NUR 265 Final Exam V1 | NUR 265 Advanced
Concepts of Medical–Surgical Nursing | Actual Q&A
with Rationale (NUR 265 Final Exam ) | Galen
1. A 55-year-old male is admitted to the ICU with a diagnosis of septic shock. His blood
pressure is 82/46 mmHg, heart rate is 126 bpm, and lactate level is 6.2 mmol/L. After
receiving a 30 mL/kg bolus of normal saline, his mean arterial pressure (MAP) remains at 58
mmHg. Which of the following is the priority pharmacological intervention?
A. Administer a bolus of 500 mL 5% Albumin.
B. Start a Vasopressin infusion at 0.03 units/minute.
C. Initiate a Norepinephrine infusion to maintain MAP > 65 mmHg.
D. Administer intravenous hydrocortisone 200 mg per day.
Correct Answer: C
Explanation: In septic shock, if fluid resuscitation fails to restore adequate tissue perfusion
and blood pressure, vasopressors are the next line of treatment. Norepinephrine is the
first-choice vasopressor to maintain a MAP of at least 65 mmHg. The patient’s current MAP
is 58 mmHg, indicating a critical need for vasopressor support to prevent further organ
dysfunction.
,2. A patient who sustained partial-thickness and full-thickness burns to 40% of their body
surface area 12 hours ago is in the emergent phase of burn management. The nurse notes the
patient’s urine output has been 20 mL/hour for the past two hours. What is the nurse’s most
appropriate action?
A. Decrease the IV fluid rate as the patient may be fluid overloaded.
B. Administer a 20 mg dose of Furosemide as ordered.
C. Increase the rate of the prescribed Lactated Ringer’s solution.
D. Document the findings as an expected outcome during the emergent phase.
Correct Answer: C
Explanation: Adequate fluid resuscitation is vital during the emergent phase of a burn
injury to prevent hypovolemic shock and acute kidney injury. The standard goal for urine
output in a burn patient is 0.5 to 1.0 mL/kg/hr, or roughly 30-50 mL/hr in an average
adult. A urine output of 20 mL/hr indicates inadequate resuscitation, necessitating an
increase in IV fluid titration.
3. A patient with a T4 spinal cord injury (SCI) reports a sudden, throbbing headache and nasal
congestion. The nurse observes the patient’s face is flushed and their blood pressure is
190/100 mmHg. Which action should the nurse take first?
A. Place the patient in a high-Fowler’s position.
B. Administer a prescribed PRN dose of Hydralazine.
C. Perform a bladder scan to assess for urinary retention.
,D. Check the patient’s skin for pressure ulcers or tight clothing.
Correct Answer: A
Explanation: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency occurring in SCI patients at or above T6. The immediate priority is to sit the
patient upright (high-Fowler’s) to lower blood pressure via orthostatic changes. Once the
patient is positioned, the nurse should then identify and eliminate the triggering stimulus,
such as a full bladder or impacted bowel.
4. An ICU nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) who
is being mechanically ventilated with high levels of Positive End-Expiratory Pressure (PEEP).
The nurse notes a sudden drop in oxygen saturation and absent breath sounds on the right
side. Which complication should the nurse suspect?
A. Ventilator-associated pneumonia.
B. Pulmonary embolism.
C. Tension pneumothorax.
D. Oxygen toxicity.
Correct Answer: C
Explanation: High levels of PEEP increase the risk of barotrauma, which can lead to a
pneumothorax. Sudden desaturation combined with absent breath sounds on one side is a
hallmark sign of a collapsed lung or tension pneumothorax. This requires immediate
intervention, such as needle decompression or chest tube insertion, to stabilize the patient.
, 5. A patient with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L and the
EKG shows peaked T-waves. The nurse should anticipate which immediate order to shift
potassium back into the cells?
A. Sodium polystyrene sulfonate (Kayexalate) orally.
B. Intravenous regular insulin and 50% dextrose.
C. Calcium gluconate intravenous push.
D. Continuous renal replacement therapy (CRRT).
Correct Answer: B
Explanation: Intravenous regular insulin, given with dextrose to prevent hypoglycemia, is
an effective way to rapidly shift potassium from the extracellular fluid into the intracellular
compartment. While calcium gluconate stabilizes the myocardium to prevent arrhythmias,
it does not lower potassium levels. Kayexalate and CRRT are methods to remove potassium
from the body, but they do not act as quickly as the insulin-dextrose shift.
6. A patient is admitted with Diabetic Ketoacidosis (DKA). The initial laboratory results show a
blood glucose of 550 mg/dL, a pH of 7.15, and a potassium level of 3.3 mEq/L. Which provider
order should the nurse implement first?
