NUR 265 Advanced Concepts of Medical-Surgical
Nursing Final Exam | Complete Practice Questions,
Answers & Detailed Rationales 2026/2027
Question 1
A client is admitted to the intensive care unit in septic shock. Despite
aggressive fluid resuscitation with 30 mL/kg of crystalloids, the client's
mean arterial pressure (MAP) remains 55 mmHg and serum lactate is
4.5 mmol/L. Which of the following is the most appropriate next step in
management?
• A. Administer a second rapid fluid bolus of 20 mL/kg.
• B. Initiate a norepinephrine infusion to maintain MAP ≥ 65
mmHg.
• C. Start a continuous infusion of regular insulin to control blood
glucose.
• D. Prepare the client for emergency endotracheal intubation and
mechanical ventilation.
Correct Answer: B. Initiate a norepinephrine infusion to maintain MAP
≥ 65 mmHg.
Detailed Rationale: In septic shock, if fluid resuscitation fails to restore
an adequate blood pressure (MAP ≥ 65 mmHg), vasopressors are
initiated immediately. Norepinephrine is the first-line vasopressor of
choice to restore vascular tone. Continued large fluid boluses without
response can lead to fluid overload and worsened outcomes.
,Question 2
A client with acute respiratory distress syndrome (ARDS) is mechanically
ventilated with low tidal volume ventilation and high positive end-
expiratory pressure (PEEP). The nurse understands that the primary
physiological purpose of PEEP in ARDS is to:
• A. Decrease the work of breathing by assisting spontaneous
inspiration.
• B. Prevent alveolar collapse at the end of expiration and improve
oxygenation.
• C. Increase peak inspiratory pressures to clear thick airway
secretions.
• D. Reduce functional residual capacity to prevent hyperinflation.
Correct Answer: B. Prevent alveolar collapse at the end of expiration
and improve oxygenation.
Detailed Rationale: PEEP applies positive pressure to the airways at the
end of expiration, keeping fragile alveoli open, preventing atelectasis,
increasing functional residual capacity, and improving oxygenation in
clients with ARDS.
Question 3
A client sustaining a traumatic brain injury (TBI) exhibits a widening
pulse pressure, bradycardia, and irregular respirations. The nurse
recognizes this constellation of findings as Cushing's triad, which is a
classic indicator of:
• A. Decreased cerebral perfusion pressure resulting from systemic
hypotension.
, • B. Impending herniation caused by significantly increased
intracranial pressure (ICP).
• C. Brainstem infarction secondary to basilar skull fracture.
• D. Neurogenic shock resulting from loss of sympathetic vasomotor
tone.
Correct Answer: B. Impending herniation caused by significantly
increased intracranial pressure (ICP).
Detailed Rationale: Cushing's triad consists of hypertension (with a
widening pulse pressure), bradycardia, and irregular respirations. It is a
late and ominous sign of severely elevated intracranial pressure
indicating pressure on the brainstem and impending brain herniation.
Question 4
A client who experienced severe dehydration and hemorrhage following
major trauma develops an acute kidney injury (AKI). Laboratory results
show a BUN-to-creatinine ratio of 25:1, a urine sodium of 12 mEq/L,
and a fractional excretion of sodium (FENa) less than 1%. The nurse
identifies these findings as characteristic of:
• A. Prerenal acute kidney injury.
• B. Intrinsic acute tubular necrosis.
• C. Postrenal urinary tract obstruction.
• D. Chronic kidney disease stage 4.
Correct Answer: A. Prerenal acute kidney injury.
Detailed Rationale: Prerenal AKI is caused by decreased renal perfusion
(e.g., hypovolemia, hemorrhage). The kidneys respond by conserving
, sodium and water, resulting in a BUN/Cr ratio > 20: 1, low urine sodium
(< 20 mEq/L), and a FENa < 1%. Intrinsic AKI (such as ATN) typically
shows a FENa > 2%.
Question 5
A client is admitted with diabetic ketoacidosis (DKA). Initial laboratory
results include blood glucose 580 mg/dL, pH 7.15, serum bicarbonate
12 mEq/L, and moderate ketonuria. Which of the following orders
should the nurse anticipate implementing first?
• A. Intravenous regular insulin bolus followed by a continuous
infusion.
• B. Intravenous infusion of 0.9% Sodium Chloride at 1000 mL/hour.
• C. Subcutaneous administration of long-acting insulin glargine.
• D. Intravenous administration of 50 mEq of sodium bicarbonate.
Correct Answer: B. Intravenous infusion of 0.9% Sodium Chloride at
1000 mL/hour.
Detailed Rationale: Fluid resuscitation is the absolute first priority in
managing DKA to restore intravascular volume, improve renal perfusion,
and help lower blood glucose levels through dilution and diuresis.
Insulin is started after initial fluid resuscitation and once serum
potassium is verified to be ≥ 3.3 mEq/L.
