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 is a 58-year-old male admitted with ARDS receiving mechanical ventilation
with PEEP of 18 cm H2O. The nurse notes a sudden drop in cardiac output and a shift in the
trachea to the right. Which complication does the nurse suspect?
A. Ventilator-associated pneumonia
B. Right-sided pleural effusion
C. Tension pneumothorax on the left side
D. Pulmonary embolism
Correct Answer: C
Explanation: High levels of PEEP increase the risk of barotrauma, which can lead to a
pneumothorax. A tension pneumothorax causes increased intrathoracic pressure that shifts
the mediastinum and trachea away from the affected side, in this case to the right. This
condition is a medical emergency that requires immediate needle decompression or chest
tube insertion.
2. A 45-year-old female, Ms. Lawson, is in the oliguric phase of acute kidney injury (AKI). Her
serum potassium is 6.7 mEq/L, and her EKG shows peaked T-waves. Which medication should
the nurse prioritize for immediate administration to protect the myocardium?
A. Sodium polystyrene sulfonate
,B. Furosemide
C. Calcium gluconate
D. Regular insulin and D50
Correct Answer: C
Explanation: Calcium gluconate is administered in the setting of severe hyperkalemia to
stabilize the myocardial cell membrane and prevent life-threatening arrhythmias. While
insulin and sodium polystyrene help lower potassium levels, they do not provide
immediate cardiac protection. The nurse must recognize that peaked T-waves indicate
significant cardiac irritability requiring rapid intervention.
3. Mr. Sterling is a 72-year-old patient with chronic kidney disease who missed his last two
dialysis sessions. He presents with crackles in all lung fields, a BP of 188/96, and an oxygen
saturation of 86% on room air. What is the priority nursing intervention?
A. Administering a dose of PO Furosemide
B. Ordering a Stat chest X-ray
C. Encouraging the patient to use the incentive spirometer
D. Preparing the patient for emergency hemodialysis
Correct Answer: D
Explanation: Fluid volume overload in a patient with end-stage renal disease who has
missed dialysis is a critical situation often requiring emergency intervention. Hemodialysis
,is the most effective way to rapidly remove excess fluid and waste products to stabilize the
patient’s respiratory status. Other interventions like diuretics are often ineffective in
patients with significant renal failure.
4. A nurse is caring for Mrs. Gable, who has a T4 spinal cord injury. The patient suddenly
complains of a pounding headache and has a BP of 210/110. What is the first action the nurse
should take?
A. Elevate the head of the bed to 90 degrees
B. Perform a bladder scan
C. Administer PRN Hydralazine
D. Check for fecal impaction
Correct Answer: A
Explanation: Autonomic dysreflexia is a medical emergency occurring in spinal cord
injuries at T6 or above. Elevating the head of the bed is the first action to take because it
uses gravity to help lower the blood pressure through orthostatic effects. Following this,
the nurse should investigate and remove the noxious stimuli, such as a full bladder or
impacted bowel.
5. Mr. Vance, a 35-year-old, was rescued from a burning building and has sustained full-
thickness burns to 40% of his body. During the first 24 hours of the emergent phase, which
laboratory finding is expected due to cellular destruction?
A. Hypernatremia
, B. Decreased hematocrit
C. Hypoglycemia
D. Hyperkalemia
Correct Answer: D
Explanation: During the emergent phase of a burn injury, massive cellular destruction
occurs, causing potassium to leak out of the cells into the extracellular fluid. This results in
hyperkalemia, which must be monitored closely to prevent cardiac dysrhythmias.
Additionally, the hematocrit usually increases due to hemoconcentration from fluid loss
into the interstitium.
6. Ms. Chen is admitted to the ICU with a diagnosis of septic shock. Despite receiving 3 liters
of normal saline, her Mean Arterial Pressure (MAP) remains at 58 mmHg. Which medication
does the nurse anticipate being ordered next?
A. Dopamine
B. Norepinephrine
C. Dobutamine
D. Nitroprusside
Correct Answer: B
Explanation: Norepinephrine is the first-line vasopressor of choice for septic shock when
fluid resuscitation fails to maintain an adequate MAP of at least 65 mmHg. It works
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 3) | Galen
1. Mr. Harrison is a 58-year-old male admitted with ARDS receiving mechanical ventilation
with PEEP of 18 cm H2O. The nurse notes a sudden drop in cardiac output and a shift in the
trachea to the right. Which complication does the nurse suspect?
