NUR 265 Exam 3 V3 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 3) |
Galen
1. Mr. Harrison, a 45-year-old male weighing 80 kg, is admitted to the burn unit with partial
and full-thickness burns to his entire right arm, anterior trunk, and the front of his right leg.
Using the Parkland formula, what is the total fluid volume the nurse should administer in the
first 8 hours of care?
A. 14,400 mL
B. 5,760 mL
C. 7,200 mL
D. 2,880 mL
Answer: B
Rationale: According to the Rule of Nines, the right arm is 9%, the anterior trunk is 18%,
and the front of the right leg is 9%, totaling 36% TBSA. The Parkland formula calculates
total 24-hour fluid as 4 mL x weight (kg) x % TBSA, which is 4 x 80 x 36 = 11,520 mL. Half
of this total volume, or 5,760 mL, must be administered within the first 8 hours following
the injury.
2. A 62-year-old patient, Mrs. Gable, is in the compensatory stage of hypovolemic shock
following a massive GI bleed. Which clinical finding should the nurse anticipate finding during
the assessment?
A. Metabolic acidosis and cold, clammy skin
B. Lethargy and decreased mean arterial pressure (MAP) of 20 mmHg from baseline
C. Narrowed pulse pressure and increased heart rate
D. Anuria and absent peripheral pulses
Answer: C
Rationale: In the compensatory stage of shock, the body initiates the fight-or-flight
response to maintain cardiac output and BP. The nurse will observe signs of sympathetic
nervous system activation, such as tachycardia and a narrowing pulse pressure as the
diastolic pressure rises due to vasoconstriction. These findings indicate the body’s attempt
to shunt blood to vital organs before progressing to the refractory stage.
,3. The nurse is caring for Mr. Jenkins, who was admitted with severe sepsis. The patient’s
blood pressure is 82/46 mmHg, heart rate is 124 bpm, and the serum lactate level is 5.2
mmol/L. After a 30 mL/kg bolus of normal saline, the BP remains 84/48 mmHg. Which
intervention should the nurse prioritize next?
A. Administer a second 30 mL/kg fluid bolus
B. Administer broad-spectrum antibiotics
C. Obtain another set of blood cultures
D. Initiate a norepinephrine infusion
Answer: D
Rationale: Mr. Jenkins is showing signs of septic shock, defined by persistent hypotension
and elevated lactate despite adequate fluid resuscitation. Norepinephrine is the first-line
vasopressor of choice to maintain a mean arterial pressure (MAP) of at least 65 mmHg in
septic shock. Delaying vasopressor therapy in the presence of fluid-refractory hypotension
increases the risk of multi-system organ failure and death.
4. A patient with a T4 spinal cord injury, Sarah, reports a sudden, throbbing headache and is
found to have a blood pressure of 190/110 mmHg. Which action should the nurse perform
first?
A. Administer a PRN dose of hydralazine
B. Place the patient in a high-Fowler’s position
C. Check the patient’s bladder for distention
D. Assess the skin for pressure injuries or tight clothing
Answer: B
Rationale: The patient is experiencing autonomic dysreflexia, a medical emergency
common in spinal cord injuries at T6 or higher. The priority nursing action is to sit the
patient upright (high-Fowler’s) to cause an immediate orthostatic drop in blood pressure.
Only after positioning the patient should the nurse proceed to identify and remove the
triggering stimulus, such as a full bladder or impacted bowel.
5. During a mass casualty incident triage, the nurse assesses a victim who has a traumatic
amputation of the lower leg, is unconscious, and has a respiratory rate of 8 breaths per
minute. Which color tag should the nurse assign to this patient?
A. Green
B. Red
C. Yellow
D. Black
, Answer: B
Rationale: The Red tag (Immediate) is used for patients who have life-threatening injuries
but high chances of survival if treated immediately. This patient has an unstable
airway/respiratory status and significant hemorrhage, meeting the criteria for immediate
intervention. Black tags are reserved for those who are deceased or have injuries
incompatible with life, while yellow is for delayed and green is for minor injuries.
