NUR 242 Exam 3 Medical-Surgical Nursing 2026 study
questions Unit 7 & and Verified Answers 100% Correct Grade
A
This exam covers advanced concepts in medical-surgical nursing, including hemodynamic monitoring, ventilator
management, acute kidney injury, liver failure, sepsis, and multi-organ dysfunction. It requires synthesis of
pathophysiology, pharmacology, and nursing interventions in complex clinical scenarios. It contains 149
multiple-choice questions, each with four distractors and a fully worked rationale that explains why the keyed
answer is correct. Questions are organized into clearly labelled sections that mirror the major content areas of
the course. Targeted learning outcomes include: Analyze complex clinical presentations to prioritize nursing
interventions.; Interpret hemodynamic and laboratory data to guide management of critically ill patients.;
Evaluate the effects of pharmacological and mechanical interventions on patient outcomes.; Synthesize knowledge
across body systems to manage patients with multi-organ dysfunction.. Every item has been reviewed for clinical
accuracy, current guidelines, and clarity so that students can study with confidence and self-correct as they work
through the bank. Use it as a high-yield review immediately before the exam, or as a structured practice tool
during the unit - the rationales double as concise teaching notes. The recommended writing time is 3 hours, with a
passing score of 80%. Aligned with Aligned with AACN and CCNE standards for baccalaureate nursing
education. standards and reflects the question style commonly seen on accredited program examinations. Students
consistently achieving above the cut score on this bank have historically gone on to earn A+ on the corresponding
Section 1: General (Questions 1-149)
1 A patient in the ICU with septic shock has a pulmonary artery catheter showing
cardiac output of 3.2 L/min, systemic vascular resistance of 900 dynes/sec/cm^-5,
and pulmonary artery occlusion pressure of 18 mm Hg. After fluid resuscitation,
mean arterial pressure remains 60 mm Hg. Which intervention is most
appropriate?
A) Add norepinephrine and consider afterload reduction
B) Increase intravenous fluids to raise preload further
C) Start dobutamine to increase cardiac contractility
D) Initiate inhaled nitric oxide to reduce pulmonary pressures
Answer: C
Rationale: The low cardiac output and elevated PAOP indicate cardiogenic
component; dobutamine improves contractility. Norepinephrine would increase
afterload, worsening output. Further fluids risk pulmonary edema. Nitric oxide is for
pulmonary hypertension, not low cardiac output.
2 A patient with acute respiratory distress syndrome is on volume-controlled
ventilation with plateau pressure of 35 cm H2O and tidal volume of 8 mL/kg ideal
body weight. What adjustment best adheres to lung-protective ventilation?
A) Increase PEEP to 20 cm H2O
B) Reduce tidal volume to 6 mL/kg
,C) Switch to pressure-controlled ventilation
D) Increase respiratory rate to maintain minute ventilation
Answer: B
Rationale: Lung-protective ventilation mandates low tidal volumes (4-6 mL/kg) to
limit volutrauma and barotrauma. Plateau pressure should be kept below 30 cm
H2O. Increasing PEEP may help oxygenation but does not address high plateau
pressure; pressure control does not guarantee safe tidal volume.
3 A patient with chronic kidney disease stage 4 is scheduled for a cardiac
catheterization with contrast. Which prophylactic measure is most evidence-based
to reduce the risk of contrast-induced nephropathy?
A) Administer N-acetylcysteine 1200 mg orally twice daily before procedure
B) Infuse normal saline 1 mL/kg/h for 12 hours pre- and post-procedure
C) Stop all nephrotoxic medications including ACE inhibitors and metformin
D) Prescribe sodium bicarbonate infusion 154 mEq/L at 3 mL/kg/h for 1 hour
pre-procedure
Answer: B
Rationale: Isotonic crystalloid hydration is the only measure consistently shown to
reduce contrast-induced nephropathy. N-acetylcysteine and sodium bicarbonate have
conflicting evidence. Stopping nephrotoxins is prudent but not sufficient alone.
4 A patient with cirrhosis and ascites develops acute confusion, asterixis, and a
serum ammonia of 90 µmol/L. Which medication protocol is most appropriate for
initial management?
A) Lactulose 30 mL orally every hour until two soft stools are produced
B) Rifaximin 550 mg orally twice daily as monotherapy
C) Polyethylene glycol 300 mL orally for rapid bowel evacuation
D) Neomycin 4 g orally daily in four divided doses
Answer: A
Rationale: Lactulose is first-line therapy for acute hepatic encephalopathy; dosing
titrated to bowel movements. Rifaximin is adjunctive or for secondary prophylaxis.
