NUR 265 Exam 4 V2 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 4) |
Galen
1. Mr. Sterling, a 64-year-old patient with ARDS, is receiving mechanical ventilation on VC-AC
mode. The provider increases the PEEP from 10 to 18 cm H2O. Shortly after, the nurse notes
the patient’s BP drops from 120/80 to 92/58 mmHg and the heart rate rises to 118 bpm.
Which action should the nurse prioritize first?
A. Administer a 500 mL normal saline bolus as ordered.
B. Increase the FiO2 to 100% to support oxygenation.
C. Perform a stat arterial blood gas (ABG) analysis.
D. Auscultate the patient’s breath sounds bilaterally.
Answer: D
Rationale: High levels of PEEP increase intrathoracic pressure, which can lead to
barotrauma and the development of a tension pneumothorax. A sudden drop in blood
pressure and increase in heart rate are clinical indicators of decreased cardiac output or a
potential lung collapse. The nurse must first assess for equal breath sounds to determine if
a pneumothorax has occurred before implementing other interventions like fluid
resuscitation.
2. Mrs. Bennett is in the ICU for septic shock. Despite adequate fluid resuscitation with 30
mL/kg of crystalloids, her Mean Arterial Pressure (MAP) remains at 58 mmHg and her serum
lactate is rising. Which pharmacological intervention is the first-line choice for this patient?
A. Dopamine 10 mcg/kg/min
B. Norepinephrine 0.05 mcg/kg/min
C. Vasopressin 0.03 units/min
D. Dobutamine 5 mcg/kg/min
Answer: B
Rationale: Norepinephrine is the first-choice vasopressor for patients in septic shock who
remain hypotensive despite adequate fluid volume replacement. It primarily acts as an
alpha-1 agonist to increase systemic vascular resistance and improve MAP. While
vasopressin can be added, it is not the primary initial vasopressor, and dobutamine is
reserved for low cardiac output states rather than refractory vasodilation.
,3. A 45-year-old male is admitted with an acute cervical spinal cord injury at the C5 level.
During the shift assessment, the nurse notes the patient is bradycardic (HR 48 bpm),
hypotensive (BP 82/44 mmHg), and his skin is warm and dry below the level of injury. Which
condition does the nurse suspect?
A. Neurogenic Shock
B. Autonomic Dysreflexia
C. Spinal Shock
D. Hypovolemic Shock
Answer: A
Rationale: Neurogenic shock occurs in cervical or high thoracic spinal cord injuries due to
the loss of sympathetic nervous system tone, leading to vasodilation and bradycardia. The
presence of warm, dry skin below the injury site distinguishes it from hypovolemic shock,
where the skin is typically cool and clammy due to compensatory vasoconstriction.
Autonomic dysreflexia is a later complication characterized by hypertension rather than
hypotension.
4. A patient with acute liver failure develops Stage III hepatic encephalopathy. The nurse
observes new-onset asterixis and increased confusion. Which laboratory result is most
directly correlated with these clinical findings?
A. Serum Potassium 3.1 mEq/L
B. International Normalized Ratio (INR) 2.8
C. Total Bilirubin 12.5 mg/dL
D. Blood Ammonia 160 mcg/dL
Answer: D
Rationale: Hepatic encephalopathy is primarily caused by the accumulation of
neurotoxins, most notably ammonia, which the damaged liver can no longer convert to
urea. Rising ammonia levels lead to cerebral edema and neurological symptoms such as
asterixis (flapping tremors) and altered mental status. While bilirubin and INR are markers
of liver function, ammonia is the specific toxin linked to encephalopathy symptoms.
5. A nurse is caring for a patient who suffered 40% Total Body Surface Area (TBSA) thermal
burns 12 hours ago. The patient’s urine output has dropped to 20 mL/hr for the last two
hours, and the urine appears dark, reddish-brown. What is the most likely cause of these
findings?
