NUR 265 Exam 1 V2 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 1) |
Galen
1. A 58-year-old male patient, Mr. Harrison, is admitted to the ICU with a diagnosis of septic
shock. His blood pressure is 82/46 mmHg, heart rate is 126 bpm, and his serum lactate level is
4.5 mmol/L. After a 30 mL/kg isotonic crystalloid bolus, his MAP remains 58 mmHg. Which
order should the nurse prioritize next?
A. Initiate a Norepinephrine infusion to maintain MAP > 65 mmHg.
B. Administer a second 2-liter bolus of Normal Saline.
C. Obtain two sets of blood cultures from different sites.
D. Administer broad-spectrum IV antibiotics immediately.
Answer: A
Rationale: In septic shock, if the Mean Arterial Pressure (MAP) remains below 65 mmHg
despite adequate fluid resuscitation (30 mL/kg), the immediate priority is the
administration of vasopressors, with Norepinephrine being the first-line agent. While
antibiotics and cultures are crucial, hemodynamic stability must be addressed to ensure
organ perfusion. The patient’s elevated lactate indicates significant tissue hypoxia that
requires immediate correction of perfusion pressure.
2. Ms. Thompson was admitted two hours ago with 40% Total Body Surface Area (TBSA)
thermal burns. She weighs 70 kg. Using the Parkland Formula (4mL/kg/%TBSA), the nurse
calculates the total 24-hour fluid requirement. What is the hourly rate for the first 8 hours of
resuscitation?
A. 700 mL/hr
B. 350 mL/hr
C. 1,400 mL/hr
D. 525 mL/hr
Answer: A
Rationale: The Parkland Formula is calculated as 4 mL x 70 kg x 40% = 11,200 mL for the
first 24 hours. Half of this total volume (5,600 mL) must be administered within the first 8
hours following the time of injury. Dividing 5,600 mL by 8 hours results in an infusion rate
of 700 mL/hr.
,3. A patient in the Emergency Department presents with a penetrating chest wound. The
nurse notes tracheal deviation to the left, absent breath sounds on the right, and extreme
respiratory distress. Which intervention is the most immediate priority?
A. Prepare for a stat portable chest X-ray.
B. Assist with a needle thoracostomy to the right second intercostal space.
C. Apply a sterile occlusive dressing taped on three sides.
D. Intubate the patient and initiate mechanical ventilation.
Answer: B
Rationale: The clinical presentation of tracheal deviation, absent breath sounds, and
distress strongly suggests a tension pneumothorax, which is a life-threatening emergency.
Needle decompression (thoracostomy) is the immediate action required to relieve the
intrapleural pressure that is causing the mediastinal shift and obstructing venous return. A
chest X-ray would delay treatment, and intubation without decompression could worsen
the tension effect.
4. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation. The nurse notes the PaO2 is 62 mmHg despite an FiO2 of 80% and PEEP of 12 cm
H2O. Which positioning strategy should the nurse anticipate discussing with the intensivist?
A. High-Fowler’s position with the legs dependent.
B. Supine positioning with frequent log-rolling.
C. Left lateral decubitus position with the head of bed flat.
D. Prone positioning for at least 16 hours a day.
Answer: D
Rationale: Prone positioning is an evidence-based intervention for patients with severe
ARDS and refractory hypoxemia to improve ventilation-perfusion (V/Q) matching. It helps
by recruiting posterior lung segments and reducing the pressure of the heart and
abdominal contents on the lungs. Current guidelines typically recommend proning for 16 to
18 hours daily to maximize benefit.
5. Following a multi-vehicle accident, the nurse is performing triage using the START (Simple
Triage and Rapid Treatment) method. A victim is found to be unconscious, with a respiratory
rate of 8 breaths per minute and a radial pulse that is weak and thready. What color tag
should the nurse assign?
