NUR 265 Exam 2 V1 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 68-year-old male, Mr. Thompson, is admitted to the ICU with a diagnosis of septic shock.
His current vital signs are BP 82/40 mmHg, HR 128 bpm, and RR 26 bpm. The nurse notes a
Mean Arterial Pressure (MAP) of 54 mmHg. After administering a 2L normal saline bolus, the
MAP remains at 56 mmHg. Which prescription should the nurse anticipate next?
A. Intravenous infusion of Norepinephrine
B. Subcutaneous injection of Heparin
C. Furosemide 40 mg IV push
D. Diltiazem drip at 5 mg/hr
Correct Answer: A
Explanation: Norepinephrine is the first-line vasopressor recommended in the Surviving
Sepsis Campaign guidelines when fluid resuscitation fails to achieve a MAP of at least 65
mmHg. The patient’s persistent hypotension despite adequate fluid resuscitation indicates
a need for vasopressor support to improve perfusion. Administering diuretics or calcium
channel blockers would further compromise the patient’s hemodynamic stability.
,2. Ms. Rodriguez, a 42-year-old patient, arrives at the emergency department with 45% Total
Body Surface Area (TBSA) thermal burns. She weighs 70 kg. Using the Parkland formula
(4mL/kg/%TBSA), the nurse calculates the total fluid requirement for the first 24 hours. How
much fluid should be administered in the first 8 hours?
A. 12,600 mL
B. 6,300 mL
C. 3,150 mL
D. 4,200 mL
Correct Answer: B
Explanation: The Parkland formula calculation is 4 mL x 70 kg x 45% = 12,600 mL for the
first 24 hours. Half of this total volume (6,300 mL) must be administered within the first 8
hours from the time of the burn injury. The remaining half is administered over the
subsequent 16 hours to maintain adequate renal perfusion and prevent hypovolemic
shock.
3. Mr. Lee is being monitored with a pulmonary artery catheter. The nurse notes the
following readings: Central Venous Pressure (CVP) 1 mmHg, Pulmonary Artery Wedge
Pressure (PAWP) 4 mmHg, and Cardiac Index (CI) 1.8 L/min/m². Which clinical condition is
most consistent with these findings?
A. Hypervolemia
B. Cardiogenic Shock
,C. Right-sided Heart Failure
D. Hypovolemic Shock
Correct Answer: D
Explanation: A low CVP (normal 2-8 mmHg) and low PAWP (normal 6-12 mmHg) indicate
decreased preload, which is characteristic of hypovolemia. The low Cardiac Index further
supports that the heart does not have enough volume to circulate effectively. In contrast,
cardiogenic shock or hypervolemia would typically present with elevated pressure
readings due to fluid overload or backup.
4. A patient with a history of T4 spinal cord injury, Mr. Evans, reports a sudden, throbbing
headache and nasal congestion. His BP is 190/110 mmHg, and his baseline is 110/70 mmHg.
After sitting the patient upright, what is the nurse’s priority action?
A. Administer PRN Hydralazine
B. Obtain a 12-lead ECG
C. Notify the physician immediately
D. Assess the patient for bladder distension
Correct Answer: D
Explanation: The patient is exhibiting signs of Autonomic Dysreflexia, which is a medical
emergency common in spinal cord injuries above T6. The most common trigger is bladder
distension or fecal impaction. The nurse must immediately check for and alleviate the
triggering stimulus while the patient is in a high-Fowler’s position to lower blood pressure.
, 5. Mrs. Bennett is admitted with acute respiratory distress syndrome (ARDS) and is receiving
mechanical ventilation. The ventilator settings include a PEEP of 15 cm H2O. Which
assessment finding should the nurse prioritize as a complication of high PEEP?
A. Increased urine output
B. Decreased cardiac output and hypotension
C. Respiratory alkalosis
D. Improved oxygen saturation
Correct Answer: B
Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase
intrathoracic pressure, which can decrease venous return to the heart (preload). This leads
to decreased cardiac output and hypotension, which can compromise systemic perfusion.
Monitoring hemodynamic stability is critical when PEEP levels are elevated beyond 10 cm
H2O.
6. A 55-year-old male is in the ICU following an acute myocardial infarction. The nurse
observes the cardiac monitor and notes a sudden onset of wide QRS complexes at a rate of
160 bpm with no visible P waves. The patient is pulseless. What is the immediate priority?