A. Ventilator-associated pneumonia
B. Right-sided pleural effusion
C. Tension pneumothorax on the left side
D. Pulmonary embolism
Correct Answer: C
Explanation: High levels of PEEP increase the risk of barotrauma, which can lead to a
pneumothorax. A tension pneumothorax causes increased intrathoracic pressure that shifts
the mediastinum and trachea away from the affected side, in this case to the right. This
condition is a medical emergency that requires immediate needle decompression or chest
tube insertion.
2. A 45-year-old female, Ms. Lawson, is in the oliguric phase of acute kidney injury (AKI). Her
serum potassium is 6.7 mEq/L, and her EKG shows peaked T-waves. Which medication should
the nurse prioritize for immediate administration to protect the myocardium?
A. Sodium polystyrene sulfonate
,B. Furosemide
C. Calcium gluconate
D. Regular insulin and D50
Correct Answer: C
Explanation: Calcium gluconate is administered in the setting of severe hyperkalemia to
stabilize the myocardial cell membrane and prevent life-threatening arrhythmias. While
insulin and sodium polystyrene help lower potassium levels, they do not provide
immediate cardiac protection. The nurse must recognize that peaked T-waves indicate
significant cardiac irritability requiring rapid intervention.
3. Mr. Sterling is a 72-year-old patient with chronic kidney disease who missed his last two
dialysis sessions. He presents with crackles in all lung fields, a BP of 188/96, and an oxygen
saturation of 86% on room air. What is the priority nursing intervention?
A. Administering a dose of PO Furosemide
B. Ordering a Stat chest X-ray
C. Encouraging the patient to use the incentive spirometer
D. Preparing the patient for emergency hemodialysis
Correct Answer: D
Explanation: Fluid volume overload in a patient with end-stage renal disease who has
missed dialysis is a critical situation often requiring emergency intervention. Hemodialysis
,is the most effective way to rapidly remove excess fluid and waste products to stabilize the
patient’s respiratory status. Other interventions like diuretics are often ineffective in
patients with significant renal failure.
4. A nurse is caring for Mrs. Gable, who has a T4 spinal cord injury. The patient suddenly
complains of a pounding headache and has a BP of 210/110. What is the first action the nurse
should take?
A. Elevate the head of the bed to 90 degrees
B. Perform a bladder scan
C. Administer PRN Hydralazine
D. Check for fecal impaction
Correct Answer: A
Explanation: Autonomic dysreflexia is a medical emergency occurring in spinal cord
injuries at T6 or above. Elevating the head of the bed is the first action to take because it
uses gravity to help lower the blood pressure through orthostatic effects. Following this,
the nurse should investigate and remove the noxious stimuli, such as a full bladder or
impacted bowel.
5. Mr. Vance, a 35-year-old, was rescued from a burning building and has sustained full-
thickness burns to 40% of his body. During the first 24 hours of the emergent phase, which
laboratory finding is expected due to cellular destruction?
A. Hypernatremia
, B. Decreased hematocrit
C. Hypoglycemia
D. Hyperkalemia
Correct Answer: D
Explanation: During the emergent phase of a burn injury, massive cellular destruction
occurs, causing potassium to leak out of the cells into the extracellular fluid. This results in
hyperkalemia, which must be monitored closely to prevent cardiac dysrhythmias.
Additionally, the hematocrit usually increases due to hemoconcentration from fluid loss
into the interstitium.
6. Ms. Chen is admitted to the ICU with a diagnosis of septic shock. Despite receiving 3 liters
of normal saline, her Mean Arterial Pressure (MAP) remains at 58 mmHg. Which medication
does the nurse anticipate being ordered next?
A. Dopamine
B. Norepinephrine
C. Dobutamine
D. Nitroprusside
Correct Answer: B
Explanation: Norepinephrine is the first-line vasopressor of choice for septic shock when
fluid resuscitation fails to maintain an adequate MAP of at least 65 mmHg. It works
