscitation with 30 mL/kg of crystalloids to prevent progression to septic shock.
Q3. A 68-year-old male with chronic hypertension presents with sudden, severe, tearing
chest pain that radiates directly into his back between the scapulae. Vital signs reveal a
blood pressure of 198/110 mmHg in the left arm and 156/98 mmHg in the right arm.
Which priority intervention should the nurse anticipate?
A. Immediate surgical repair without blood pressure management
B. Administration of IV heparin for anticoagulation
C. Aggressive fluid resuscitation with normal saline
D. IV beta-blocker administration to reduce aortic wall shear stress
Correct Answer: D
Rationale: Correct because the priority medical management for aortic dissection is
immediate blood pressure and heart rate control using IV beta-blockers such as esmolol or
labetalol to reduce shear stress on the torn aortic intima and prevent further propagation
of the dissection. The vastly unequal blood pressures between arms (pulse deficit) and the
classic tearing interscapular back pain are pathognomonic for aortic dissection, and the
target parameters are heart rate <60 bpm and systolic blood pressure of 100 -120 mmHg.
The nurse must initiate continuous cardiac and hemodynamic monitoring, prepare for
,emergent surgical consultation, and avoid anticoagulation or aggressive fluid resuscitation
which could worsen bleeding or increase aortic wall stress.
Q4. A patient receiving chemotherapy for acute myeloid leukemia develops a temperature
of 38.6°C, chills, and absolute neutrophil count (ANC) of 320/mm³. Which nursing action is
the priority?
A. Administer acetaminophen and monitor temperature every 4 hours
B. Obtain blood cultures and initiate broad-spectrum antibiotics immediately
C. Place the patient in droplet precautions and restrict visitors
D. Administer granulocyte colony-stimulating factor (G-CSF) subcutaneously
Correct Answer: B
Rationale: Correct because febrile neutropenia (temperature >38.3°C with ANC
<500/mm³) is a life-threatening oncologic emergency requiring immediate blood cultures
from all lumens and initiation of broad-spectrum antibiotics within one hour to prevent
sepsis and death. The nurse must recognize that infection is the most common cause of
chemotherapy-related mortality, and delays in antibiotic administration significantly
increase mortality rates. While G-CSF may be part of the long-term management plan, it
does not address the acute bacterial infection, and droplet precautions are inappropriate as
the source is typically endogenous bacterial translocation rather than respiratory
transmission.
Q5. A patient with severe diarrhea for 5 days is admitted with lethargy, dry mucous
membranes, and orthostatic hypotension. Laboratory results show sodium 138 mEq/L,
potassium 3.0 mEq/L, and bicarbonate 18 mEq/L. Which IV fluid should the nurse
anticipate as the gold standard for resuscitation?
A. 0.9% Normal Saline
B. 3% Hypertonic Saline
, C. Lactated Ringer's
D. D5W with 20 mEq KCl
Correct Answer: A
Rationale: Correct because Lactated Ringer's is the gold standard fluid for severe
dehydration from prolonged diarrhea, as it contains physiologic concentrations of sodium,
potassium, calcium, and lactate which is converted to bicarbonate in the liver to buffer the
metabolic acidosis caused by bicarbonate loss in stool. This patient's hypokalemia (3.0
mEq/L), metabolic acidosis (bicarbonate 18 mEq/L), and clinical signs of severe
dehydration indicate significant electrolyte and fluid deficits that LR addresses more
effectively than normal saline, which lacks buffering capacity and contains higher chloride
concentrations that can worsen acidosis. The nurse must initiate continuous cardiac
monitoring for hypokalemia, track strict intake and output, and prepare for potas sium
replacement once adequate urine output is established.
Q6 – Select all that apply. A 35-year-old male is admitted with full-thickness burns
covering 40% TBSA sustained in a workplace explosion 2 hours ago. Which initial
stabilization interventions should the nurse implement? (Select all that apply.)
A. Apply ice packs directly to burned areas to reduce tissue damage
B. Establish two large-bore IV lines through unburned skin if possible
C. Secure a patent airway and administer 100% humidified oxygen
D. Break blisters to assess the extent of underlying tissue damage
E. Remove all rings, watches, and constrictive clothing immediately
Correct Answer: B, C, E
Rationale: Correct because establishing two large-bore IV lines is essential for Parkland
Formula fluid resuscitation (4 mL × kg × %TBSA), securing the airway with humidified
oxygen addresses potential inhalation injury from the explosion, and removing constrictive
items prevents tourniquet effect from rapidly developing edema. Ice application is
contraindicated as it causes vasoconstriction, worsens tissue ischemia, and can induce
hypothermia in patients with large burn surface areas. Breaking blisters destroys the
protective barrier against infection and increases fluid loss, while the exact time of injury