A. Defibrillation
B. Administration of Amiodarone 150 mg IV
C. Synchronized cardioversion
D. Carotid sinus massage
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 68-year-old male, Mr. Thompson, is admitted to the ICU with a diagnosis of septic shock.
His current vital signs are BP 82/40 mmHg, HR 128 bpm, and RR 26 bpm. The nurse notes a
Mean Arterial Pressure (MAP) of 54 mmHg. After administering a 2L normal saline bolus, the
MAP remains at 56 mmHg. Which prescription should the nurse anticipate next?
A. Intravenous infusion of Norepinephrine
B. Subcutaneous injection of Heparin
C. Furosemide 40 mg IV push
D. Diltiazem drip at 5 mg/hr
Correct Answer: A
Explanation: Norepinephrine is the first-line vasopressor recommended in the Surviving
Sepsis Campaign guidelines when fluid resuscitation fails to achieve a MAP of at least 65
mmHg. The patient’s persistent hypotension despite adequate fluid resuscitation indicates
a need for vasopressor support to improve perfusion. Administering diuretics or calcium
channel blockers would further compromise the patient’s hemodynamic stability.
,2. Ms. Rodriguez, a 42-year-old patient, arrives at the emergency department with 45% Total
Body Surface Area (TBSA) thermal burns. She weighs 70 kg. Using the Parkland formula
(4mL/kg/%TBSA), the nurse calculates the total fluid requirement for the first 24 hours. How
much fluid should be administered in the first 8 hours?
A. 12,600 mL
B. 6,300 mL
C. 3,150 mL
D. 4,200 mL
Correct Answer: B
Explanation: The Parkland formula calculation is 4 mL x 70 kg x 45% = 12,600 mL for the
first 24 hours. Half of this total volume (6,300 mL) must be administered within the first 8
hours from the time of the burn injury. The remaining half is administered over the
subsequent 16 hours to maintain adequate renal perfusion and prevent hypovolemic
shock.
3. Mr. Lee is being monitored with a pulmonary artery catheter. The nurse notes the
following readings: Central Venous Pressure (CVP) 1 mmHg, Pulmonary Artery Wedge
Pressure (PAWP) 4 mmHg, and Cardiac Index (CI) 1.8 L/min/m². Which clinical condition is
most consistent with these findings?
A. Hypervolemia
B. Cardiogenic Shock
,C. Right-sided Heart Failure
D. Hypovolemic Shock
Correct Answer: D
Explanation: A low CVP (normal 2-8 mmHg) and low PAWP (normal 6-12 mmHg) indicate
decreased preload, which is characteristic of hypovolemia. The low Cardiac Index further
supports that the heart does not have enough volume to circulate effectively. In contrast,
cardiogenic shock or hypervolemia would typically present with elevated pressure
readings due to fluid overload or backup.
4. A patient with a history of T4 spinal cord injury, Mr. Evans, reports a sudden, throbbing
headache and nasal congestion. His BP is 190/110 mmHg, and his baseline is 110/70 mmHg.
After sitting the patient upright, what is the nurse’s priority action?
A. Administer PRN Hydralazine
B. Obtain a 12-lead ECG
C. Notify the physician immediately
D. Assess the patient for bladder distension
Correct Answer: D
Explanation: The patient is exhibiting signs of Autonomic Dysreflexia, which is a medical
emergency common in spinal cord injuries above T6. The most common trigger is bladder
distension or fecal impaction. The nurse must immediately check for and alleviate the
triggering stimulus while the patient is in a high-Fowler’s position to lower blood pressure.
, 5. Mrs. Bennett is admitted with acute respiratory distress syndrome (ARDS) and is receiving
mechanical ventilation. The ventilator settings include a PEEP of 15 cm H2O. Which
assessment finding should the nurse prioritize as a complication of high PEEP?
A. Increased urine output
B. Decreased cardiac output and hypotension
C. Respiratory alkalosis
D. Improved oxygen saturation
Correct Answer: B
Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase
intrathoracic pressure, which can decrease venous return to the heart (preload). This leads
to decreased cardiac output and hypotension, which can compromise systemic perfusion.
Monitoring hemodynamic stability is critical when PEEP levels are elevated beyond 10 cm
H2O.
6. A 55-year-old male is in the ICU following an acute myocardial infarction. The nurse
observes the cardiac monitor and notes a sudden onset of wide QRS complexes at a rate of
160 bpm with no visible P waves. The patient is pulseless. What is the immediate priority?
A. Defibrillation
B. Administration of Amiodarone 150 mg IV
C. Synchronized cardioversion
D. Carotid sinus massage
