NUR 265 Exam 2 V3 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 42-year-old female patient, Mrs. Sarah Jenkins, is admitted to the burn unit following a
house fire. She has deep partial-thickness burns to her entire left arm, her anterior chest, and
her entire left leg. Using the Rule of Nines, what is the estimated Total Body Surface Area
(TBSA) burned?
A. 27%
B. 36%
C. 45%
D. 54%
Correct Answer: C
Explanation: According to the Rule of Nines, the entire left arm is 9%, the anterior chest
(half of the trunk) is 18%, and the entire left leg is 18%. Adding these together (9 + 18 +
18) results in a total of 45% TBSA. Accurate calculation of TBSA is critical for determining
fluid resuscitation needs using the Parkland formula.
,2. Mr. Robert Miller, a 68-year-old patient with a history of heart failure, presents to the
emergency department with a BP of 82/40 mmHg, pulse 122 bpm, and a Pulmonary Artery
Wedge Pressure (PAWP) of 22 mmHg. Which type of shock is Mr. Miller most likely
experiencing?
A. Hypovolemic shock
B. Septic shock
C. Cardiogenic shock
D. Anaphylactic shock
Correct Answer: C
Explanation: Cardiogenic shock is characterized by hypotension and tachycardia in the
presence of an elevated PAWP, which indicates fluid backup into the lungs due to pump
failure. Hypovolemic shock would typically show a low PAWP because of decreased
circulating volume. Management focuses on improving contractility and reducing afterload
while maintaining perfusion.
3. A nurse is caring for a client who is in the early stages of septic shock. The client’s heart
rate is 115 bpm, respiratory rate is 26, and skin is warm and flushed. Which physiological
process explains the warm skin during this phase?
A. Increased systemic vascular resistance
B. Peripheral vasodilation due to inflammatory mediators
C. Increased stroke volume from fluid resuscitation
,D. Compensatory vasoconstriction in the periphery
Correct Answer: B
Explanation: In the early (hyperdynamic) phase of septic shock, inflammatory mediators
cause massive peripheral vasodilation, resulting in warm, flushed skin. This is a
distinguishing feature compared to hypovolemic or cardiogenic shock, where skin is
typically cool and clammy. As shock progresses to the cold phase, cardiac output falls and
peripheral vasoconstriction occurs.
4. Mrs. Thompson is 48 hours post-admission for a 50% TBSA burn. She is receiving fluid
resuscitation via the Parkland formula. Which finding would best indicate that fluid
resuscitation is adequate?
A. Heart rate of 110 bpm
B. Urine output of 0.5 to 1 mL/kg/hr
C. Mean Arterial Pressure (MAP) of 55 mmHg
D. Central Venous Pressure (CVP) of 2 mmHg
Correct Answer: B
Explanation: Urine output remains the most reliable indicator of organ perfusion and fluid
resuscitation adequacy in burn patients. The target is generally 0.5 to 1 mL/kg/hr for
adults. A MAP of at least 65 mmHg is typically desired, and a CVP of 2 is too low, suggesting
continued hypovolemia.
, 5. A patient arrives at the trauma center following an industrial explosion. He is unconscious,
has a respiratory rate of 8 breaths per minute, and a weak carotid pulse. Using the START
triage system, how should this patient be tagged?
A. Green (Minor)
B. Yellow (Delayed)
C. Red (Immediate)
D. Black (Deceased)
Correct Answer: C
Explanation: In the START triage system, an individual who is not breathing initially but
starts breathing after the airway is opened, or who has a respiratory rate outside the 10-30
range, or has an absent radial pulse is tagged Red. This patient has a respiratory rate of 8
and is unconscious, necessitating immediate life-saving intervention. Black tags are
reserved for those who are not breathing even after airway manipulation.
6. A patient with Disseminated Intravascular Coagulation (DIC) is showing signs of active
bleeding from IV sites and the gums. Which laboratory result is most consistent with this
diagnosis?