A. Acute tubular necrosis due to hypovolemia
B. Urinary tract infection resulting from catheterization
C. Normal physiological response to the emergent phase
, D. Hemoglobinuria and myoglobinuria causing renal blockage
Answer: D
Rationale: In major burns, extensive muscle and red blood cell damage releases myoglobin
and hemoglobin into the bloodstream. These large molecules can clog the renal tubules,
leading to acute kidney injury and characteristic dark ‘tea-colored’ urine. The nurse must
anticipate increasing IV fluid rates to maintain a higher urine output goal (typically 75-100
mL/hr) to flush these toxins through the kidneys.
6. A patient is admitted with Acute Pancreatitis. The nurse notes bluish discoloration around
the umbilicus during the physical exam. How should the nurse document this finding and
what does it indicate?
A. Grey Turner’s sign; indicates retroperitoneal hemorrhage.
B. Kehr’s sign; indicates splenic rupture.
C. Murphy’s sign; indicates gallbladder inflammation.
D. Cullen’s sign; indicates intra-abdominal hemorrhage.
Answer: D
Rationale: Cullen’s sign is the superficial edema and bruising in the subcutaneous fatty
tissue around the umbilicus, signaling severe necrotizing pancreatitis and intra-abdominal
bleeding. Grey Turner’s sign refers to bruising on the flanks, which also indicates
hemorrhage but in the retroperitoneal space. These are late, critical signs indicating
significant clinical deterioration and the need for urgent intervention.
7. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 24 mmHg.
The nurse is administering Mannitol 20% IV bolus. Which monitoring parameter is most
critical to evaluate the effectiveness and safety of this medication?
A. Daily weights and abdominal girth
B. Deep tendon reflexes and pupillary response
C. Arterial blood gases and PaO2 levels
D. Serum osmolality and urine output
Answer: D
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the brain tissue into the
vascular space to reduce ICP. The nurse must monitor serum osmolality (typically kept
below 320 mOsm/kg) to prevent systemic dehydration and renal failure, and urine output
to ensure the drug is causing the desired diuresis. Monitoring pupillary response is
important for neuro status, but serum osmolality is the specific safety check for Mannitol
administration.
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 4) |
Galen
1. Mr. Sterling, a 64-year-old patient with ARDS, is receiving mechanical ventilation on VC-AC
mode. The provider increases the PEEP from 10 to 18 cm H2O. Shortly after, the nurse notes
the patient’s BP drops from 120/80 to 92/58 mmHg and the heart rate rises to 118 bpm.
Which action should the nurse prioritize first?
A. Administer a 500 mL normal saline bolus as ordered.
B. Increase the FiO2 to 100% to support oxygenation.
C. Perform a stat arterial blood gas (ABG) analysis.
D. Auscultate the patient’s breath sounds bilaterally.
Answer: D
Rationale: High levels of PEEP increase intrathoracic pressure, which can lead to
barotrauma and the development of a tension pneumothorax. A sudden drop in blood
pressure and increase in heart rate are clinical indicators of decreased cardiac output or a
potential lung collapse. The nurse must first assess for equal breath sounds to determine if
a pneumothorax has occurred before implementing other interventions like fluid
resuscitation.
2. Mrs. Bennett is in the ICU for septic shock. Despite adequate fluid resuscitation with 30
mL/kg of crystalloids, her Mean Arterial Pressure (MAP) remains at 58 mmHg and her serum
lactate is rising. Which pharmacological intervention is the first-line choice for this patient?
A. Dopamine 10 mcg/kg/min
B. Norepinephrine 0.05 mcg/kg/min
C. Vasopressin 0.03 units/min
D. Dobutamine 5 mcg/kg/min
Answer: B
Rationale: Norepinephrine is the first-choice vasopressor for patients in septic shock who
remain hypotensive despite adequate fluid volume replacement. It primarily acts as an
alpha-1 agonist to increase systemic vascular resistance and improve MAP. While
vasopressin can be added, it is not the primary initial vasopressor, and dobutamine is
reserved for low cardiac output states rather than refractory vasodilation.
,3. A 45-year-old male is admitted with an acute cervical spinal cord injury at the C5 level.
