NUR 265 Exam 2 V3 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 2) |
Galen
1. A 52-year-old male patient is admitted to the ICU with a diagnosis of septic shock. Despite
receiving 4 liters of normal saline, his blood pressure remains 84/46 mmHg and his Mean
Arterial Pressure (MAP) is 58 mmHg. Which pharmacological intervention should the nurse
anticipate next?
A. Initiation of a norepinephrine infusion.
B. Administration of a 500 mL bolus of 5% albumin.
C. Starting a dobutamine drip at 5 mcg/kg/min.
D. A one-time dose of intravenous furosemide.
Answer: A
Rationale: Norepinephrine is the first-line vasopressor recommended in the Surviving
Sepsis Campaign guidelines when fluid resuscitation fails to restore an adequate MAP. The
goal is to maintain a MAP of at least 65 mmHg to ensure adequate end-organ perfusion. The
nurse must ensure the patient has adequate fluid volume before initiating vasopressors to
prevent worsening tissue ischemia.
2. A 35-year-old female was rescued from a house fire and has sustained partial-thickness
burns to her entire right arm, her entire left leg, and her anterior trunk. Using the Rule of
Nines, what is the estimated Percentage of Total Body Surface Area (TBSA) burned?
A. 36%
B. 54%
C. 45%
D. 27%
Answer: C
Rationale: According to the Rule of Nines, the entire arm is 9%, the entire leg is 18%, and
the anterior trunk is 18%. Adding these together (9 + 18 + 18) results in a total of 45%
TBSA. Accurate calculation of TBSA is critical for determining the appropriate fluid
resuscitation volume using the Parkland Formula.
3. A patient with a T4 spinal cord injury suddenly reports a severe, throbbing headache and
nasal congestion. The nurse notes the patient is flushed above the level of the injury and has
a blood pressure of 190/110 mmHg. What is the nurse’s priority action?
A. Administer an ordered PRN dose of hydralazine.
,B. Notify the rapid response team immediately.
C. Perform a bladder scan to check for urinary retention.
D. Place the patient in a high-Fowler’s position.
Answer: D
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency in spinal cord injury patients. The immediate priority is to sit the patient
upright to utilize orthostatic pressure to help lower the dangerously high blood pressure.
Following positioning, the nurse should assess for the triggering stimulus, such as a
distended bladder or fecal impaction.
4. An intubated patient with Acute Respiratory Distress Syndrome (ARDS) is receiving
mechanical ventilation with a PEEP of 15 cm H2O. The nurse notes a sudden drop in oxygen
saturation and absent breath sounds on the right side. Which complication does the nurse
suspect?
A. Tension pneumothorax.
B. Displaced endotracheal tube.
C. Pulmonary embolism.
D. Ventilator-associated pneumonia.
Answer: A
Rationale: High levels of Positive End-Expiratory Pressure (PEEP) increase the risk of
barotrauma, which can lead to a tension pneumothorax. Absent breath sounds on one side
and sudden desaturation are hallmark signs of this life-threatening complication.
Immediate needle decompression or chest tube insertion is required to relieve the
pressure.
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. Intravenous insulin and dextrose.
C. Sodium bicarbonate.
D. Calcium gluconate.
Answer: D
Rationale: Calcium gluconate does not lower potassium but is administered first to
stabilize the myocardial cell membrane and prevent lethal arrhythmias. While
insulin/dextrose and Kayexalate are used to lower potassium levels, they do not provide
, the immediate cardiac protection needed in the presence of ECG changes. This intervention
is a temporary measure while other methods are initiated to remove potassium from the
body.
6. A 28-year-old patient is admitted with Diabetic Ketoacidosis (DKA). The initial labs show a
glucose of 550 mg/dL, pH of 7.15, and a potassium of 3.2 mEq/L. What is the nurse’s priority
action before starting the insulin drip?
A. Administer a potassium supplement.
B. Check the patient’s urine output.
C. Obtain a 12-lead ECG.
D. Assess the patient’s neurological status.
Answer: A
Rationale: Insulin causes potassium to shift from the extracellular fluid into the cells,
which can severely worsen hypokalemia. If the potassium is already low (below 3.3
mEq/L), it must be supplemented before starting insulin to prevent life-threatening
arrhythmias. Frequent monitoring of electrolytes is essential during the treatment of DKA.
7. A patient with a traumatic brain injury (TBI) is being monitored for increased intracranial
pressure (ICP). The nurse notes the patient has a blood pressure of 170/60 mmHg, a pulse of
48 bpm, and irregular respirations. This cluster of symptoms is known as:
A. Virchow’s triad.
B. Beck’s triad.
C. Cushing’s triad.
D. Horner’s syndrome.
Answer: C
Rationale: Cushing’s triad consists of widening pulse pressure (systolic hypertension),
bradycardia, and irregular respirations. This is a late sign of increased intracranial pressure
and indicates impending brain herniation. The nurse must act immediately to reduce ICP
and notify the surgical team.
8. During a mass casualty incident, the nurse is triaging patients in the field. A patient is found
with an open femur fracture, is conscious, but has a respiratory rate of 34 breaths per minute
and a capillary refill of 4 seconds. Which color tag should the nurse assign?
