NSG 223 MED SURG 2 HESI FINAL EXAM
COMPREHENSIVE REVIEW
1. A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical
ventilation. The nurse notes the peak inspiratory pressure is rising. Which action should the
nurse take first?
A. Check the tubing for kinks or obstruction.
B. Suction the patient’s airway for secretions.
C. Increase the fraction of inspired oxygen (FiO2).
D. Administer a sedative to the patient.
Answer: A
Conceptual Explanation: Rising peak inspiratory pressure often indicates an obstruction
in the circuit. Checking for kinks is the quickest and least invasive initial action before
proceeding to suctioning or sedation.
2. A client is admitted with a spinal cord injury at the T4 level. The nurse notes a sudden
increase in blood pressure to 190/100 mmHg, a pounding headache, and bradycardia. What is
the priority nursing intervention?
A. Administer an antihypertensive medication.
,B. Check the client’s bladder for distention.
C. Lower the head of the bed immediately.
D. Notify the healthcare provider for a CT scan.
Answer: B
Conceptual Explanation: The symptoms describe Autonomic Dysreflexia, often triggered
by bladder distention or fecal impaction. Relieving the trigger is the priority management
step.
3. Which laboratory value is most indicative of a patient entering the oliguric phase of acute
kidney injury (AKI)?
A. BUN 15 mg/dL and Creatinine 0.8 mg/dL
B. Specific gravity of 1.005
C. Serum potassium 6.2 mEq/L
D. Urine output of 600 mL per 24 hours
Answer: C
Conceptual Explanation: In the oliguric phase of AKI, potassium excretion is impaired,
leading to hyperkalemia. Specific gravity is usually high (fixed), and urine output is less
than 400 mL/day.
, 4. A patient with a burn injury covering 40% of the total body surface area (TBSA) is in the
emergent phase. Which electrolyte imbalance should the nurse anticipate?
A. Hypokalemia
B. Hypernatremia
C. Hyperkalemia
D. Hypercalcemia
Answer: C
Conceptual Explanation: During the emergent phase of a burn, massive cell destruction
releases potassium into the extracellular fluid, resulting in hyperkalemia.
5. A client is diagnosed with Diabetic Ketoacidosis (DKA). The nurse should prioritize which IV
fluid administration initially?
A. 0.9% Normal Saline
B. 0.45% Normal Saline
C. D5W (5% Dextrose in Water)
D. D5 1/2 Normal Saline
Answer: A
Conceptual Explanation: Initial treatment for DKA focuses on volume resuscitation using
isotonic saline (0.9% NS) to restore perfusion.
COMPREHENSIVE REVIEW
1. A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical
ventilation. The nurse notes the peak inspiratory pressure is rising. Which action should the
nurse take first?
A. Check the tubing for kinks or obstruction.
B. Suction the patient’s airway for secretions.
C. Increase the fraction of inspired oxygen (FiO2).
D. Administer a sedative to the patient.
Answer: A
Conceptual Explanation: Rising peak inspiratory pressure often indicates an obstruction
in the circuit. Checking for kinks is the quickest and least invasive initial action before
proceeding to suctioning or sedation.
2. A client is admitted with a spinal cord injury at the T4 level. The nurse notes a sudden
increase in blood pressure to 190/100 mmHg, a pounding headache, and bradycardia. What is
the priority nursing intervention?
A. Administer an antihypertensive medication.
,B. Check the client’s bladder for distention.
C. Lower the head of the bed immediately.
D. Notify the healthcare provider for a CT scan.
Answer: B
Conceptual Explanation: The symptoms describe Autonomic Dysreflexia, often triggered
by bladder distention or fecal impaction. Relieving the trigger is the priority management
step.
3. Which laboratory value is most indicative of a patient entering the oliguric phase of acute
kidney injury (AKI)?
A. BUN 15 mg/dL and Creatinine 0.8 mg/dL
B. Specific gravity of 1.005
C. Serum potassium 6.2 mEq/L
D. Urine output of 600 mL per 24 hours
Answer: C
Conceptual Explanation: In the oliguric phase of AKI, potassium excretion is impaired,
leading to hyperkalemia. Specific gravity is usually high (fixed), and urine output is less
than 400 mL/day.
, 4. A patient with a burn injury covering 40% of the total body surface area (TBSA) is in the
emergent phase. Which electrolyte imbalance should the nurse anticipate?
A. Hypokalemia
B. Hypernatremia
C. Hyperkalemia
D. Hypercalcemia
Answer: C
Conceptual Explanation: During the emergent phase of a burn, massive cell destruction
releases potassium into the extracellular fluid, resulting in hyperkalemia.
5. A client is diagnosed with Diabetic Ketoacidosis (DKA). The nurse should prioritize which IV
fluid administration initially?
A. 0.9% Normal Saline
B. 0.45% Normal Saline
C. D5W (5% Dextrose in Water)
D. D5 1/2 Normal Saline
Answer: A
Conceptual Explanation: Initial treatment for DKA focuses on volume resuscitation using
isotonic saline (0.9% NS) to restore perfusion.
