NUR 265 Exam 2 V2 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 58-year-old patient, Mr. Miller, is admitted to the ICU with a diagnosis of septic shock.
His blood pressure is 82/46 mmHg, heart rate is 126 bpm, and his serum lactate level is 5.2
mmol/L. After a 30 mL/kg crystalloid bolus, his MAP remains 54 mmHg. Which of the
following is the nurse’s priority intervention?
A. Administer a second 30 mL/kg bolus of 0.9% Normal Saline.
B. Initiate a Norepinephrine infusion to maintain MAP > 65 mmHg.
C. Obtain blood cultures and start broad-spectrum antibiotics.
D. Administer Sodium Bicarbonate to correct metabolic acidosis.
Correct Answer: B
Explanation: In septic shock, if the patient remains hypotensive (MAP < 65 mmHg) despite
adequate fluid resuscitation, the priority is to initiate vasopressors. Norepinephrine is the
first-line vasopressor recommended by the Surviving Sepsis Campaign. Delaying
vasopressor support can lead to prolonged tissue hypoperfusion and multi-organ
dysfunction.
,2. Mrs. Henderson is brought to the emergency department with full-thickness burns to her
entire right arm, the anterior chest, and the anterior right leg. Using the Rule of Nines, what is
the estimated total body surface area (TBSA) burned?
A. 36%
B. 27%
C. 45%
D. 18%
Correct Answer: B
Explanation: According to the Rule of Nines, the entire right arm counts as 9%, the
anterior chest counts as 9%, and the anterior right leg counts as 9%. Adding these
components results in a total of 27% TBSA. Accurate calculation of TBSA is critical for
determining fluid resuscitation needs via the Parkland formula.
3. A patient with end-stage liver disease is exhibiting confusion, flapping tremors of the hands
(asterixis), and a serum ammonia level of 110 µmol/L. Which medication should the nurse
anticipate administering to decrease the ammonia levels?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
,Correct Answer: C
Explanation: Lactulose is the primary treatment for hepatic encephalopathy as it
promotes the excretion of ammonia through the stool. It works by acidifying the colon,
which converts ammonia to ammonium, preventing its absorption into the bloodstream.
The goal of therapy is usually 2-3 soft bowel movements per day to ensure toxin clearance.
4. Mr. Rodriguez, a patient in the ICU with ARDS, has a PaO2/FiO2 ratio of 120 while on a
ventilator with a PEEP of 12 cm H2O. The nurse notes that the patient’s oxygenation is not
improving despite high FiO2. What evidence-based position change should the nurse
facilitate?
A. High-Fowler’s position
B. Lateral recumbent position
C. Trendelenburg position
D. Prone positioning
Correct Answer: D
Explanation: Prone positioning is recommended for patients with moderate to severe
ARDS (PaO2/FiO2 ratio < 150) to improve oxygenation. This position redistributes
pulmonary blood flow and improves ventilation-perfusion matching by opening up
posterior alveoli. It is typically maintained for 16-18 hours a day in clinical protocols.
, 5. A patient with acute kidney injury (AKI) has a potassium level of 6.8 mEq/L and the ECG
shows peaked T-waves. Which medication should the nurse expect to administer first to
protect the heart from lethal arrhythmias?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Calcium Gluconate
C. Regular Insulin and D50W
D. Furosemide
Correct Answer: B
Explanation: Calcium gluconate is administered in the setting of hyperkalemia with ECG
changes to stabilize the myocardial cell membrane. While it does not lower the potassium
level, it prevents life-threatening arrhythmias like ventricular fibrillation. Once the heart is
protected, other medications like insulin or Kayexalate are used to actually shift or remove
potassium from the body.
6. A patient is admitted following a motor vehicle accident with a suspected tension
pneumothorax. The nurse observes tracheal deviation to the left and absent breath sounds
on the right. Which action is the absolute priority?
A. Obtain a portable chest X-ray.
B. Insert a large-bore IV and start fluids.
C. Perform immediate needle decompression.
D. Assess the patient’s arterial blood gases.
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 58-year-old patient, Mr. Miller, is admitted to the ICU with a diagnosis of septic shock.