6. Mr. Wallace is admitted to the ICU with a diagnosis of Multiple Organ Dysfunction
Syndrome (MODS) secondary to pancreatitis. Which assessment finding most likely indicates
that the respiratory system is the first to fail?
A. Alanine aminotransferase (ALT) level of 150 U/L
B. Serum creatinine level of 2.8 mg/dL
C. PaO2/FiO2 ratio of less than 200
D. Platelet count of 90,000/mm3
Answer: C
Rationale: In MODS, the lungs are typically the first organ system to show signs of failure,
often manifesting as Acute Respiratory Distress Syndrome (ARDS). A PaO2/FiO2 ratio
below 200 is a hallmark diagnostic criteria for severe ARDS, indicating significant shunting
and gas exchange impairment. Monitoring this ratio is critical for evaluating the
progression of respiratory failure and the effectiveness of mechanical ventilation.
7. A 30-year-old female was rescued from a house fire and has soot in her nose and mouth.
She is coughing and has a hoarse voice. What is the nurse’s priority action?
A. Assess the patient’s burn surface area using the Rule of Nines
B. Prepare for immediate endotracheal intubation
C. Calculate the Parkland formula for fluid resuscitation
D. Administer IV morphine for pain management
Answer: B
Rationale: Soot in the airway, hoarseness, and coughing are classic indicators of an
inhalation injury above the glottis. These signs suggest that the airway may rapidly swell
and close, making intubation difficult or impossible later. The nurse must prioritize airway
stabilization before addressing fluid needs or pain, as the edema can progress within
minutes to hours.
8. The nurse is evaluating the hemodynamic parameters of a patient in cardiogenic shock.
Which set of findings is most consistent with this condition?
A. Low CVP, Low PAWP, High CO
B. High CVP, Low PAWP, Low CO
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 3) |
Galen
1. Mr. Harrison, a 45-year-old male weighing 80 kg, is admitted to the burn unit with partial
and full-thickness burns to his entire right arm, anterior trunk, and the front of his right leg.
Using the Parkland formula, what is the total fluid volume the nurse should administer in the
first 8 hours of care?
A. 14,400 mL
B. 5,760 mL
C. 7,200 mL
D. 2,880 mL
Answer: B
Rationale: According to the Rule of Nines, the right arm is 9%, the anterior trunk is 18%,
and the front of the right leg is 9%, totaling 36% TBSA. The Parkland formula calculates
total 24-hour fluid as 4 mL x weight (kg) x % TBSA, which is 4 x 80 x 36 = 11,520 mL. Half
of this total volume, or 5,760 mL, must be administered within the first 8 hours following
the injury.
2. A 62-year-old patient, Mrs. Gable, is in the compensatory stage of hypovolemic shock
following a massive GI bleed. Which clinical finding should the nurse anticipate finding during
the assessment?
A. Metabolic acidosis and cold, clammy skin
B. Lethargy and decreased mean arterial pressure (MAP) of 20 mmHg from baseline
C. Narrowed pulse pressure and increased heart rate
D. Anuria and absent peripheral pulses
Answer: C
Rationale: In the compensatory stage of shock, the body initiates the fight-or-flight
response to maintain cardiac output and BP. The nurse will observe signs of sympathetic
nervous system activation, such as tachycardia and a narrowing pulse pressure as the
diastolic pressure rises due to vasoconstriction. These findings indicate the body’s attempt
to shunt blood to vital organs before progressing to the refractory stage.
,3. The nurse is caring for Mr. Jenkins, who was admitted with severe sepsis. The patient’s
blood pressure is 82/46 mmHg, heart rate is 124 bpm, and the serum lactate level is 5.2
mmol/L. After a 30 mL/kg bolus of normal saline, the BP remains 84/48 mmHg. Which
intervention should the nurse prioritize next?