A. Start an intravenous insulin drip at 0.1 units/kg/hr.
B. Add 20 mEq of Potassium Chloride to the IV fluids.
C. Administer a 1-liter bolus of 0.9% Normal Saline.
D. Administer intravenous Sodium Bicarbonate.
Concepts of Medical–Surgical Nursing | Actual Q&A
with Rationale (NUR 265 Final Exam ) | Galen
1. A 55-year-old male is admitted to the ICU with a diagnosis of septic shock. His blood
pressure is 82/46 mmHg, heart rate is 126 bpm, and lactate level is 6.2 mmol/L. After
receiving a 30 mL/kg bolus of normal saline, his mean arterial pressure (MAP) remains at 58
mmHg. Which of the following is the priority pharmacological intervention?
A. Administer a bolus of 500 mL 5% Albumin.
B. Start a Vasopressin infusion at 0.03 units/minute.
C. Initiate a Norepinephrine infusion to maintain MAP > 65 mmHg.
D. Administer intravenous hydrocortisone 200 mg per day.
Correct Answer: C
Explanation: In septic shock, if fluid resuscitation fails to restore adequate tissue perfusion
and blood pressure, vasopressors are the next line of treatment. Norepinephrine is the
first-choice vasopressor to maintain a MAP of at least 65 mmHg. The patient’s current MAP
is 58 mmHg, indicating a critical need for vasopressor support to prevent further organ
dysfunction.
,2. A patient who sustained partial-thickness and full-thickness burns to 40% of their body
surface area 12 hours ago is in the emergent phase of burn management. The nurse notes the
patient’s urine output has been 20 mL/hour for the past two hours. What is the nurse’s most
appropriate action?
A. Decrease the IV fluid rate as the patient may be fluid overloaded.
B. Administer a 20 mg dose of Furosemide as ordered.
C. Increase the rate of the prescribed Lactated Ringer’s solution.
D. Document the findings as an expected outcome during the emergent phase.
Correct Answer: C
Explanation: Adequate fluid resuscitation is vital during the emergent phase of a burn
injury to prevent hypovolemic shock and acute kidney injury. The standard goal for urine
output in a burn patient is 0.5 to 1.0 mL/kg/hr, or roughly 30-50 mL/hr in an average
adult. A urine output of 20 mL/hr indicates inadequate resuscitation, necessitating an
increase in IV fluid titration.
3. A patient with a T4 spinal cord injury (SCI) reports a sudden, throbbing headache and nasal
congestion. The nurse observes the patient’s face is flushed and their blood pressure is
190/100 mmHg. Which action should the nurse take first?
A. Place the patient in a high-Fowler’s position.
B. Administer a prescribed PRN dose of Hydralazine.
C. Perform a bladder scan to assess for urinary retention.
,D. Check the patient’s skin for pressure ulcers or tight clothing.
Correct Answer: A
Explanation: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency occurring in SCI patients at or above T6. The immediate priority is to sit the
patient upright (high-Fowler’s) to lower blood pressure via orthostatic changes. Once the
patient is positioned, the nurse should then identify and eliminate the triggering stimulus,
such as a full bladder or impacted bowel.
4. An ICU nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) who
is being mechanically ventilated with high levels of Positive End-Expiratory Pressure (PEEP).
The nurse notes a sudden drop in oxygen saturation and absent breath sounds on the right
side. Which complication should the nurse suspect?
A. Ventilator-associated pneumonia.
B. Pulmonary embolism.
C. Tension pneumothorax.
D. Oxygen toxicity.
Correct Answer: C
Explanation: High levels of PEEP increase the risk of barotrauma, which can lead to a
pneumothorax. Sudden desaturation combined with absent breath sounds on one side is a
hallmark sign of a collapsed lung or tension pneumothorax. This requires immediate
intervention, such as needle decompression or chest tube insertion, to stabilize the patient.
, 5. A patient with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L and the
EKG shows peaked T-waves. The nurse should anticipate which immediate order to shift
potassium back into the cells?
A. Sodium polystyrene sulfonate (Kayexalate) orally.
B. Intravenous regular insulin and 50% dextrose.
C. Calcium gluconate intravenous push.
D. Continuous renal replacement therapy (CRRT).
Correct Answer: B
Explanation: Intravenous regular insulin, given with dextrose to prevent hypoglycemia, is
an effective way to rapidly shift potassium from the extracellular fluid into the intracellular
compartment. While calcium gluconate stabilizes the myocardium to prevent arrhythmias,
it does not lower potassium levels. Kayexalate and CRRT are methods to remove potassium
from the body, but they do not act as quickly as the insulin-dextrose shift.
6. A patient is admitted with Diabetic Ketoacidosis (DKA). The initial laboratory results show a
blood glucose of 550 mg/dL, a pH of 7.15, and a potassium level of 3.3 mEq/L. Which provider
order should the nurse implement first?
A. Start an intravenous insulin drip at 0.1 units/kg/hr.
B. Add 20 mEq of Potassium Chloride to the IV fluids.
C. Administer a 1-liter bolus of 0.9% Normal Saline.
D. Administer intravenous Sodium Bicarbonate.
