NUR 265 Exam 2 V2 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 62-year-old male patient, Mr. Henderson, is admitted with ARDS and is currently
receiving mechanical ventilation with PEEP set at 15 cm H2O. The nurse notes a sudden drop
in blood pressure and absent breath sounds on the right side. What is the nurse’s priority
action?
A. Prepare for immediate needle decompression or chest tube insertion.
B. Increase the PEEP setting to improve oxygenation.
C. Obtain an arterial blood gas (ABG) to check for hypoxia.
D. Suction the patient to clear potential mucus plugs.
Correct Answer: A
Explanation: High levels of PEEP increase the risk of barotrauma, which can lead to a
tension pneumothorax. The sudden drop in blood pressure and absent breath sounds are
classic signs of this life-threatening complication. Immediate intervention with
decompression is required to restore cardiac output and lung expansion.
2. Mrs. Bennett is a 55-year-old female in the ICU being treated for septic shock. Despite fluid
resuscitation of 30 mL/kg, her MAP remains at 58 mmHg. Which medication should the nurse
anticipate administering next?
A. Norepinephrine via central line
,B. Dopamine at 5 mcg/kg/min
C. Furosemide to improve renal perfusion
D. Nitroglycerin to reduce afterload
Correct Answer: A
Explanation: Norepinephrine is the first-line vasopressor recommended in septic shock
when fluid resuscitation fails to maintain a MAP of at least 65 mmHg. It should be
administered through a central line to prevent tissue necrosis from extravasation. The goal
is to improve systemic vascular resistance and ensure vital organ perfusion.
3. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg. The
nurse is preparing to administer Mannitol. What is the primary nursing consideration for this
medication?
A. Use a filter needle and tubing for administration.
B. Monitor for hypertension as a side effect.
C. Administer the drug over a period of 4 to 6 hours.
D. Maintain the serum osmolality below 250 mOsm/kg.
Correct Answer: A
Explanation: Mannitol is an osmotic diuretic that can crystallize at room temperature,
requiring the use of a filter needle and in-line filter. It works by drawing fluid from the
,brain tissue into the vascular space to reduce ICP. The nurse must also monitor serum
osmolality and electrolytes closely during therapy.
4. Mr. Rodriguez is a 40-year-old male with a T4 spinal cord injury who suddenly reports a
severe headache and blurred vision. His BP is 190/110 mmHg. Which action should the nurse
perform first?
A. Administer PRN Hydralazine as ordered.
B. Check the patient for a fecal impaction.
C. Perform a straight catheterization to empty the bladder.
D. Place the patient in a high-Fowler’s position.
Correct Answer: D
Explanation: The patient is exhibiting signs of Autonomic Dysreflexia, a medical
emergency in spinal cord injuries above T6. The first priority is to sit the patient upright to
utilize orthostatic changes to lower blood pressure. Once the patient is positioned, the
nurse should then identify and remove the triggering stimulus, such as a full bladder.
5. In the management of a patient with Acute Kidney Injury (AKI) in the oliguric phase, which
laboratory finding would most concern the nurse?
A. Serum Sodium of 132 mEq/L
B. Serum Potassium of 6.2 mEq/L
C. Serum Creatinine of 2.1 mg/dL
, D. Hemoglobin of 10.5 g/dL
Correct Answer: B
Explanation: Hyperkalemia is a common and dangerous complication of the oliguric phase
of AKI due to decreased renal excretion. A level of 6.2 mEq/L can lead to life-threatening
cardiac dysrhythmias and requires immediate intervention. While the other values are
abnormal, they do not pose the same immediate risk to the patient’s stability.
6. A patient is admitted to the ICU with Diabetic Ketoacidosis (DKA). The initial blood glucose
is 580 mg/dL, and the pH is 7.15. After two hours of insulin infusion, the glucose is 245 mg/dL.
What should the nurse do next?
A. Stop the insulin infusion immediately.
B. Continue the current IV fluid without changes.
C. Increase the insulin infusion rate to clear ketones.
D. Switch the IV fluid to one containing 5% Dextrose.
Correct Answer: D
Explanation: When blood glucose levels drop to approximately 250 mg/dL in DKA,
dextrose is added to the IV fluids. This prevents hypoglycemia and allows for the continued
administration of insulin to resolve the acidosis. The insulin infusion should not be stopped
until the anion gap is closed and the acidosis is corrected.
