NUR 265 Exam 4 V2 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. Mr. Roberts is admitted with severe sepsis and a Mean Arterial Pressure (MAP) of 58
mmHg despite receiving 3 liters of Lactated Ringer’s. The nurse notes cool, clammy skin and a
serum lactate of 4.2 mmol/L. Which intervention should the nurse prioritize next to improve
tissue perfusion?
A. Administer a broad-spectrum antibiotic within the next hour.
B. Insert a second large-bore peripheral IV for more fluid boluses.
C. Place the patient in a Trendelenburg position to increase venous return.
D. Initiate a norepinephrine infusion via a central venous catheter.
Correct Answer: D
Explanation: In septic shock, if the MAP remains below 65 mmHg after adequate fluid
resuscitation, vasopressors like norepinephrine are the first-line choice. The elevated
lactate level indicates ongoing anaerobic metabolism and tissue hypoxia. Administering
vasopressors helps restore systemic vascular resistance and ensures vital organ perfusion.
2. A 45-year-old female, Ms. Garcia, is brought to the ED with deep partial-thickness burns to
her entire right arm, anterior chest, and anterior right leg. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) burned?
A. 36%
,B. 27%
C. 45%
D. 18%
Correct Answer: A
Explanation: According to the Rule of Nines, the entire arm counts as 9%, the anterior
chest counts as 18%, and the anterior leg counts as 9%. Adding these figures together (9 +
18 + 9) results in a total of 36%. Accurate TBSA calculation is critical for determining fluid
resuscitation needs in the emergent phase of burn care.
3. A patient with ARDS is being mechanically ventilated with high levels of PEEP (15 cm H2O).
The nurse suddenly notices the patient’s heart rate increases to 130 bpm, blood pressure
drops to 82/40 mmHg, and the high-pressure alarm sounds. What is the nurse’s immediate
action?
A. Assess for tracheal deviation and absent breath sounds.
B. Increase the PEEP setting to improve oxygenation.
C. Suction the endotracheal tube to clear secretions.
D. Administer a sedative to reduce patient-ventilator dyssynchrony.
Correct Answer: A
Explanation: High PEEP levels increase the risk of barotrauma, potentially leading to a
tension pneumothorax. The sudden hemodynamic instability combined with high-pressure
,alarms suggests a collapsed lung causing obstructive shock. Assessing for tracheal shift and
diminished breath sounds is the first step in confirming this life-threatening complication
before needle decompression.
4. Mrs. Thompson is in the compensatory stage of hypovolemic shock. Which clinical
manifestation is the nurse most likely to observe as a result of the body’s attempts to
maintain homeostasis?
A. Decreased heart rate and narrowed pulse pressure.
B. Increased urine output and peripheral vasodilation.
C. Restlessness, tachycardia, and cool, pale skin.
D. Respiratory alkalosis with a decrease in respiratory rate.
Correct Answer: C
Explanation: During the compensatory stage, the sympathetic nervous system triggers the
‘fight or flight’ response, causing tachycardia and peripheral vasoconstriction to shunt
blood to vital organs. Restlessness is an early sign of decreased cerebral perfusion or
hypoxia. The skin becomes cool and pale as blood is diverted away from the integumentary
system.
5. A trauma patient, Mr. Miller, was involved in a motor vehicle accident and is suspected of
having a flail chest. Which assessment finding is pathognomonic for this condition?
A. Subcutaneous emphysema around the neck.
B. Hyperresonance and decreased breath sounds.
, C. Dullness to percussion over the affected lung field.
D. Paradoxical chest wall movement during respiration.
Correct Answer: D
Explanation: Flail chest occurs when three or more adjacent ribs are fractured in two or
more places, creating a floating segment. This segment moves inward during inspiration
and outward during expiration, known as paradoxical movement. This condition
significantly impairs ventilation and often requires stabilization and aggressive pain
management.
6. Which lab result most strongly indicates that a patient with disseminated intravascular
coagulation (DIC) is responding to treatment?
A. Decreasing Fibrin Degradation Products (FDPs).
B. Increasing D-dimer levels.
C. Decrease in serum Platelet count.
D. Prolongation of the Prothrombin Time (PT).
Correct Answer: A
Explanation: DIC is characterized by excessive clotting followed by the breakdown of
those clots, which produces FDPs. A decrease in FDP levels suggests that the excessive
clotting and fibrinolysis cycle is slowing down. Conversely, increasing platelets and
decreasing D-dimer levels would also indicate improvement in the patient’s condition.
