NUR 265 Exam 3 V2 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 3) |
Galen
1. Mr. Henderson is admitted to the ICU with a diagnosis of septic shock. His blood pressure is
82/46 mmHg, heart rate is 126 bpm, and central venous pressure (CVP) is 2 mmHg. Which
order should the nurse implement first?
A. Start norepinephrine (Levophed) infusion at 2 mcg/min.
B. Administer 30 mL/kg of 0.9% Normal Saline bolus.
C. Obtain two sets of blood cultures from different sites.
D. Administer broad-spectrum antibiotics (Vancomycin).
Answer: B
Rationale: According to the Surviving Sepsis Campaign bundles, fluid resuscitation is the
priority for a patient in septic shock with hypotension and low CVP. A CVP of 2 mmHg
indicates significant hypovolemia, and vasopressors like norepinephrine will not be
effective if the intravascular volume is depleted. Once fluid resuscitation has begun, the
nurse should then obtain cultures before administering antibiotics within the first hour.
2. Ms. Garcia has suffered full-thickness burns to 45% of her total body surface area (TBSA).
During the emergent phase, which electrolyte abnormality should the nurse most closely
monitor for?
A. Hypocalcemia
B. Hypokalemia
C. Hypernatremia
D. Hyperkalemia
Answer: D
Rationale: In the emergent phase of a major burn, massive cell destruction occurs,
releasing intracellular potassium into the extracellular space. This leads to hyperkalemia,
which can cause life-threatening cardiac dysrhythmias. The nurse must monitor the ECG
and serum potassium levels frequently until the acute phase begins and diuresis occurs.
3. A 55-year-old male patient with cirrhosis and chronic portal hypertension is scheduled for a
paracentesis to relieve severe ascites. Which nursing intervention is a priority post-
procedure?
A. Monitor for signs of orthostatic hypotension and tachycardia.
B. Keep the patient NPO for at least 4 hours.
,C. Place the patient in a prone position for 2 hours.
D. Apply a tight abdominal binder immediately.
Answer: A
Rationale: A paracentesis involves the removal of large amounts of fluid, which can cause a
rapid shift in intravascular volume. This shift increases the risk of hypovolemic shock,
manifesting as hypotension and tachycardia. The nurse must monitor vital signs closely
and may need to administer albumin as ordered to maintain oncotic pressure.
4. The nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) who is
on mechanical ventilation. The provider increases the Positive End-Expiratory Pressure (PEEP)
from 5 cm H2O to 15 cm H2O. Which assessment finding requires immediate intervention?
A. SpO2 increases from 88% to 94%.
B. Crackles are audible in the lung bases.
C. Blood pressure drops from 120/80 to 90/60 mmHg.
D. End-tidal CO2 is 38 mmHg.
Answer: C
Rationale: High levels of PEEP increase intrathoracic pressure, which can decrease venous
return to the heart and subsequently lower cardiac output and blood pressure. While PEEP
improves oxygenation, the nurse must monitor for hemodynamic compromise. A drop in
blood pressure to 90/60 mmHg indicates that the patient is not tolerating the increased
PEEP, and the provider should be notified immediately.
5. A patient with acute liver failure develops hepatic encephalopathy. The nurse notes the
patient is increasingly confused and has a flapping tremor of the hands. Which medication is
the standard treatment for this condition?
A. Lactulose
B. Spironolactone
C. Propranolol
D. Furosemide
Answer: A
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it promotes
the excretion of ammonia through the stool. The ammonia is trapped in the gut and
eliminated, which helps reduce serum ammonia levels and improve cognitive function. The
goal of therapy is typically 2 to 3 soft stools per day.
, 6. Mr. Taylor is a 68-year-old male with a history of heart failure who presents with an Acute
Kidney Injury (AKI). His serum potassium is 6.8 mEq/L and his ECG shows peaked T waves.
Which treatment should the nurse anticipate first to protect the heart?
A. Intravenous Calcium Gluconate
B. Sodium polystyrene sulfonate (Kayexalate)
C. Regular insulin and 50% Dextrose
D. Furosemide (Lasix) IV push
Answer: A
Rationale: Calcium gluconate is administered in the setting of severe hyperkalemia with
ECG changes to stabilize the myocardial cell membrane. It does not lower the potassium
level but prevents lethal dysrhythmias while other treatments (like insulin/D50 or
dialysis) work to shift or remove potassium. The nurse must prioritize cardiac protection in
this emergency situation.
7. A nurse is evaluating the recovery of a patient with full-thickness burns during the acute
phase. Which clinical indicator signifies that the patient is entering the diuresis period?
A. Increasing hematocrit levels.
B. Decreasing urine output below 30 mL/hr.
C. Development of metabolic acidosis.
D. Increased urine output and decreased weight.
Answer: D
Rationale: During the acute phase of burn recovery (usually 48-72 hours post-injury), fluid
shifts back into the intravascular space, leading to increased renal perfusion and diuresis.
As the patient diureses the excess fluid accumulated during the emergent phase, their
weight will decrease. This is a positive sign that the edema is resolving and renal function is
maintained.
8. A patient is admitted with suspected Disseminated Intravascular Coagulation (DIC)
following a severe postpartum hemorrhage. Which laboratory finding is most characteristic of
DIC?
