NUR 265 Exam 4 V1 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. Mr. Thompson is a 68-year-old patient admitted with septic shock secondary to a urinary
tract infection. His current blood pressure is 82/46 mmHg, heart rate is 124 bpm, and his
serum lactate level is 4.5 mmol/L. Which intervention should the nurse prioritize first
according to the Surviving Sepsis Bundle?
A. Initiate norepinephrine to maintain a MAP >65 mmHg.
B. Administer a 30 mL/kg isotonic crystalloid bolus.
C. Obtain blood cultures from two different sites.
D. Administer broad-spectrum antibiotics within the first hour.
Correct Answer: B
Explanation: The initial management for septic shock involves aggressive fluid
resuscitation to restore tissue perfusion, especially when hypotension or elevated lactate is
present. While blood cultures and antibiotics are critical, the immediate physiological
threat is hypoperfusion, which is addressed first by a 30 mL/kg fluid bolus. Only after fluid
resuscitation has failed to maintain adequate MAP should vasopressors like
norepinephrine be initiated.
,2. A 24-year-old patient, Sarah, was admitted with a T4 spinal cord injury. She suddenly
reports a severe, throbbing headache and her blood pressure is 192/104 mmHg. Her skin is
flushed and diaphoretic above the level of the injury. What is the nurse’s immediate priority
action?
A. Place the patient in a high-Fowler’s position.
B. Administer a prescribed dose of hydralazine intravenously.
C. Assess the patient for bladder distension or a blocked catheter.
D. Perform a digital rectal exam to check for fecal impaction.
Correct Answer: A
Explanation: The patient is exhibiting symptoms of autonomic dysreflexia, which is a
medical emergency in patients with T6 or higher spinal cord injuries. The first action the
nurse must take is to sit the patient upright (high-Fowler’s) to utilize orthostatic pressure
changes to help lower the dangerously high blood pressure. Once the patient is positioned,
the nurse should then investigate the cause, such as bladder distension or bowel impaction,
and notify the provider.
3. James is being treated for Acute Respiratory Distress Syndrome (ARDS) and is currently on
mechanical ventilation with PEEP set at 15 cm H2O. The nurse notes a sudden drop in blood
pressure and absent breath sounds on the right side. Which complication should the nurse
suspect?
A. Tension pneumothorax
,B. Pulmonary embolism
C. Ventilator-associated pneumonia
D. Decreased cardiac output due to high PEEP
Correct Answer: A
Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase the risk of
barotrauma, which can lead to a pneumothorax. The sudden loss of breath sounds on one
side combined with hemodynamic instability (hypotension) strongly suggests a tension
pneumothorax. The nurse must immediately prepare for needle decompression or chest
tube insertion to relieve the pressure in the pleural space.
4. A 45-year-old male, David, weighs 80 kg and was admitted with 40% Total Body Surface
Area (TBSA) burns at 10:00 AM. Using the Parkland Formula (4mL/kg/%TBSA), the total 24-
hour fluid requirement is 12,800 mL. How many mL of lactated Ringer’s should be
administered in the first 8 hours?
A. 6,400 mL
B. 4,266 mL
C. 3,200 mL
D. 12,800 mL
Correct Answer: A
, Explanation: According to the Parkland Formula, half of the total calculated volume for the
first 24 hours must be administered within the first 8 hours post-injury. For David, 12,800
mL divided by 2 equals 6,400 mL to be infused in that initial 8-hour window. It is crucial to
remember that the timing starts from the time of the burn injury, not the time of arrival at
the hospital.
5. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. The ECG
shows peaked T waves and a widened QRS complex. Which medication should the nurse
expect to administer first to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Calcium gluconate
C. Intravenous regular insulin and dextrose
D. Sodium bicarbonate
Correct Answer: B
Explanation: In the setting of severe hyperkalemia with ECG changes, the immediate
priority is to stabilize the myocardial cell membrane to prevent lethal arrhythmias. Calcium
gluconate does not lower the potassium level but acts quickly to antagonize the effects of
potassium on the heart. Subsequent treatments like insulin with dextrose or Kayexalate
will then be used to shift or remove potassium from the body.
