NUR 265 Exam 1 V1 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 1) |
Galen
1. Mr. Harrison, a 54-year-old patient with a history of COPD, is admitted with worsening
dyspnea. His ABG results show: pH 7.28, PaCO2 58 mmHg, and HCO3 28 mEq/L. Which
interpretation and nursing priority are most accurate?
A. Metabolic Acidosis; prepare to administer sodium bicarbonate intravenously.
B. Metabolic Alkalosis; assess for electrolyte imbalances and history of vomiting.
C. Respiratory Alkalosis; provided a rebreather mask to increase CO2 levels.
D. Respiratory Acidosis; encourage deep breathing and monitor for increased work of
breathing.
Answer: D
Rationale: The pH is low and the PaCO2 is high, which indicates a primary respiratory
acidosis. The slightly elevated HCO3 indicates partial compensation by the kidneys, which
is common in chronic COPD patients. The nurse must prioritize improving gas exchange
and monitoring the patient for signs of respiratory failure or the need for mechanical
ventilation.
2. A 32-year-old female, Ms. Rodriguez, is brought to the Emergency Department with
thermal burns to her entire right arm, anterior chest, and the front of her right leg. Using the
Rule of Nines, what is the estimated Total Body Surface Area (TBSA) burned?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Rationale: The Rule of Nines assigns 9% for the entire arm, 18% for the anterior trunk,
and 9% for the anterior leg (half of the total 18% for the whole leg). Adding 9% (arm) + 9%
(chest, assuming ‘anterior chest’ refers to upper half of the 18% anterior trunk) + 9%
(anterior leg) might vary by source, but consistently, ‘entire arm (9)’, ‘anterior chest (9)’,
and ‘anterior leg (9)’ equals 27%. This assessment is foundational for calculating fluid
resuscitation requirements in burn patients.
,3. The nurse is caring for a patient, Mr. Miller, who weighs 80 kg and has sustained 40% TBSA
burns. Using the Parkland formula (4 mL/kg/%TBSA), calculate the infusion rate (mL/hr) for
the first 8 hours of fluid resuscitation.
A. 400 mL/hr
B. 1600 mL/hr
C. 1200 mL/hr
D. 800 mL/hr
Answer: D
Rationale: Total fluid is 4 mL x 80 kg x 40% = 12,800 mL over 24 hours. Half of this
amount, 6,400 mL, must be given in the first 8 hours following the injury. Dividing 6,400
mL by 8 hours results in an infusion rate of 800 mL/hr. Accuracy in this calculation is vital
to prevent hypovolemic shock in the acute phase of burn injury.
4. A patient is in the progressive stage of hypovolemic shock. Which clinical finding should the
nurse anticipate?
A. Increased urinary output and bradycardia
B. Cold, dry skin and bounding peripheral pulses
C. Metabolic alkalosis due to rapid respirations
D. Mean Arterial Pressure (MAP) decrease of 20 mmHg from baseline
Answer: D
Rationale: In the progressive stage of shock, compensatory mechanisms begin to fail,
leading to reduced tissue perfusion. A MAP decrease of 20 mmHg or more from the
baseline indicates the body can no longer maintain hemodynamics. The nurse would also
observe anaerobic metabolism leading to lactic acidosis and decreased organ function.
5. A client presents to the ED with a potassium level of 6.8 mEq/L. Which EKG change is most
characteristic of this electrolyte imbalance?
A. Tall, peaked T waves
B. ST-segment depression
C. Presence of U waves
D. Shortened PR interval
Answer: A
Rationale: Hyperkalemia (K+ > 5.0 mEq/L) typically causes tall, peaked T waves, a
widened QRS complex, and a prolonged PR interval. These changes occur because high
potassium levels affect the repolarization of the cardiac muscle. The nurse should
, immediately prepare for interventions like calcium gluconate or insulin with dextrose to
protect the heart and shift potassium into cells.
6. Following a mass casualty event, the triage nurse uses the START method. A victim is found
with a respiratory rate of 34 breaths/min and a delayed capillary refill. Which color tag
should the nurse assign?
A. Green (Minor)
B. Yellow (Delayed)
C. Black (Deceased)
D. Red (Immediate)
Answer: D
Rationale: According to the START triage system, if respirations are over 30 breaths/min,
the patient is tagged as Red (Immediate). Rapid assessment of ‘RPM’ (Respirations,
Perfusion, Mental Status) is the standard for prioritizing care when resources are limited.
This patient requires urgent medical intervention to survive the primary injury or prevent
further deterioration.
7. The nurse is monitoring a patient with septic shock. The patient’s Central Venous Pressure
(CVP) is 1 mmHg and the Mean Arterial Pressure (MAP) is 55 mmHg. What is the priority
nursing intervention?
A. Start a norepinephrine (Levophed) infusion at 2 mcg/min.
B. Administer a prescribed bolus of 0.9% normal saline.
C. Perform a neurological assessment for signs of cerebral edema.
D. Request a blood culture to identify the causative organism.
Answer: B
Rationale: A CVP of 1 mmHg is significantly below the normal range (2-6 mmHg),
indicating fluid volume deficit or low preload. In septic shock, the ‘Surviving Sepsis’ bundle
prioritizes fluid resuscitation before starting vasopressors unless the patient remains
hypotensive after adequate fluid load. Restoring effective circulating volume is the first
step to improving cardiac output and tissue perfusion.
8. A patient with full-thickness burns to the face and neck develops soot in the sputum and a
hoarse voice. Which action is the highest priority?