During the shift assessment, the nurse notes the patient is bradycardic (HR 48 bpm),
hypotensive (BP 82/44 mmHg), and his skin is warm and dry below the level of injury. Which
condition does the nurse suspect?
A. Neurogenic Shock
B. Autonomic Dysreflexia
C. Spinal Shock
D. Hypovolemic Shock
Answer: A
Rationale: Neurogenic shock occurs in cervical or high thoracic spinal cord injuries due to
the loss of sympathetic nervous system tone, leading to vasodilation and bradycardia. The
presence of warm, dry skin below the injury site distinguishes it from hypovolemic shock,
where the skin is typically cool and clammy due to compensatory vasoconstriction.
Autonomic dysreflexia is a later complication characterized by hypertension rather than
hypotension.
4. A patient with acute liver failure develops Stage III hepatic encephalopathy. The nurse
observes new-onset asterixis and increased confusion. Which laboratory result is most
directly correlated with these clinical findings?
A. Serum Potassium 3.1 mEq/L
B. International Normalized Ratio (INR) 2.8
C. Total Bilirubin 12.5 mg/dL
D. Blood Ammonia 160 mcg/dL
Answer: D
Rationale: Hepatic encephalopathy is primarily caused by the accumulation of
neurotoxins, most notably ammonia, which the damaged liver can no longer convert to
urea. Rising ammonia levels lead to cerebral edema and neurological symptoms such as
asterixis (flapping tremors) and altered mental status. While bilirubin and INR are markers
of liver function, ammonia is the specific toxin linked to encephalopathy symptoms.
5. A nurse is caring for a patient who suffered 40% Total Body Surface Area (TBSA) thermal
burns 12 hours ago. The patient’s urine output has dropped to 20 mL/hr for the last two
hours, and the urine appears dark, reddish-brown. What is the most likely cause of these
findings?
A. Acute tubular necrosis due to hypovolemia
B. Urinary tract infection resulting from catheterization
C. Normal physiological response to the emergent phase
, D. Hemoglobinuria and myoglobinuria causing renal blockage
Answer: D
Rationale: In major burns, extensive muscle and red blood cell damage releases myoglobin
and hemoglobin into the bloodstream. These large molecules can clog the renal tubules,
leading to acute kidney injury and characteristic dark ‘tea-colored’ urine. The nurse must
anticipate increasing IV fluid rates to maintain a higher urine output goal (typically 75-100
mL/hr) to flush these toxins through the kidneys.
6. A patient is admitted with Acute Pancreatitis. The nurse notes bluish discoloration around
the umbilicus during the physical exam. How should the nurse document this finding and
what does it indicate?
A. Grey Turner’s sign; indicates retroperitoneal hemorrhage.
B. Kehr’s sign; indicates splenic rupture.
C. Murphy’s sign; indicates gallbladder inflammation.
D. Cullen’s sign; indicates intra-abdominal hemorrhage.
Answer: D
Rationale: Cullen’s sign is the superficial edema and bruising in the subcutaneous fatty
tissue around the umbilicus, signaling severe necrotizing pancreatitis and intra-abdominal
bleeding. Grey Turner’s sign refers to bruising on the flanks, which also indicates
hemorrhage but in the retroperitoneal space. These are late, critical signs indicating
significant clinical deterioration and the need for urgent intervention.
7. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 24 mmHg.
The nurse is administering Mannitol 20% IV bolus. Which monitoring parameter is most
critical to evaluate the effectiveness and safety of this medication?
A. Daily weights and abdominal girth
B. Deep tendon reflexes and pupillary response
C. Arterial blood gases and PaO2 levels
D. Serum osmolality and urine output
Answer: D
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the brain tissue into the
vascular space to reduce ICP. The nurse must monitor serum osmolality (typically kept
below 320 mOsm/kg) to prevent systemic dehydration and renal failure, and urine output
to ensure the drug is causing the desired diuresis. Monitoring pupillary response is
important for neuro status, but serum osmolality is the specific safety check for Mannitol
administration.