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 4) | Galen
1. Mr. Roberts is admitted with severe sepsis and a Mean Arterial Pressure (MAP) of 58
mmHg despite receiving 3 liters of Lactated Ringer’s. The nurse notes cool, clammy skin and a
serum lactate of 4.2 mmol/L. Which intervention should the nurse prioritize next to improve
tissue perfusion?
A. Administer a broad-spectrum antibiotic within the next hour.
B. Insert a second large-bore peripheral IV for more fluid boluses.
C. Place the patient in a Trendelenburg position to increase venous return.
D. Initiate a norepinephrine infusion via a central venous catheter.
Correct Answer: D
Explanation: In septic shock, if the MAP remains below 65 mmHg after adequate fluid
resuscitation, vasopressors like norepinephrine are the first-line choice. The elevated
lactate level indicates ongoing anaerobic metabolism and tissue hypoxia. Administering
vasopressors helps restore systemic vascular resistance and ensures vital organ perfusion.
2. A 45-year-old female, Ms. Garcia, is brought to the ED with deep partial-thickness burns to
her entire right arm, anterior chest, and anterior right leg. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) burned?
A. 36%
,B. 27%
C. 45%
D. 18%
Correct Answer: A
Explanation: According to the Rule of Nines, the entire arm counts as 9%, the anterior
chest counts as 18%, and the anterior leg counts as 9%. Adding these figures together (9 +
18 + 9) results in a total of 36%. Accurate TBSA calculation is critical for determining fluid
resuscitation needs in the emergent phase of burn care.
3. A patient with ARDS is being mechanically ventilated with high levels of PEEP (15 cm H2O).
The nurse suddenly notices the patient’s heart rate increases to 130 bpm, blood pressure
drops to 82/40 mmHg, and the high-pressure alarm sounds. What is the nurse’s immediate
action?
A. Assess for tracheal deviation and absent breath sounds.
B. Increase the PEEP setting to improve oxygenation.
C. Suction the endotracheal tube to clear secretions.
D. Administer a sedative to reduce patient-ventilator dyssynchrony.
Correct Answer: A
Explanation: High PEEP levels increase the risk of barotrauma, potentially leading to a
tension pneumothorax. The sudden hemodynamic instability combined with high-pressure
,alarms suggests a collapsed lung causing obstructive shock. Assessing for tracheal shift and
diminished breath sounds is the first step in confirming this life-threatening complication
before needle decompression.
4. Mrs. Thompson is in the compensatory stage of hypovolemic shock. Which clinical
manifestation is the nurse most likely to observe as a result of the body’s attempts to
maintain homeostasis?
A. Decreased heart rate and narrowed pulse pressure.
B. Increased urine output and peripheral vasodilation.
C. Restlessness, tachycardia, and cool, pale skin.
D. Respiratory alkalosis with a decrease in respiratory rate.
Correct Answer: C
Explanation: During the compensatory stage, the sympathetic nervous system triggers the
‘fight or flight’ response, causing tachycardia and peripheral vasoconstriction to shunt
blood to vital organs. Restlessness is an early sign of decreased cerebral perfusion or
hypoxia. The skin becomes cool and pale as blood is diverted away from the integumentary
system.
5. A trauma patient, Mr. Miller, was involved in a motor vehicle accident and is suspected of
having a flail chest. Which assessment finding is pathognomonic for this condition?
A. Subcutaneous emphysema around the neck.
B. Hyperresonance and decreased breath sounds.
, C. Dullness to percussion over the affected lung field.
D. Paradoxical chest wall movement during respiration.
Correct Answer: D
Explanation: Flail chest occurs when three or more adjacent ribs are fractured in two or
more places, creating a floating segment. This segment moves inward during inspiration
and outward during expiration, known as paradoxical movement. This condition
significantly impairs ventilation and often requires stabilization and aggressive pain
management.
6. Which lab result most strongly indicates that a patient with disseminated intravascular
coagulation (DIC) is responding to treatment?
A. Decreasing Fibrin Degradation Products (FDPs).
B. Increasing D-dimer levels.
C. Decrease in serum Platelet count.
D. Prolongation of the Prothrombin Time (PT).
Correct Answer: A
Explanation: DIC is characterized by excessive clotting followed by the breakdown of
those clots, which produces FDPs. A decrease in FDP levels suggests that the excessive
clotting and fibrinolysis cycle is slowing down. Conversely, increasing platelets and
decreasing D-dimer levels would also indicate improvement in the patient’s condition.
