NUR 425 Exam 1: Medical Surgical V3 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse assesses a patient with a spinal cord injury at T5 and notes a sudden onset of severe headache,
sweating above the level of injury, and a blood pressure of 210/110 mmHg. What is the priority nursing
action?
A. Administer an ordered analgesic for the headache
B. Check the patient’s temperature for signs of infection
C. Place the patient in a high-Fowler’s position
D. Perform a neurological assessment using the Glasgow Coma Scale
Ans: C
Explanation: The patient is exhibiting classic symptoms of Autonomic Dysreflexia, which is a life-
threatening medical emergency. Placing the patient in a high-Fowler’s position is the first priority to help
lower blood pressure via orthostatic changes. After positioning, the nurse should investigate the trigger,
which is commonly a distended bladder or bowel. Failure to treat this condition quickly can lead to a
stroke or cardiac arrest. This syndrome occurs in patients with spinal cord injuries at or above the T6
level.
2. A patient in the ICU is being treated for septic shock and has a blood pressure of 82/40 mmHg despite
fluid resuscitation. Which medication should the nurse anticipate administering next?
A. Norepinephrine
B. Dobutamine
C. Nitroglycerin
,D. Furosemide
Ans: A
Explanation: Norepinephrine is the first-choice vasopressor used for septic shock when fluid
resuscitation fails to maintain adequate perfusion. It works by causing peripheral vasoconstriction to
increase mean arterial pressure. The goal is to maintain a MAP of at least 65 mmHg to ensure organ
perfusion. Dobutamine is typically reserved for cardiogenic shock or as an add-on in low cardiac output
states. Nurses must monitor the infusion site closely for extravasation which can cause tissue necrosis.
3. The nurse is caring for a patient on a mechanical ventilator when the high-pressure alarm sounds. What is
the nurse’s first action?
A. Auscultate the patient’s breath sounds
B. Silence the alarm and check the settings
C. Manually ventilate the patient with a bag-valve mask
D. Increase the oxygen concentration to 100%
Ans: A
Explanation: The high-pressure alarm indicates that there is resistance to the flow of air from the
ventilator. Auscultating breath sounds allows the nurse to assess for causes such as secretions,
bronchospasm, or a pneumothorax. Common issues also include the patient biting the ET tube or kinks in
the tubing. If the patient is in respiratory distress, the nurse should manually ventilate them. However,
assessment always precedes intervention when the patient is stable enough to do so.
4. A patient with Acute Respiratory Distress Syndrome (ARDS) is placed in the prone position. What is the
primary rationale for this intervention?
A. To prevent the development of pressure ulcers on the sacrum
, B. To facilitate the drainage of oral secretions
C. To improve oxygenation by recruiting dorsal lung segments
D. To reduce the risk of ventilator-associated pneumonia
Ans: C
Explanation: Prone positioning in ARDS helps to improve oxygenation by redistributing blood flow to
better-ventilated lung areas. In the supine position, the heart and abdominal contents compress the
posterior lung segments. Flipping the patient allows for recruitment of these dorsal alveoli which usually
have the best perfusion. This technique is often used when standard ventilatory settings fail to provide
adequate PaO2 levels. It requires a coordinated team effort to safely move the patient and protect their
airway.
5. A patient’s ABG results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these findings?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Ans: A
Explanation: A pH of 7.30 is below the normal range, indicating acidosis. The PaCO2 of 52 mmHg is
elevated, which is a respiratory cause for the decreased pH. Because the bicarbonate level is within the
normal range, the condition is uncompensated. This pattern is typical in patients with hypoventilation or
obstructive lung diseases like COPD. The nurse should focus on interventions that improve the patient’s
ventilation and gas exchange.
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse assesses a patient with a spinal cord injury at T5 and notes a sudden onset of severe headache,
sweating above the level of injury, and a blood pressure of 210/110 mmHg. What is the priority nursing
action?
A. Administer an ordered analgesic for the headache
B. Check the patient’s temperature for signs of infection
C. Place the patient in a high-Fowler’s position
D. Perform a neurological assessment using the Glasgow Coma Scale
Ans: C
Explanation: The patient is exhibiting classic symptoms of Autonomic Dysreflexia, which is a life-
threatening medical emergency. Placing the patient in a high-Fowler’s position is the first priority to help
lower blood pressure via orthostatic changes. After positioning, the nurse should investigate the trigger,
which is commonly a distended bladder or bowel. Failure to treat this condition quickly can lead to a
stroke or cardiac arrest. This syndrome occurs in patients with spinal cord injuries at or above the T6
level.
2. A patient in the ICU is being treated for septic shock and has a blood pressure of 82/40 mmHg despite
fluid resuscitation. Which medication should the nurse anticipate administering next?
A. Norepinephrine
B. Dobutamine
C. Nitroglycerin
,D. Furosemide
Ans: A
Explanation: Norepinephrine is the first-choice vasopressor used for septic shock when fluid
resuscitation fails to maintain adequate perfusion. It works by causing peripheral vasoconstriction to
increase mean arterial pressure. The goal is to maintain a MAP of at least 65 mmHg to ensure organ
perfusion. Dobutamine is typically reserved for cardiogenic shock or as an add-on in low cardiac output
states. Nurses must monitor the infusion site closely for extravasation which can cause tissue necrosis.
3. The nurse is caring for a patient on a mechanical ventilator when the high-pressure alarm sounds. What is
the nurse’s first action?
A. Auscultate the patient’s breath sounds
B. Silence the alarm and check the settings
C. Manually ventilate the patient with a bag-valve mask
D. Increase the oxygen concentration to 100%
Ans: A
Explanation: The high-pressure alarm indicates that there is resistance to the flow of air from the
ventilator. Auscultating breath sounds allows the nurse to assess for causes such as secretions,
bronchospasm, or a pneumothorax. Common issues also include the patient biting the ET tube or kinks in
the tubing. If the patient is in respiratory distress, the nurse should manually ventilate them. However,
assessment always precedes intervention when the patient is stable enough to do so.
4. A patient with Acute Respiratory Distress Syndrome (ARDS) is placed in the prone position. What is the
primary rationale for this intervention?
A. To prevent the development of pressure ulcers on the sacrum
, B. To facilitate the drainage of oral secretions
C. To improve oxygenation by recruiting dorsal lung segments
D. To reduce the risk of ventilator-associated pneumonia
Ans: C
Explanation: Prone positioning in ARDS helps to improve oxygenation by redistributing blood flow to
better-ventilated lung areas. In the supine position, the heart and abdominal contents compress the
posterior lung segments. Flipping the patient allows for recruitment of these dorsal alveoli which usually
have the best perfusion. This technique is often used when standard ventilatory settings fail to provide
adequate PaO2 levels. It requires a coordinated team effort to safely move the patient and protect their
airway.
5. A patient’s ABG results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these findings?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Ans: A
Explanation: A pH of 7.30 is below the normal range, indicating acidosis. The PaCO2 of 52 mmHg is
elevated, which is a respiratory cause for the decreased pH. Because the bicarbonate level is within the
normal range, the condition is uncompensated. This pattern is typical in patients with hypoventilation or
obstructive lung diseases like COPD. The nurse should focus on interventions that improve the patient’s
ventilation and gas exchange.