Question 6
A client is recovering from an acute anterior wall myocardial infarction
(STEMI). On the third day post-infarction, the client suddenly develops a
harsh, loud holosystolic murmur at the apex, acute pulmonary edema,
Nursing Final Exam | Complete Practice Questions,
Answers & Detailed Rationales 2026/2027
Question 1
A client is admitted to the intensive care unit in septic shock. Despite
aggressive fluid resuscitation with 30 mL/kg of crystalloids, the client's
mean arterial pressure (MAP) remains 55 mmHg and serum lactate is
4.5 mmol/L. Which of the following is the most appropriate next step in
management?
• A. Administer a second rapid fluid bolus of 20 mL/kg.
• B. Initiate a norepinephrine infusion to maintain MAP ≥ 65
mmHg.
• C. Start a continuous infusion of regular insulin to control blood
glucose.
• D. Prepare the client for emergency endotracheal intubation and
mechanical ventilation.
Correct Answer: B. Initiate a norepinephrine infusion to maintain MAP
≥ 65 mmHg.
Detailed Rationale: In septic shock, if fluid resuscitation fails to restore
an adequate blood pressure (MAP ≥ 65 mmHg), vasopressors are
initiated immediately. Norepinephrine is the first-line vasopressor of
choice to restore vascular tone. Continued large fluid boluses without
response can lead to fluid overload and worsened outcomes.
,Question 2
A client with acute respiratory distress syndrome (ARDS) is mechanically
ventilated with low tidal volume ventilation and high positive end-
expiratory pressure (PEEP). The nurse understands that the primary
physiological purpose of PEEP in ARDS is to:
• A. Decrease the work of breathing by assisting spontaneous
inspiration.
• B. Prevent alveolar collapse at the end of expiration and improve
oxygenation.
• C. Increase peak inspiratory pressures to clear thick airway
secretions.
• D. Reduce functional residual capacity to prevent hyperinflation.
Correct Answer: B. Prevent alveolar collapse at the end of expiration
and improve oxygenation.
Detailed Rationale: PEEP applies positive pressure to the airways at the
end of expiration, keeping fragile alveoli open, preventing atelectasis,
increasing functional residual capacity, and improving oxygenation in
clients with ARDS.
Question 3
A client sustaining a traumatic brain injury (TBI) exhibits a widening
pulse pressure, bradycardia, and irregular respirations. The nurse
recognizes this constellation of findings as Cushing's triad, which is a
classic indicator of:
• A. Decreased cerebral perfusion pressure resulting from systemic
hypotension.
, • B. Impending herniation caused by significantly increased
intracranial pressure (ICP).
• C. Brainstem infarction secondary to basilar skull fracture.
• D. Neurogenic shock resulting from loss of sympathetic vasomotor
tone.
Correct Answer: B. Impending herniation caused by significantly
increased intracranial pressure (ICP).
Detailed Rationale: Cushing's triad consists of hypertension (with a
widening pulse pressure), bradycardia, and irregular respirations. It is a
late and ominous sign of severely elevated intracranial pressure
indicating pressure on the brainstem and impending brain herniation.
Question 4
A client who experienced severe dehydration and hemorrhage following
major trauma develops an acute kidney injury (AKI). Laboratory results
show a BUN-to-creatinine ratio of 25:1, a urine sodium of 12 mEq/L,
and a fractional excretion of sodium (FENa) less than 1%. The nurse
identifies these findings as characteristic of:
• A. Prerenal acute kidney injury.
• B. Intrinsic acute tubular necrosis.
• C. Postrenal urinary tract obstruction.
• D. Chronic kidney disease stage 4.
Correct Answer: A. Prerenal acute kidney injury.
Detailed Rationale: Prerenal AKI is caused by decreased renal perfusion
(e.g., hypovolemia, hemorrhage). The kidneys respond by conserving
, sodium and water, resulting in a BUN/Cr ratio > 20: 1, low urine sodium
(< 20 mEq/L), and a FENa < 1%. Intrinsic AKI (such as ATN) typically
shows a FENa > 2%.
Question 5
A client is admitted with diabetic ketoacidosis (DKA). Initial laboratory
results include blood glucose 580 mg/dL, pH 7.15, serum bicarbonate
12 mEq/L, and moderate ketonuria. Which of the following orders
should the nurse anticipate implementing first?
• A. Intravenous regular insulin bolus followed by a continuous
infusion.
• B. Intravenous infusion of 0.9% Sodium Chloride at 1000 mL/hour.
• C. Subcutaneous administration of long-acting insulin glargine.
• D. Intravenous administration of 50 mEq of sodium bicarbonate.
Correct Answer: B. Intravenous infusion of 0.9% Sodium Chloride at
1000 mL/hour.
Detailed Rationale: Fluid resuscitation is the absolute first priority in
managing DKA to restore intravascular volume, improve renal perfusion,
and help lower blood glucose levels through dilution and diuresis.
Insulin is started after initial fluid resuscitation and once serum
potassium is verified to be ≥ 3.3 mEq/L.
Question 6
A client is recovering from an acute anterior wall myocardial infarction
(STEMI). On the third day post-infarction, the client suddenly develops a
harsh, loud holosystolic murmur at the apex, acute pulmonary edema,