A. Green
B. Yellow
C. Black
D. Red
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 2) |
Galen
1. A 52-year-old male patient is admitted to the ICU with a diagnosis of septic shock. Despite
receiving 4 liters of normal saline, his blood pressure remains 84/46 mmHg and his Mean
Arterial Pressure (MAP) is 58 mmHg. Which pharmacological intervention should the nurse
anticipate next?
A. Initiation of a norepinephrine infusion.
B. Administration of a 500 mL bolus of 5% albumin.
C. Starting a dobutamine drip at 5 mcg/kg/min.
D. A one-time dose of intravenous furosemide.
Answer: A
Rationale: Norepinephrine is the first-line vasopressor recommended in the Surviving
Sepsis Campaign guidelines when fluid resuscitation fails to restore an adequate MAP. The
goal is to maintain a MAP of at least 65 mmHg to ensure adequate end-organ perfusion. The
nurse must ensure the patient has adequate fluid volume before initiating vasopressors to
prevent worsening tissue ischemia.
2. A 35-year-old female was rescued from a house fire and has sustained partial-thickness
burns to her entire right arm, her entire left leg, and her anterior trunk. Using the Rule of
Nines, what is the estimated Percentage of Total Body Surface Area (TBSA) burned?
A. 36%
B. 54%
C. 45%
D. 27%
Answer: C
Rationale: According to the Rule of Nines, the entire arm is 9%, the entire leg is 18%, and
the anterior trunk is 18%. Adding these together (9 + 18 + 18) results in a total of 45%
TBSA. Accurate calculation of TBSA is critical for determining the appropriate fluid
resuscitation volume using the Parkland Formula.
3. A patient with a T4 spinal cord injury suddenly reports a severe, throbbing headache and
nasal congestion. The nurse notes the patient is flushed above the level of the injury and has
a blood pressure of 190/110 mmHg. What is the nurse’s priority action?
A. Administer an ordered PRN dose of hydralazine.
,B. Notify the rapid response team immediately.
C. Perform a bladder scan to check for urinary retention.
D. Place the patient in a high-Fowler’s position.
Answer: D
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency in spinal cord injury patients. The immediate priority is to sit the patient
upright to utilize orthostatic pressure to help lower the dangerously high blood pressure.
Following positioning, the nurse should assess for the triggering stimulus, such as a
distended bladder or fecal impaction.
4. An intubated patient with Acute Respiratory Distress Syndrome (ARDS) is receiving
mechanical ventilation with a PEEP of 15 cm H2O. The nurse notes a sudden drop in oxygen
saturation and absent breath sounds on the right side. Which complication does the nurse
suspect?
A. Tension pneumothorax.
B. Displaced endotracheal tube.
C. Pulmonary embolism.
D. Ventilator-associated pneumonia.
Answer: A
Rationale: High levels of Positive End-Expiratory Pressure (PEEP) increase the risk of
barotrauma, which can lead to a tension pneumothorax. Absent breath sounds on one side
and sudden desaturation are hallmark signs of this life-threatening complication.
Immediate needle decompression or chest tube insertion is required to relieve the
pressure.
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. Intravenous insulin and dextrose.
C. Sodium bicarbonate.
D. Calcium gluconate.
Answer: D
Rationale: Calcium gluconate does not lower potassium but is administered first to
stabilize the myocardial cell membrane and prevent lethal arrhythmias. While
insulin/dextrose and Kayexalate are used to lower potassium levels, they do not provide
, the immediate cardiac protection needed in the presence of ECG changes. This intervention
is a temporary measure while other methods are initiated to remove potassium from the
body.
6. A 28-year-old patient is admitted with Diabetic Ketoacidosis (DKA). The initial labs show a
glucose of 550 mg/dL, pH of 7.15, and a potassium of 3.2 mEq/L. What is the nurse’s priority
action before starting the insulin drip?
A. Administer a potassium supplement.
B. Check the patient’s urine output.
C. Obtain a 12-lead ECG.
D. Assess the patient’s neurological status.
Answer: A
Rationale: Insulin causes potassium to shift from the extracellular fluid into the cells,
which can severely worsen hypokalemia. If the potassium is already low (below 3.3
mEq/L), it must be supplemented before starting insulin to prevent life-threatening
arrhythmias. Frequent monitoring of electrolytes is essential during the treatment of DKA.
7. A patient with a traumatic brain injury (TBI) is being monitored for increased intracranial
pressure (ICP). The nurse notes the patient has a blood pressure of 170/60 mmHg, a pulse of
48 bpm, and irregular respirations. This cluster of symptoms is known as:
A. Virchow’s triad.
B. Beck’s triad.
C. Cushing’s triad.
D. Horner’s syndrome.
Answer: C
Rationale: Cushing’s triad consists of widening pulse pressure (systolic hypertension),
bradycardia, and irregular respirations. This is a late sign of increased intracranial pressure
and indicates impending brain herniation. The nurse must act immediately to reduce ICP
and notify the surgical team.
8. During a mass casualty incident, the nurse is triaging patients in the field. A patient is found
with an open femur fracture, is conscious, but has a respiratory rate of 34 breaths per minute
and a capillary refill of 4 seconds. Which color tag should the nurse assign?
A. Green
B. Yellow
C. Black
D. Red