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. Mr. Thompson is a 68-year-old patient admitted with septic shock secondary to a urinary
tract infection. His current blood pressure is 82/46 mmHg, heart rate is 124 bpm, and his
serum lactate level is 4.5 mmol/L. Which intervention should the nurse prioritize first
according to the Surviving Sepsis Bundle?
A. Initiate norepinephrine to maintain a MAP >65 mmHg.
B. Administer a 30 mL/kg isotonic crystalloid bolus.
C. Obtain blood cultures from two different sites.
D. Administer broad-spectrum antibiotics within the first hour.
Correct Answer: B
Explanation: The initial management for septic shock involves aggressive fluid
resuscitation to restore tissue perfusion, especially when hypotension or elevated lactate is
present. While blood cultures and antibiotics are critical, the immediate physiological
threat is hypoperfusion, which is addressed first by a 30 mL/kg fluid bolus. Only after fluid
resuscitation has failed to maintain adequate MAP should vasopressors like
norepinephrine be initiated.
,2. A 24-year-old patient, Sarah, was admitted with a T4 spinal cord injury. She suddenly
reports a severe, throbbing headache and her blood pressure is 192/104 mmHg. Her skin is
flushed and diaphoretic above the level of the injury. What is the nurse’s immediate priority
action?
A. Place the patient in a high-Fowler’s position.
B. Administer a prescribed dose of hydralazine intravenously.
C. Assess the patient for bladder distension or a blocked catheter.
D. Perform a digital rectal exam to check for fecal impaction.
Correct Answer: A
Explanation: The patient is exhibiting symptoms of autonomic dysreflexia, which is a
medical emergency in patients with T6 or higher spinal cord injuries. The first action the
nurse must take is to sit the patient upright (high-Fowler’s) to utilize orthostatic pressure
changes to help lower the dangerously high blood pressure. Once the patient is positioned,
the nurse should then investigate the cause, such as bladder distension or bowel impaction,
and notify the provider.
3. James is being treated for Acute Respiratory Distress Syndrome (ARDS) and is currently on
mechanical ventilation with PEEP set at 15 cm H2O. The nurse notes a sudden drop in blood
pressure and absent breath sounds on the right side. Which complication should the nurse
suspect?
A. Tension pneumothorax
,B. Pulmonary embolism
C. Ventilator-associated pneumonia
D. Decreased cardiac output due to high PEEP
Correct Answer: A
Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase the risk of
barotrauma, which can lead to a pneumothorax. The sudden loss of breath sounds on one
side combined with hemodynamic instability (hypotension) strongly suggests a tension
pneumothorax. The nurse must immediately prepare for needle decompression or chest
tube insertion to relieve the pressure in the pleural space.
4. A 45-year-old male, David, weighs 80 kg and was admitted with 40% Total Body Surface
Area (TBSA) burns at 10:00 AM. Using the Parkland Formula (4mL/kg/%TBSA), the total 24-
hour fluid requirement is 12,800 mL. How many mL of lactated Ringer’s should be
administered in the first 8 hours?
A. 6,400 mL
B. 4,266 mL
C. 3,200 mL
D. 12,800 mL
Correct Answer: A
, Explanation: According to the Parkland Formula, half of the total calculated volume for the
first 24 hours must be administered within the first 8 hours post-injury. For David, 12,800
mL divided by 2 equals 6,400 mL to be infused in that initial 8-hour window. It is crucial to
remember that the timing starts from the time of the burn injury, not the time of arrival at
the hospital.
5. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. The ECG
shows peaked T waves and a widened QRS complex. Which medication should the nurse
expect to administer first to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Calcium gluconate
C. Intravenous regular insulin and dextrose
D. Sodium bicarbonate
Correct Answer: B
Explanation: In the setting of severe hyperkalemia with ECG changes, the immediate
priority is to stabilize the myocardial cell membrane to prevent lethal arrhythmias. Calcium
gluconate does not lower the potassium level but acts quickly to antagonize the effects of
potassium on the heart. Subsequent treatments like insulin with dextrose or Kayexalate
will then be used to shift or remove potassium from the body.