Polyethylene glycol may be used but not standard first-line. Neomycin is reserved
for those who cannot tolerate lactulose.
5 In a patient with severe sepsis and lactic acidosis, which fluid resuscitation
strategy is most consistent with Surviving Sepsis Campaign guidelines?
A) Administer 30 mL/kg crystalloid for initial hypotension or lactate 4 mmol/L
B) Use colloids (albumin) in all patients to reduce fluid requirements
,C) Target a central venous pressure of 12 mm Hg in all patients
D) Limit fluids to avoid pulmonary edema and start vasopressors immediately
Answer: A
Rationale: Guidelines recommend initial crystalloid bolus of 30 mL/kg for
hypotension or lactate 4. Albumin is considered in those requiring large volumes,
but not universally. CVP targeting is no longer recommended as a sole endpoint.
Vasopressors are added if hypotension persists after fluids.
6 A patient in the ICU develops acute kidney injury with urine output of 0.2
mL/kg/h and a serum potassium of 6.8 mEq/L. Which intervention should be
initiated first?
A) Intravenous calcium gluconate 10%
B) Inhaled albuterol nebulization
C) Sodium polystyrene sulfonate (Kayexalate) orally
D) Emergent hemodialysis
Answer: A
Rationale: Hyperkalemia with ECG changes or >6.5 mEq/L requires immediate
cardiac stabilization with IV calcium. Albuterol and Kayexalate lower potassium but
take time. Dialysis is definitive but not as immediate for cardiac protection.
7 A patient with severe acute pancreatitis develops sudden respiratory distress with
oxygen saturation of 85% on 100% non-rebreather mask. Chest X-ray shows
bilateral infiltrates. Which intervention is most appropriate?
A) Immediate endotracheal intubation and mechanical ventilation with low tidal
volumes
B) Continue non-rebreather and monitor arterial blood gas in 30 minutes
C) Administer diuretics to treat fluid overload
D) Place patient on bi-level positive airway pressure (BiPAP)
Answer: A
Rationale: Acute respiratory distress syndrome likely; refractory hypoxemia requires
intubation. Low tidal volume ventilation improves survival. BiPAP may be
considered in milder cases but not with severe hypoxemia. Diuretics are not
indicated for ARDS unless fluid overload is present.
8 A patient with sepsis and disseminated intravascular coagulation has a platelet
count of 20,000/µL and active bleeding from venipuncture sites. Which blood
product is indicated?
A) Platelet transfusion
, B) Fresh frozen plasma
C) Cryoprecipitate
D) Packed red blood cells
Answer: A
Rationale: In DIC with severe thrombocytopenia and bleeding, platelet transfusion is
indicated when count <50,000. FFP is given for prolonged PT/INR; cryoprecipitate
for low fibrinogen; RBCs for anemia. Platelets are the first priority here.
9 A patient in the ICU with multi-organ dysfunction syndrome has a serum lactate
of 6 mmol/L, mean arterial pressure of 55 mm Hg on norepinephrine 20 mcg/min,
and a central venous oxygen saturation of 55%. What additional therapy is most
appropriate?
A) Add vasopressin infusion
B) Increase norepinephrine to 30 mcg/min
C) Start dobutamine at 5 mcg/kg/min
D) Administer hydrocortisone 200 mg/day
Answer: A
Rationale: Persistent hypotension on high-dose norepinephrine suggests vasoplegia;
add vasopressin. Increasing norepinephrine may increase afterload excessively.
Dobutamine is indicated for low cardiac output with adequate perfusion pressure.
Steroids are considered for refractory shock but usually after adding vasopressin.
10 A patient with cirrhosis and acute variceal bleeding is started on octreotide and
undergoes endoscopic band ligation. Which additional medication is
recommended to prevent rebleeding and reduce mortality?
A) Propranolol
B) Somatostatin
C) Terlipressin
D) Pantoprazole
Answer: A
Rationale: Non-selective beta-blockers (propranolol) are used for primary and
secondary prophylaxis of variceal bleeding. Somatostatin/terlipressin are acute
management. Pantoprazole is for ulcer prophylaxis, not variceal prevention.
Propranolol reduces portal pressure and long-term rebleeding risk.