A. Administering pain medication intravenously.
B. Applying antibiotic ointment to the burned areas.
C. Preparing for immediate endotracheal intubation.
D. Starting a large-bore IV for fluid resuscitation.
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 1) |
Galen
1. Mr. Harrison, a 54-year-old patient with a history of COPD, is admitted with worsening
dyspnea. His ABG results show: pH 7.28, PaCO2 58 mmHg, and HCO3 28 mEq/L. Which
interpretation and nursing priority are most accurate?
A. Metabolic Acidosis; prepare to administer sodium bicarbonate intravenously.
B. Metabolic Alkalosis; assess for electrolyte imbalances and history of vomiting.
C. Respiratory Alkalosis; provided a rebreather mask to increase CO2 levels.
D. Respiratory Acidosis; encourage deep breathing and monitor for increased work of
breathing.
Answer: D
Rationale: The pH is low and the PaCO2 is high, which indicates a primary respiratory
acidosis. The slightly elevated HCO3 indicates partial compensation by the kidneys, which
is common in chronic COPD patients. The nurse must prioritize improving gas exchange
and monitoring the patient for signs of respiratory failure or the need for mechanical
ventilation.
2. A 32-year-old female, Ms. Rodriguez, is brought to the Emergency Department with
thermal burns to her entire right arm, anterior chest, and the front of her right leg. Using the
Rule of Nines, what is the estimated Total Body Surface Area (TBSA) burned?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Rationale: The Rule of Nines assigns 9% for the entire arm, 18% for the anterior trunk,
and 9% for the anterior leg (half of the total 18% for the whole leg). Adding 9% (arm) + 9%
(chest, assuming ‘anterior chest’ refers to upper half of the 18% anterior trunk) + 9%
(anterior leg) might vary by source, but consistently, ‘entire arm (9)’, ‘anterior chest (9)’,
and ‘anterior leg (9)’ equals 27%. This assessment is foundational for calculating fluid
resuscitation requirements in burn patients.
,3. The nurse is caring for a patient, Mr. Miller, who weighs 80 kg and has sustained 40% TBSA
burns. Using the Parkland formula (4 mL/kg/%TBSA), calculate the infusion rate (mL/hr) for
the first 8 hours of fluid resuscitation.
A. 400 mL/hr
B. 1600 mL/hr
C. 1200 mL/hr
D. 800 mL/hr
Answer: D
Rationale: Total fluid is 4 mL x 80 kg x 40% = 12,800 mL over 24 hours. Half of this
amount, 6,400 mL, must be given in the first 8 hours following the injury. Dividing 6,400
mL by 8 hours results in an infusion rate of 800 mL/hr. Accuracy in this calculation is vital
to prevent hypovolemic shock in the acute phase of burn injury.
4. A patient is in the progressive stage of hypovolemic shock. Which clinical finding should the
nurse anticipate?
A. Increased urinary output and bradycardia
B. Cold, dry skin and bounding peripheral pulses
C. Metabolic alkalosis due to rapid respirations
D. Mean Arterial Pressure (MAP) decrease of 20 mmHg from baseline
Answer: D
Rationale: In the progressive stage of shock, compensatory mechanisms begin to fail,
leading to reduced tissue perfusion. A MAP decrease of 20 mmHg or more from the
baseline indicates the body can no longer maintain hemodynamics. The nurse would also
observe anaerobic metabolism leading to lactic acidosis and decreased organ function.
5. A client presents to the ED with a potassium level of 6.8 mEq/L. Which EKG change is most
characteristic of this electrolyte imbalance?
A. Tall, peaked T waves
B. ST-segment depression
C. Presence of U waves
D. Shortened PR interval
Answer: A
Rationale: Hyperkalemia (K+ > 5.0 mEq/L) typically causes tall, peaked T waves, a
widened QRS complex, and a prolonged PR interval. These changes occur because high
potassium levels affect the repolarization of the cardiac muscle. The nurse should
, immediately prepare for interventions like calcium gluconate or insulin with dextrose to
protect the heart and shift potassium into cells.
6. Following a mass casualty event, the triage nurse uses the START method. A victim is found
with a respiratory rate of 34 breaths/min and a delayed capillary refill. Which color tag
should the nurse assign?
A. Green (Minor)
B. Yellow (Delayed)
C. Black (Deceased)
D. Red (Immediate)
Answer: D
Rationale: According to the START triage system, if respirations are over 30 breaths/min,
the patient is tagged as Red (Immediate). Rapid assessment of ‘RPM’ (Respirations,
Perfusion, Mental Status) is the standard for prioritizing care when resources are limited.
This patient requires urgent medical intervention to survive the primary injury or prevent
further deterioration.
7. The nurse is monitoring a patient with septic shock. The patient’s Central Venous Pressure
(CVP) is 1 mmHg and the Mean Arterial Pressure (MAP) is 55 mmHg. What is the priority
nursing intervention?
A. Start a norepinephrine (Levophed) infusion at 2 mcg/min.
B. Administer a prescribed bolus of 0.9% normal saline.
C. Perform a neurological assessment for signs of cerebral edema.
D. Request a blood culture to identify the causative organism.
Answer: B
Rationale: A CVP of 1 mmHg is significantly below the normal range (2-6 mmHg),
indicating fluid volume deficit or low preload. In septic shock, the ‘Surviving Sepsis’ bundle
prioritizes fluid resuscitation before starting vasopressors unless the patient remains
hypotensive after adequate fluid load. Restoring effective circulating volume is the first
step to improving cardiac output and tissue perfusion.
8. A patient with full-thickness burns to the face and neck develops soot in the sputum and a
hoarse voice. Which action is the highest priority?
A. Administering pain medication intravenously.
B. Applying antibiotic ointment to the burned areas.
C. Preparing for immediate endotracheal intubation.
D. Starting a large-bore IV for fluid resuscitation.