His blood pressure is 82/46 mmHg, heart rate is 126 bpm, and his serum lactate level is 5.2
mmol/L. After a 30 mL/kg crystalloid bolus, his MAP remains 54 mmHg. Which of the
following is the nurse’s priority intervention?
A. Administer a second 30 mL/kg bolus of 0.9% Normal Saline.
B. Initiate a Norepinephrine infusion to maintain MAP > 65 mmHg.
C. Obtain blood cultures and start broad-spectrum antibiotics.
D. Administer Sodium Bicarbonate to correct metabolic acidosis.
Correct Answer: B
Explanation: In septic shock, if the patient remains hypotensive (MAP < 65 mmHg) despite
adequate fluid resuscitation, the priority is to initiate vasopressors. Norepinephrine is the
first-line vasopressor recommended by the Surviving Sepsis Campaign. Delaying
vasopressor support can lead to prolonged tissue hypoperfusion and multi-organ
dysfunction.
,2. Mrs. Henderson is brought to the emergency department with full-thickness burns to her
entire right arm, the anterior chest, and the anterior right leg. Using the Rule of Nines, what is
the estimated total body surface area (TBSA) burned?
A. 36%
B. 27%
C. 45%
D. 18%
Correct Answer: B
Explanation: According to the Rule of Nines, the entire right arm counts as 9%, the
anterior chest counts as 9%, and the anterior right leg counts as 9%. Adding these
components results in a total of 27% TBSA. Accurate calculation of TBSA is critical for
determining fluid resuscitation needs via the Parkland formula.
3. A patient with end-stage liver disease is exhibiting confusion, flapping tremors of the hands
(asterixis), and a serum ammonia level of 110 µmol/L. Which medication should the nurse
anticipate administering to decrease the ammonia levels?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
,Correct Answer: C
Explanation: Lactulose is the primary treatment for hepatic encephalopathy as it
promotes the excretion of ammonia through the stool. It works by acidifying the colon,
which converts ammonia to ammonium, preventing its absorption into the bloodstream.
The goal of therapy is usually 2-3 soft bowel movements per day to ensure toxin clearance.
4. Mr. Rodriguez, a patient in the ICU with ARDS, has a PaO2/FiO2 ratio of 120 while on a
ventilator with a PEEP of 12 cm H2O. The nurse notes that the patient’s oxygenation is not
improving despite high FiO2. What evidence-based position change should the nurse
facilitate?
A. High-Fowler’s position
B. Lateral recumbent position
C. Trendelenburg position
D. Prone positioning
Correct Answer: D
Explanation: Prone positioning is recommended for patients with moderate to severe
ARDS (PaO2/FiO2 ratio < 150) to improve oxygenation. This position redistributes
pulmonary blood flow and improves ventilation-perfusion matching by opening up
posterior alveoli. It is typically maintained for 16-18 hours a day in clinical protocols.
, 5. A patient with acute kidney injury (AKI) has a potassium level of 6.8 mEq/L and the ECG
shows peaked T-waves. Which medication should the nurse expect to administer first to
protect the heart from lethal arrhythmias?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Calcium Gluconate
C. Regular Insulin and D50W
D. Furosemide
Correct Answer: B
Explanation: Calcium gluconate is administered in the setting of hyperkalemia with ECG
changes to stabilize the myocardial cell membrane. While it does not lower the potassium
level, it prevents life-threatening arrhythmias like ventricular fibrillation. Once the heart is
protected, other medications like insulin or Kayexalate are used to actually shift or remove
potassium from the body.
6. A patient is admitted following a motor vehicle accident with a suspected tension
pneumothorax. The nurse observes tracheal deviation to the left and absent breath sounds
on the right. Which action is the absolute priority?
A. Obtain a portable chest X-ray.
B. Insert a large-bore IV and start fluids.
C. Perform immediate needle decompression.
D. Assess the patient’s arterial blood gases.