A. Increased D-Dimer levels
B. Increased Fibrinogen levels
C. Decreased Prothrombin Time (PT)
D. Increased Platelet count
Answer: A
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 3) |
Galen
1. Mr. Henderson is admitted to the ICU with a diagnosis of septic shock. His blood pressure is
82/46 mmHg, heart rate is 126 bpm, and central venous pressure (CVP) is 2 mmHg. Which
order should the nurse implement first?
A. Start norepinephrine (Levophed) infusion at 2 mcg/min.
B. Administer 30 mL/kg of 0.9% Normal Saline bolus.
C. Obtain two sets of blood cultures from different sites.
D. Administer broad-spectrum antibiotics (Vancomycin).
Answer: B
Rationale: According to the Surviving Sepsis Campaign bundles, fluid resuscitation is the
priority for a patient in septic shock with hypotension and low CVP. A CVP of 2 mmHg
indicates significant hypovolemia, and vasopressors like norepinephrine will not be
effective if the intravascular volume is depleted. Once fluid resuscitation has begun, the
nurse should then obtain cultures before administering antibiotics within the first hour.
2. Ms. Garcia has suffered full-thickness burns to 45% of her total body surface area (TBSA).
During the emergent phase, which electrolyte abnormality should the nurse most closely
monitor for?
A. Hypocalcemia
B. Hypokalemia
C. Hypernatremia
D. Hyperkalemia
Answer: D
Rationale: In the emergent phase of a major burn, massive cell destruction occurs,
releasing intracellular potassium into the extracellular space. This leads to hyperkalemia,
which can cause life-threatening cardiac dysrhythmias. The nurse must monitor the ECG
and serum potassium levels frequently until the acute phase begins and diuresis occurs.
3. A 55-year-old male patient with cirrhosis and chronic portal hypertension is scheduled for a
paracentesis to relieve severe ascites. Which nursing intervention is a priority post-
procedure?
A. Monitor for signs of orthostatic hypotension and tachycardia.
B. Keep the patient NPO for at least 4 hours.
,C. Place the patient in a prone position for 2 hours.
D. Apply a tight abdominal binder immediately.
Answer: A
Rationale: A paracentesis involves the removal of large amounts of fluid, which can cause a
rapid shift in intravascular volume. This shift increases the risk of hypovolemic shock,
manifesting as hypotension and tachycardia. The nurse must monitor vital signs closely
and may need to administer albumin as ordered to maintain oncotic pressure.
4. The nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) who is
on mechanical ventilation. The provider increases the Positive End-Expiratory Pressure (PEEP)
from 5 cm H2O to 15 cm H2O. Which assessment finding requires immediate intervention?
A. SpO2 increases from 88% to 94%.
B. Crackles are audible in the lung bases.
C. Blood pressure drops from 120/80 to 90/60 mmHg.
D. End-tidal CO2 is 38 mmHg.
Answer: C
Rationale: High levels of PEEP increase intrathoracic pressure, which can decrease venous
return to the heart and subsequently lower cardiac output and blood pressure. While PEEP
improves oxygenation, the nurse must monitor for hemodynamic compromise. A drop in
blood pressure to 90/60 mmHg indicates that the patient is not tolerating the increased
PEEP, and the provider should be notified immediately.
5. A patient with acute liver failure develops hepatic encephalopathy. The nurse notes the
patient is increasingly confused and has a flapping tremor of the hands. Which medication is
the standard treatment for this condition?
A. Lactulose
B. Spironolactone
C. Propranolol
D. Furosemide
Answer: A
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it promotes
the excretion of ammonia through the stool. The ammonia is trapped in the gut and
eliminated, which helps reduce serum ammonia levels and improve cognitive function. The
goal of therapy is typically 2 to 3 soft stools per day.
, 6. Mr. Taylor is a 68-year-old male with a history of heart failure who presents with an Acute
Kidney Injury (AKI). His serum potassium is 6.8 mEq/L and his ECG shows peaked T waves.
Which treatment should the nurse anticipate first to protect the heart?
A. Intravenous Calcium Gluconate
B. Sodium polystyrene sulfonate (Kayexalate)
C. Regular insulin and 50% Dextrose
D. Furosemide (Lasix) IV push
Answer: A
Rationale: Calcium gluconate is administered in the setting of severe hyperkalemia with
ECG changes to stabilize the myocardial cell membrane. It does not lower the potassium
level but prevents lethal dysrhythmias while other treatments (like insulin/D50 or
dialysis) work to shift or remove potassium. The nurse must prioritize cardiac protection in
this emergency situation.
7. A nurse is evaluating the recovery of a patient with full-thickness burns during the acute
phase. Which clinical indicator signifies that the patient is entering the diuresis period?
A. Increasing hematocrit levels.
B. Decreasing urine output below 30 mL/hr.
C. Development of metabolic acidosis.
D. Increased urine output and decreased weight.
Answer: D
Rationale: During the acute phase of burn recovery (usually 48-72 hours post-injury), fluid
shifts back into the intravascular space, leading to increased renal perfusion and diuresis.
As the patient diureses the excess fluid accumulated during the emergent phase, their
weight will decrease. This is a positive sign that the edema is resolving and renal function is
maintained.
8. A patient is admitted with suspected Disseminated Intravascular Coagulation (DIC)
following a severe postpartum hemorrhage. Which laboratory finding is most characteristic of
DIC?
A. Increased D-Dimer levels
B. Increased Fibrinogen levels
C. Decreased Prothrombin Time (PT)
D. Increased Platelet count
Answer: A