11 A patient with sepsis and acute kidney injury is receiving norepinephrine and has
a mean arterial pressure of 58 mm Hg despite maximal dosing. Which
intervention is most appropriate to improve renal perfusion?
questions Unit 7 & and Verified Answers 100% Correct Grade
A
This exam covers advanced concepts in medical-surgical nursing, including hemodynamic monitoring, ventilator
management, acute kidney injury, liver failure, sepsis, and multi-organ dysfunction. It requires synthesis of
pathophysiology, pharmacology, and nursing interventions in complex clinical scenarios. It contains 149
multiple-choice questions, each with four distractors and a fully worked rationale that explains why the keyed
answer is correct. Questions are organized into clearly labelled sections that mirror the major content areas of
the course. Targeted learning outcomes include: Analyze complex clinical presentations to prioritize nursing
interventions.; Interpret hemodynamic and laboratory data to guide management of critically ill patients.;
Evaluate the effects of pharmacological and mechanical interventions on patient outcomes.; Synthesize knowledge
across body systems to manage patients with multi-organ dysfunction.. Every item has been reviewed for clinical
accuracy, current guidelines, and clarity so that students can study with confidence and self-correct as they work
through the bank. Use it as a high-yield review immediately before the exam, or as a structured practice tool
during the unit - the rationales double as concise teaching notes. The recommended writing time is 3 hours, with a
passing score of 80%. Aligned with Aligned with AACN and CCNE standards for baccalaureate nursing
education. standards and reflects the question style commonly seen on accredited program examinations. Students
consistently achieving above the cut score on this bank have historically gone on to earn A+ on the corresponding
Section 1: General (Questions 1-149)
1 A patient in the ICU with septic shock has a pulmonary artery catheter showing
cardiac output of 3.2 L/min, systemic vascular resistance of 900 dynes/sec/cm^-5,
and pulmonary artery occlusion pressure of 18 mm Hg. After fluid resuscitation,
mean arterial pressure remains 60 mm Hg. Which intervention is most
appropriate?
A) Add norepinephrine and consider afterload reduction
B) Increase intravenous fluids to raise preload further
C) Start dobutamine to increase cardiac contractility
D) Initiate inhaled nitric oxide to reduce pulmonary pressures
Answer: C
Rationale: The low cardiac output and elevated PAOP indicate cardiogenic
component; dobutamine improves contractility. Norepinephrine would increase
afterload, worsening output. Further fluids risk pulmonary edema. Nitric oxide is for
pulmonary hypertension, not low cardiac output.
2 A patient with acute respiratory distress syndrome is on volume-controlled
ventilation with plateau pressure of 35 cm H2O and tidal volume of 8 mL/kg ideal
body weight. What adjustment best adheres to lung-protective ventilation?
A) Increase PEEP to 20 cm H2O
B) Reduce tidal volume to 6 mL/kg
,C) Switch to pressure-controlled ventilation
D) Increase respiratory rate to maintain minute ventilation
Answer: B
Rationale: Lung-protective ventilation mandates low tidal volumes (4-6 mL/kg) to
limit volutrauma and barotrauma. Plateau pressure should be kept below 30 cm
H2O. Increasing PEEP may help oxygenation but does not address high plateau
pressure; pressure control does not guarantee safe tidal volume.
3 A patient with chronic kidney disease stage 4 is scheduled for a cardiac
catheterization with contrast. Which prophylactic measure is most evidence-based
to reduce the risk of contrast-induced nephropathy?
A) Administer N-acetylcysteine 1200 mg orally twice daily before procedure
B) Infuse normal saline 1 mL/kg/h for 12 hours pre- and post-procedure
C) Stop all nephrotoxic medications including ACE inhibitors and metformin
D) Prescribe sodium bicarbonate infusion 154 mEq/L at 3 mL/kg/h for 1 hour
pre-procedure
Answer: B
Rationale: Isotonic crystalloid hydration is the only measure consistently shown to
reduce contrast-induced nephropathy. N-acetylcysteine and sodium bicarbonate have
conflicting evidence. Stopping nephrotoxins is prudent but not sufficient alone.
4 A patient with cirrhosis and ascites develops acute confusion, asterixis, and a
serum ammonia of 90 µmol/L. Which medication protocol is most appropriate for
initial management?
A) Lactulose 30 mL orally every hour until two soft stools are produced
B) Rifaximin 550 mg orally twice daily as monotherapy
C) Polyethylene glycol 300 mL orally for rapid bowel evacuation
D) Neomycin 4 g orally daily in four divided doses
Answer: A
Rationale: Lactulose is first-line therapy for acute hepatic encephalopathy; dosing
titrated to bowel movements. Rifaximin is adjunctive or for secondary prophylaxis.