A. Increased D-dimer levels
B. Decreased Prothrombin Time (PT)
C. Elevated fibrinogen levels
D. Elevated platelet count
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 42-year-old female patient, Mrs. Sarah Jenkins, is admitted to the burn unit following a
house fire. She has deep partial-thickness burns to her entire left arm, her anterior chest, and
her entire left leg. Using the Rule of Nines, what is the estimated Total Body Surface Area
(TBSA) burned?
A. 27%
B. 36%
C. 45%
D. 54%
Correct Answer: C
Explanation: According to the Rule of Nines, the entire left arm is 9%, the anterior chest
(half of the trunk) is 18%, and the entire left leg is 18%. Adding these together (9 + 18 +
18) results in a total of 45% TBSA. Accurate calculation of TBSA is critical for determining
fluid resuscitation needs using the Parkland formula.
,2. Mr. Robert Miller, a 68-year-old patient with a history of heart failure, presents to the
emergency department with a BP of 82/40 mmHg, pulse 122 bpm, and a Pulmonary Artery
Wedge Pressure (PAWP) of 22 mmHg. Which type of shock is Mr. Miller most likely
experiencing?
A. Hypovolemic shock
B. Septic shock
C. Cardiogenic shock
D. Anaphylactic shock
Correct Answer: C
Explanation: Cardiogenic shock is characterized by hypotension and tachycardia in the
presence of an elevated PAWP, which indicates fluid backup into the lungs due to pump
failure. Hypovolemic shock would typically show a low PAWP because of decreased
circulating volume. Management focuses on improving contractility and reducing afterload
while maintaining perfusion.
3. A nurse is caring for a client who is in the early stages of septic shock. The client’s heart
rate is 115 bpm, respiratory rate is 26, and skin is warm and flushed. Which physiological
process explains the warm skin during this phase?
A. Increased systemic vascular resistance
B. Peripheral vasodilation due to inflammatory mediators
C. Increased stroke volume from fluid resuscitation
,D. Compensatory vasoconstriction in the periphery
Correct Answer: B
Explanation: In the early (hyperdynamic) phase of septic shock, inflammatory mediators
cause massive peripheral vasodilation, resulting in warm, flushed skin. This is a
distinguishing feature compared to hypovolemic or cardiogenic shock, where skin is
typically cool and clammy. As shock progresses to the cold phase, cardiac output falls and
peripheral vasoconstriction occurs.
4. Mrs. Thompson is 48 hours post-admission for a 50% TBSA burn. She is receiving fluid
resuscitation via the Parkland formula. Which finding would best indicate that fluid
resuscitation is adequate?
A. Heart rate of 110 bpm
B. Urine output of 0.5 to 1 mL/kg/hr
C. Mean Arterial Pressure (MAP) of 55 mmHg
D. Central Venous Pressure (CVP) of 2 mmHg
Correct Answer: B
Explanation: Urine output remains the most reliable indicator of organ perfusion and fluid
resuscitation adequacy in burn patients. The target is generally 0.5 to 1 mL/kg/hr for
adults. A MAP of at least 65 mmHg is typically desired, and a CVP of 2 is too low, suggesting
continued hypovolemia.
, 5. A patient arrives at the trauma center following an industrial explosion. He is unconscious,
has a respiratory rate of 8 breaths per minute, and a weak carotid pulse. Using the START
triage system, how should this patient be tagged?
A. Green (Minor)
B. Yellow (Delayed)
C. Red (Immediate)
D. Black (Deceased)
Correct Answer: C
Explanation: In the START triage system, an individual who is not breathing initially but
starts breathing after the airway is opened, or who has a respiratory rate outside the 10-30
range, or has an absent radial pulse is tagged Red. This patient has a respiratory rate of 8
and is unconscious, necessitating immediate life-saving intervention. Black tags are
reserved for those who are not breathing even after airway manipulation.
6. A patient with Disseminated Intravascular Coagulation (DIC) is showing signs of active
bleeding from IV sites and the gums. Which laboratory result is most consistent with this
diagnosis?
A. Increased D-dimer levels
B. Decreased Prothrombin Time (PT)
C. Elevated fibrinogen levels
D. Elevated platelet count
