BSN HESI 266 MED SURG EXAM 4
QUESTIONS WITH CORRECT ANSWERS
(LATEST ), (A+ GUARANTEE).
1. A patient is admitted with suspected septic shock. Which of the following clinical findings
should the nurse prioritize as the earliest indicator of systemic inflammatory response
syndrome (SIRS)?
A. Mean Arterial Pressure (MAP) of 60 mmHg
B. White blood cell count of 14,000/mm³
C. Urine output of 20 mL/hr
D. Serum lactate level of 3.0 mmol/L
Answer: B
Conceptual Explanation: SIRS criteria include a WBC count >12,000 or <4,000, or >10%
bands. While lactate and MAP are critical in shock, the WBC count is a primary diagnostic
criterion for SIRS.
2. A nurse is caring for a client with a 40% Total Body Surface Area (TBSA) burn. Using the
Parkland formula (4mL x kg x %TBSA), how much fluid should be administered in the first 8
hours for a patient weighing 75 kg?
A. 3,000 mL
,B. 12,000 mL
C. 6,000 mL
D. 4,500 mL
Answer: C
Conceptual Explanation: Calculation: 4mL x 75kg x 40 = 12,000 mL total for 24 hours. The
Parkland formula dictates that half of the total volume (6,000 mL) must be given in the first
8 hours.
3. A client with a T4 spinal cord injury reports a sudden, throbbing headache and has a blood
pressure of 190/100 mmHg. Which action should the nurse take first?
A. Administer an antihypertensive medication
B. Check the client’s bladder for distension
C. Notify the healthcare provider immediately
D. Place the client in a high-Fowler’s position
Answer: D
Conceptual Explanation: The client is experiencing autonomic dysreflexia. The first
priority is to sit the patient up (high-Fowler’s) to help lower blood pressure through
orthostatic changes before addressing the cause (like bladder distension).
, 4. Which laboratory value is most indicative of the ‘ebb phase’ in a patient following major
trauma?
A. Increased cardiac output
B. Negative nitrogen balance
C. Hyperglycemia
D. Decreased body temperature
Answer: D
Conceptual Explanation: The ebb phase occurs immediately after injury and is
characterized by decreased oxygen consumption, hypometabolism, and decreased body
temperature. The flow phase follows with hypermetabolism.
5. A client with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which medication order should the nurse implement first to protect the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate) orally
B. Regular insulin and 50% Dextrose IV
C. Furosemide (Lasix) IV
D. Calcium Gluconate IV
Answer: D
QUESTIONS WITH CORRECT ANSWERS
(LATEST ), (A+ GUARANTEE).
1. A patient is admitted with suspected septic shock. Which of the following clinical findings
should the nurse prioritize as the earliest indicator of systemic inflammatory response
syndrome (SIRS)?
A. Mean Arterial Pressure (MAP) of 60 mmHg
B. White blood cell count of 14,000/mm³
C. Urine output of 20 mL/hr
D. Serum lactate level of 3.0 mmol/L
Answer: B
Conceptual Explanation: SIRS criteria include a WBC count >12,000 or <4,000, or >10%
bands. While lactate and MAP are critical in shock, the WBC count is a primary diagnostic
criterion for SIRS.
2. A nurse is caring for a client with a 40% Total Body Surface Area (TBSA) burn. Using the
Parkland formula (4mL x kg x %TBSA), how much fluid should be administered in the first 8
hours for a patient weighing 75 kg?
A. 3,000 mL
,B. 12,000 mL
C. 6,000 mL
D. 4,500 mL
Answer: C
Conceptual Explanation: Calculation: 4mL x 75kg x 40 = 12,000 mL total for 24 hours. The
Parkland formula dictates that half of the total volume (6,000 mL) must be given in the first
8 hours.
3. A client with a T4 spinal cord injury reports a sudden, throbbing headache and has a blood
pressure of 190/100 mmHg. Which action should the nurse take first?
A. Administer an antihypertensive medication
B. Check the client’s bladder for distension
C. Notify the healthcare provider immediately
D. Place the client in a high-Fowler’s position
Answer: D
Conceptual Explanation: The client is experiencing autonomic dysreflexia. The first
priority is to sit the patient up (high-Fowler’s) to help lower blood pressure through
orthostatic changes before addressing the cause (like bladder distension).
, 4. Which laboratory value is most indicative of the ‘ebb phase’ in a patient following major
trauma?
A. Increased cardiac output
B. Negative nitrogen balance
C. Hyperglycemia
D. Decreased body temperature
Answer: D
Conceptual Explanation: The ebb phase occurs immediately after injury and is
characterized by decreased oxygen consumption, hypometabolism, and decreased body
temperature. The flow phase follows with hypermetabolism.
5. A client with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which medication order should the nurse implement first to protect the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate) orally
B. Regular insulin and 50% Dextrose IV
C. Furosemide (Lasix) IV
D. Calcium Gluconate IV
Answer: D