Polyethylene glycol may be used but not standard first-line. Neomycin is reserved
for those who cannot tolerate lactulose.
5 In a patient with severe sepsis and lactic acidosis, which fluid resuscitation
strategy is most consistent with Surviving Sepsis Campaign guidelines?
A) Administer 30 mL/kg crystalloid for initial hypotension or lactate 4 mmol/L
B) Use colloids (albumin) in all patients to reduce fluid requirements
,C) Target a central venous pressure of 12 mm Hg in all patients
D) Limit fluids to avoid pulmonary edema and start vasopressors immediately
Answer: A
Rationale: Guidelines recommend initial crystalloid bolus of 30 mL/kg for
hypotension or lactate 4. Albumin is considered in those requiring large volumes,
but not universally. CVP targeting is no longer recommended as a sole endpoint.
Vasopressors are added if hypotension persists after fluids.
6 A patient in the ICU develops acute kidney injury with urine output of 0.2
mL/kg/h and a serum potassium of 6.8 mEq/L. Which intervention should be
initiated first?
A) Intravenous calcium gluconate 10%
B) Inhaled albuterol nebulization
C) Sodium polystyrene sulfonate (Kayexalate) orally
D) Emergent hemodialysis
Answer: A
Rationale: Hyperkalemia with ECG changes or >6.5 mEq/L requires immediate
cardiac stabilization with IV calcium. Albuterol and Kayexalate lower potassium but
take time. Dialysis is definitive but not as immediate for cardiac protection.
7 A patient with severe acute pancreatitis develops sudden respiratory distress with
oxygen saturation of 85% on 100% non-rebreather mask. Chest X-ray shows
bilateral infiltrates. Which intervention is most appropriate?
A) Immediate endotracheal intubation and mechanical ventilation with low tidal
volumes
B) Continue non-rebreather and monitor arterial blood gas in 30 minutes
C) Administer diuretics to treat fluid overload
D) Place patient on bi-level positive airway pressure (BiPAP)
Answer: A
Rationale: Acute respiratory distress syndrome likely; refractory hypoxemia requires
intubation. Low tidal volume ventilation improves survival. BiPAP may be
considered in milder cases but not with severe hypoxemia. Diuretics are not
indicated for ARDS unless fluid overload is present.
8 A patient with sepsis and disseminated intravascular coagulation has a platelet
count of 20,000/µL and active bleeding from venipuncture sites. Which blood
product is indicated?
A) Platelet transfusion
, B) Fresh frozen plasma
C) Cryoprecipitate
D) Packed red blood cells
Answer: A
Rationale: In DIC with severe thrombocytopenia and bleeding, platelet transfusion is
indicated when count <50,000. FFP is given for prolonged PT/INR; cryoprecipitate
for low fibrinogen; RBCs for anemia. Platelets are the first priority here.
9 A patient in the ICU with multi-organ dysfunction syndrome has a serum lactate
of 6 mmol/L, mean arterial pressure of 55 mm Hg on norepinephrine 20 mcg/min,
and a central venous oxygen saturation of 55%. What additional therapy is most
appropriate?
A) Add vasopressin infusion
B) Increase norepinephrine to 30 mcg/min
C) Start dobutamine at 5 mcg/kg/min
D) Administer hydrocortisone 200 mg/day
Answer: A
Rationale: Persistent hypotension on high-dose norepinephrine suggests vasoplegia;
add vasopressin. Increasing norepinephrine may increase afterload excessively.
Dobutamine is indicated for low cardiac output with adequate perfusion pressure.
Steroids are considered for refractory shock but usually after adding vasopressin.
10 A patient with cirrhosis and acute variceal bleeding is started on octreotide and
undergoes endoscopic band ligation. Which additional medication is
recommended to prevent rebleeding and reduce mortality?
A) Propranolol
B) Somatostatin
C) Terlipressin
D) Pantoprazole
Answer: A
Rationale: Non-selective beta-blockers (propranolol) are used for primary and
secondary prophylaxis of variceal bleeding. Somatostatin/terlipressin are acute
management. Pantoprazole is for ulcer prophylaxis, not variceal prevention.
Propranolol reduces portal pressure and long-term rebleeding risk.
11 A patient with sepsis and acute kidney injury is receiving norepinephrine and has
a mean arterial pressure of 58 mm Hg despite maximal dosing. Which
intervention is most appropriate to improve renal perfusion?