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 62-year-old male patient, Mr. Henderson, is admitted with ARDS and is currently
receiving mechanical ventilation with PEEP set at 15 cm H2O. The nurse notes a sudden drop
in blood pressure and absent breath sounds on the right side. What is the nurse’s priority
action?
A. Prepare for immediate needle decompression or chest tube insertion.
B. Increase the PEEP setting to improve oxygenation.
C. Obtain an arterial blood gas (ABG) to check for hypoxia.
D. Suction the patient to clear potential mucus plugs.
Correct Answer: A
Explanation: High levels of PEEP increase the risk of barotrauma, which can lead to a
tension pneumothorax. The sudden drop in blood pressure and absent breath sounds are
classic signs of this life-threatening complication. Immediate intervention with
decompression is required to restore cardiac output and lung expansion.
2. Mrs. Bennett is a 55-year-old female in the ICU being treated for septic shock. Despite fluid
resuscitation of 30 mL/kg, her MAP remains at 58 mmHg. Which medication should the nurse
anticipate administering next?
A. Norepinephrine via central line
,B. Dopamine at 5 mcg/kg/min
C. Furosemide to improve renal perfusion
D. Nitroglycerin to reduce afterload
Correct Answer: A
Explanation: Norepinephrine is the first-line vasopressor recommended in septic shock
when fluid resuscitation fails to maintain a MAP of at least 65 mmHg. It should be
administered through a central line to prevent tissue necrosis from extravasation. The goal
is to improve systemic vascular resistance and ensure vital organ perfusion.
3. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg. The
nurse is preparing to administer Mannitol. What is the primary nursing consideration for this
medication?
A. Use a filter needle and tubing for administration.
B. Monitor for hypertension as a side effect.
C. Administer the drug over a period of 4 to 6 hours.
D. Maintain the serum osmolality below 250 mOsm/kg.
Correct Answer: A
Explanation: Mannitol is an osmotic diuretic that can crystallize at room temperature,
requiring the use of a filter needle and in-line filter. It works by drawing fluid from the
,brain tissue into the vascular space to reduce ICP. The nurse must also monitor serum
osmolality and electrolytes closely during therapy.
4. Mr. Rodriguez is a 40-year-old male with a T4 spinal cord injury who suddenly reports a
severe headache and blurred vision. His BP is 190/110 mmHg. Which action should the nurse
perform first?
A. Administer PRN Hydralazine as ordered.
B. Check the patient for a fecal impaction.
C. Perform a straight catheterization to empty the bladder.
D. Place the patient in a high-Fowler’s position.
Correct Answer: D
Explanation: The patient is exhibiting signs of Autonomic Dysreflexia, a medical
emergency in spinal cord injuries above T6. The first priority is to sit the patient upright to
utilize orthostatic changes to lower blood pressure. Once the patient is positioned, the
nurse should then identify and remove the triggering stimulus, such as a full bladder.
5. In the management of a patient with Acute Kidney Injury (AKI) in the oliguric phase, which
laboratory finding would most concern the nurse?
A. Serum Sodium of 132 mEq/L
B. Serum Potassium of 6.2 mEq/L
C. Serum Creatinine of 2.1 mg/dL
, D. Hemoglobin of 10.5 g/dL
Correct Answer: B
Explanation: Hyperkalemia is a common and dangerous complication of the oliguric phase
of AKI due to decreased renal excretion. A level of 6.2 mEq/L can lead to life-threatening
cardiac dysrhythmias and requires immediate intervention. While the other values are
abnormal, they do not pose the same immediate risk to the patient’s stability.
6. A patient is admitted to the ICU with Diabetic Ketoacidosis (DKA). The initial blood glucose
is 580 mg/dL, and the pH is 7.15. After two hours of insulin infusion, the glucose is 245 mg/dL.
What should the nurse do next?
A. Stop the insulin infusion immediately.
B. Continue the current IV fluid without changes.
C. Increase the insulin infusion rate to clear ketones.
D. Switch the IV fluid to one containing 5% Dextrose.
Correct Answer: D
Explanation: When blood glucose levels drop to approximately 250 mg/dL in DKA,
dextrose is added to the IV fluids. This prevents hypoglycemia and allows for the continued
administration of insulin to resolve the acidosis. The insulin infusion should not be stopped
until the anion gap is closed and the acidosis is corrected.