A. Administer a second 30 mL/kg fluid bolus
B. Administer broad-spectrum antibiotics
C. Obtain another set of blood cultures
D. Initiate a norepinephrine infusion
Answer: D
Rationale: Mr. Jenkins is showing signs of septic shock, defined by persistent hypotension
and elevated lactate despite adequate fluid resuscitation. Norepinephrine is the first-line
vasopressor of choice to maintain a mean arterial pressure (MAP) of at least 65 mmHg in
septic shock. Delaying vasopressor therapy in the presence of fluid-refractory hypotension
increases the risk of multi-system organ failure and death.
4. A patient with a T4 spinal cord injury, Sarah, reports a sudden, throbbing headache and is
found to have a blood pressure of 190/110 mmHg. Which action should the nurse perform
first?
A. Administer a PRN dose of hydralazine
B. Place the patient in a high-Fowler’s position
C. Check the patient’s bladder for distention
D. Assess the skin for pressure injuries or tight clothing
Answer: B
Rationale: The patient is experiencing autonomic dysreflexia, a medical emergency
common in spinal cord injuries at T6 or higher. The priority nursing action is to sit the
patient upright (high-Fowler’s) to cause an immediate orthostatic drop in blood pressure.
Only after positioning the patient should the nurse proceed to identify and remove the
triggering stimulus, such as a full bladder or impacted bowel.
5. During a mass casualty incident triage, the nurse assesses a victim who has a traumatic
amputation of the lower leg, is unconscious, and has a respiratory rate of 8 breaths per
minute. Which color tag should the nurse assign to this patient?
A. Green
B. Red
C. Yellow
D. Black
, Answer: B
Rationale: The Red tag (Immediate) is used for patients who have life-threatening injuries
but high chances of survival if treated immediately. This patient has an unstable
airway/respiratory status and significant hemorrhage, meeting the criteria for immediate
intervention. Black tags are reserved for those who are deceased or have injuries
incompatible with life, while yellow is for delayed and green is for minor injuries.
6. Mr. Wallace is admitted to the ICU with a diagnosis of Multiple Organ Dysfunction
Syndrome (MODS) secondary to pancreatitis. Which assessment finding most likely indicates
that the respiratory system is the first to fail?
A. Alanine aminotransferase (ALT) level of 150 U/L
B. Serum creatinine level of 2.8 mg/dL
C. PaO2/FiO2 ratio of less than 200
D. Platelet count of 90,000/mm3
Answer: C
Rationale: In MODS, the lungs are typically the first organ system to show signs of failure,
often manifesting as Acute Respiratory Distress Syndrome (ARDS). A PaO2/FiO2 ratio
below 200 is a hallmark diagnostic criteria for severe ARDS, indicating significant shunting
and gas exchange impairment. Monitoring this ratio is critical for evaluating the
progression of respiratory failure and the effectiveness of mechanical ventilation.
7. A 30-year-old female was rescued from a house fire and has soot in her nose and mouth.
She is coughing and has a hoarse voice. What is the nurse’s priority action?
A. Assess the patient’s burn surface area using the Rule of Nines
B. Prepare for immediate endotracheal intubation
C. Calculate the Parkland formula for fluid resuscitation
D. Administer IV morphine for pain management
Answer: B
Rationale: Soot in the airway, hoarseness, and coughing are classic indicators of an
inhalation injury above the glottis. These signs suggest that the airway may rapidly swell
and close, making intubation difficult or impossible later. The nurse must prioritize airway
stabilization before addressing fluid needs or pain, as the edema can progress within
minutes to hours.
8. The nurse is evaluating the hemodynamic parameters of a patient in cardiogenic shock.
Which set of findings is most consistent with this condition?
A. Low CVP, Low PAWP, High CO
B. High CVP, Low PAWP, Low CO