A. Green (Minor)
B. Yellow (Delayed)
C. Black (Deceased/Expectant)
D. Red (Immediate)
, Answer: D
Rationale: Under the START triage system, any patient who is unconscious or has
abnormal vital signs (RR < 10 or > 30, or impaired perfusion) is categorized as Red
(Immediate). This patient has a compromised airway/neurological status and poor
perfusion, requiring immediate life-saving interventions. Black tags are reserved for those
who are not breathing even after airway repositioning.
6. A patient in the progressive stage of shock has developed Disseminated Intravascular
Coagulation (DIC). The nurse monitors for which laboratory finding that is most characteristic
of this condition?
A. Decreased Prothrombin Time (PT).
B. Increased Fibrinogen levels.
C. Increased Fibrin Degradation Products (FDPs).
D. Decreased D-dimer levels.
Answer: C
Rationale: DIC is characterized by the widespread activation of the clotting cascade, which
subsequently consumes clotting factors and leads to secondary fibrinolysis. This process
results in increased Fibrin Degradation Products (FDPs) and D-dimer levels as the body
attempts to break down the excessive clots. Conversely, PT/PTT would be prolonged and
fibrinogen levels would be decreased.
7. Mr. Rodriguez is admitted with hypovolemic shock following a massive GI bleed. His CVP is
1 mmHg and his PAWP is 3 mmHg. Which IV fluid choice is most appropriate for rapid volume
expansion?
A. Lactated Ringer’s
B. 0.45% Sodium Chloride (Half-normal saline)
C. D5W (5% Dextrose in Water)
D. 3% Hypertonic Saline
Answer: A
Rationale: Isotonic crystalloids, such as Lactated Ringer’s or 0.9% Normal Saline, are the
preferred fluids for initial resuscitation in hypovolemic shock because they stay in the
intravascular space longer than hypotonic fluids. D5W and 0.45% saline are hypotonic and
would shift into the intracellular space, worsening edema without effectively increasing
intravascular volume. Lactated Ringer’s is often preferred in trauma/bleeding to help
buffer acidosis.
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 1) |
Galen
1. A 58-year-old male patient, Mr. Harrison, is admitted to the ICU with a diagnosis of septic
shock. His blood pressure is 82/46 mmHg, heart rate is 126 bpm, and his serum lactate level is
4.5 mmol/L. After a 30 mL/kg isotonic crystalloid bolus, his MAP remains 58 mmHg. Which
order should the nurse prioritize next?
A. Initiate a Norepinephrine infusion to maintain MAP > 65 mmHg.
B. Administer a second 2-liter bolus of Normal Saline.
C. Obtain two sets of blood cultures from different sites.
D. Administer broad-spectrum IV antibiotics immediately.
Answer: A
Rationale: In septic shock, if the Mean Arterial Pressure (MAP) remains below 65 mmHg
despite adequate fluid resuscitation (30 mL/kg), the immediate priority is the
administration of vasopressors, with Norepinephrine being the first-line agent. While
antibiotics and cultures are crucial, hemodynamic stability must be addressed to ensure
organ perfusion. The patient’s elevated lactate indicates significant tissue hypoxia that
requires immediate correction of perfusion pressure.
2. Ms. Thompson was admitted two hours ago with 40% Total Body Surface Area (TBSA)
thermal burns. She weighs 70 kg. Using the Parkland Formula (4mL/kg/%TBSA), the nurse
calculates the total 24-hour fluid requirement. What is the hourly rate for the first 8 hours of
resuscitation?
A. 700 mL/hr
B. 350 mL/hr
C. 1,400 mL/hr
D. 525 mL/hr
Answer: A
Rationale: The Parkland Formula is calculated as 4 mL x 70 kg x 40% = 11,200 mL for the
first 24 hours. Half of this total volume (5,600 mL) must be administered within the first 8
hours following the time of injury. Dividing 5,600 mL by 8 hours results in an infusion rate
of 700 mL/hr.
,3. A patient in the Emergency Department presents with a penetrating chest wound. The
nurse notes tracheal deviation to the left, absent breath sounds on the right, and extreme
respiratory distress. Which intervention is the most immediate priority?
A. Prepare for a stat portable chest X-ray.
B. Assist with a needle thoracostomy to the right second intercostal space.
C. Apply a sterile occlusive dressing taped on three sides.
D. Intubate the patient and initiate mechanical ventilation.
Answer: B
Rationale: The clinical presentation of tracheal deviation, absent breath sounds, and
distress strongly suggests a tension pneumothorax, which is a life-threatening emergency.
Needle decompression (thoracostomy) is the immediate action required to relieve the
intrapleural pressure that is causing the mediastinal shift and obstructing venous return. A
chest X-ray would delay treatment, and intubation without decompression could worsen
the tension effect.
4. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation. The nurse notes the PaO2 is 62 mmHg despite an FiO2 of 80% and PEEP of 12 cm
H2O. Which positioning strategy should the nurse anticipate discussing with the intensivist?
A. High-Fowler’s position with the legs dependent.
B. Supine positioning with frequent log-rolling.
C. Left lateral decubitus position with the head of bed flat.
D. Prone positioning for at least 16 hours a day.
Answer: D
Rationale: Prone positioning is an evidence-based intervention for patients with severe
ARDS and refractory hypoxemia to improve ventilation-perfusion (V/Q) matching. It helps
by recruiting posterior lung segments and reducing the pressure of the heart and
abdominal contents on the lungs. Current guidelines typically recommend proning for 16 to
18 hours daily to maximize benefit.
5. Following a multi-vehicle accident, the nurse is performing triage using the START (Simple
Triage and Rapid Treatment) method. A victim is found to be unconscious, with a respiratory
rate of 8 breaths per minute and a radial pulse that is weak and thready. What color tag
should the nurse assign?
A. Green (Minor)
B. Yellow (Delayed)
C. Black (Deceased/Expectant)
D. Red (Immediate)
, Answer: D
Rationale: Under the START triage system, any patient who is unconscious or has
abnormal vital signs (RR < 10 or > 30, or impaired perfusion) is categorized as Red
(Immediate). This patient has a compromised airway/neurological status and poor
perfusion, requiring immediate life-saving interventions. Black tags are reserved for those
who are not breathing even after airway repositioning.
6. A patient in the progressive stage of shock has developed Disseminated Intravascular
Coagulation (DIC). The nurse monitors for which laboratory finding that is most characteristic
of this condition?
A. Decreased Prothrombin Time (PT).
B. Increased Fibrinogen levels.
C. Increased Fibrin Degradation Products (FDPs).
D. Decreased D-dimer levels.
Answer: C
Rationale: DIC is characterized by the widespread activation of the clotting cascade, which
subsequently consumes clotting factors and leads to secondary fibrinolysis. This process
results in increased Fibrin Degradation Products (FDPs) and D-dimer levels as the body
attempts to break down the excessive clots. Conversely, PT/PTT would be prolonged and
fibrinogen levels would be decreased.
7. Mr. Rodriguez is admitted with hypovolemic shock following a massive GI bleed. His CVP is
1 mmHg and his PAWP is 3 mmHg. Which IV fluid choice is most appropriate for rapid volume
expansion?
A. Lactated Ringer’s
B. 0.45% Sodium Chloride (Half-normal saline)
C. D5W (5% Dextrose in Water)
D. 3% Hypertonic Saline
Answer: A
Rationale: Isotonic crystalloids, such as Lactated Ringer’s or 0.9% Normal Saline, are the
preferred fluids for initial resuscitation in hypovolemic shock because they stay in the
intravascular space longer than hypotonic fluids. D5W and 0.45% saline are hypotonic and
would shift into the intracellular space, worsening edema without effectively increasing
intravascular volume. Lactated Ringer’s is often preferred in trauma/bleeding to help
buffer acidosis.
