NUR 265 Exam 3 V1 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 3) |
Galen
1. A 45-year-old patient, Mr. Miller, is admitted to the ICU with severe burns covering 40% of
his Total Body Surface Area (TBSA) following a house fire. During the first 8 hours of the
emergent phase, the nurse notes a drop in urine output to 15 mL/hour and a heart rate of
128 bpm. Which action should the nurse prioritize based on these clinical findings?
A. Increase the rate of the prescribed Lactated Ringer’s solution.
B. Administer a prescribed diuretic to increase renal perfusion.
C. Notify the provider to request a stat serum creatinine level.
D. Perform a focused assessment of the patient’s respiratory status.
Answer: A
Rationale: In the emergent phase of burn management, fluid resuscitation is critical to
prevent hypovolemic shock. A urine output of less than 0.5 mL/kg/hr or 30 mL/hr
indicates inadequate volume replacement. The nurse must increase the IV fluid rate,
typically Lactated Ringer’s, to maintain organ perfusion and stabilize the patient’s
hemodynamic status.
2. Mrs. Rodriguez is a 68-year-old female diagnosed with Septic Shock. Despite receiving 30
mL/kg of crystalloid fluids, her Mean Arterial Pressure (MAP) remains at 58 mmHg, and her
serum lactate is 4.2 mmol/L. Which medication should the nurse anticipate administering
next to maintain a MAP of 65 mmHg or greater?
A. Nitroprusside
B. Amiodarone
C. Norepinephrine
D. Furosemide
Answer: C
Rationale: Norepinephrine is the first-line vasopressor recommended in the Surviving
Sepsis Guidelines for patients who remain hypotensive despite adequate fluid
resuscitation. It acts primarily on alpha-1 receptors to cause vasoconstriction and increase
systemic vascular resistance. The goal is to maintain a MAP above 65 mmHg to ensure
adequate end-organ perfusion.
,3. A patient with a T4 spinal cord injury, Mr. Davis, reports a sudden, pounding headache and
nasal congestion. The nurse observes the patient is flushed above the level of injury and has a
blood pressure of 210/110 mmHg. What is the nurse’s first action?
A. Elevate the head of the bed to a sitting position.
B. Check the patient’s bladder for distention or catheter kinks.
C. Administer the ordered PRN dose of hydralazine.
D. Assess the patient for a possible fecal impaction.
Answer: A
Rationale: Autonomic dysreflexia is a medical emergency that can occur in patients with
spinal cord injuries at or above T6. The immediate priority is to sit the patient upright to
lower blood pressure through postural hypotension. Once the patient is positioned safely,
the nurse should then identify and remove the triggering stimulus, such as a full bladder or
impacted bowel.
4. A 55-year-old male, Mr. Henderson, is on mechanical ventilation for Acute Respiratory
Distress Syndrome (ARDS). The ventilator settings include a PEEP of 15 cm H2O. The nurse
notices the patient’s blood pressure has dropped from 120/80 to 90/60 mmHg over the last
30 minutes. Which pathophysiological mechanism best explains this change?
A. Increased PEEP leads to decreased venous return and cardiac output.
B. ARDS causes a systemic inflammatory response leading to vasodilation.
C. High levels of PEEP increase coronary artery perfusion pressure.
D. The patient is experiencing a secondary pneumothorax from barotrauma.
Answer: A
Rationale: Positive End-Expiratory Pressure (PEEP) is essential in ARDS to keep alveoli
open and improve oxygenation. However, high levels of PEEP increase intrathoracic
pressure, which can compress the vena cava and decrease venous return to the right heart.
This reduction in preload leads to a decrease in cardiac output and systemic blood
pressure.
5. A patient in the Intensive Care Unit is suspected of developing Disseminated Intravascular
Coagulation (DIC) secondary to Gram-negative sepsis. Which laboratory finding most strongly
supports this diagnosis?
A. Increased Platelet count
B. Decreased D-dimer levels
C. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT)
D. Elevated Fibrinogen levels
, Answer: C
Rationale: DIC is characterized by the systemic activation of the coagulation cascade,
leading to the depletion of clotting factors and platelets. Laboratory results typically show
prolonged PT and PTT due to the consumption of factors, as well as elevated D-dimer levels
reflecting fibrinolysis. Platelets and fibrinogen levels are generally decreased as they are
consumed in the formation of microthrombi.
6. During a mass casualty incident triage, the nurse assesses a 30-year-old victim who has a
respiratory rate of 34 breaths per minute, a capillary refill of 4 seconds, and is unable to
follow simple commands. Using the START triage system, how should this patient be tagged?
A. Green (Minor)
B. Red (Immediate)
C. Yellow (Delayed)
D. Black (Deceased)
Answer: B
Rationale: According to the START (Simple Triage and Rapid Treatment) algorithm, a
patient is tagged Red (Immediate) if they meet any of the following criteria: Respirations >
30, absent radial pulse or capillary refill > 2 seconds, or inability to follow simple
commands. This patient meets all three criteria, indicating a life-threatening condition that
requires immediate intervention. Triage ensures that resources are allocated to those most
likely to survive with prompt care.
7. Mr. Kelly is receiving an infusion of Magnesium Sulfate for the management of pre-
eclampsia with severe features. Upon assessment, the nurse finds the patient is lethargic, has
a respiratory rate of 8 breaths per minute, and absent deep tendon reflexes. Which
medication should the nurse have immediately available?
A. Naloxone
B. Calcium Gluconate
C. Protamine Sulfate
D. Vitamin K
Answer: B
Rationale: Magnesium toxicity is characterized by respiratory depression, loss of deep
tendon reflexes, and altered mental status. Calcium Gluconate is the specific antagonist for
magnesium sulfate and should be readily available whenever magnesium is being infused.
The nurse must stop the infusion immediately and administer the reversal agent to prevent
cardiac arrest.
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 3) |
Galen
1. A 45-year-old patient, Mr. Miller, is admitted to the ICU with severe burns covering 40% of
his Total Body Surface Area (TBSA) following a house fire. During the first 8 hours of the
emergent phase, the nurse notes a drop in urine output to 15 mL/hour and a heart rate of
128 bpm. Which action should the nurse prioritize based on these clinical findings?
A. Increase the rate of the prescribed Lactated Ringer’s solution.
B. Administer a prescribed diuretic to increase renal perfusion.
C. Notify the provider to request a stat serum creatinine level.
D. Perform a focused assessment of the patient’s respiratory status.
Answer: A
Rationale: In the emergent phase of burn management, fluid resuscitation is critical to
prevent hypovolemic shock. A urine output of less than 0.5 mL/kg/hr or 30 mL/hr
indicates inadequate volume replacement. The nurse must increase the IV fluid rate,
typically Lactated Ringer’s, to maintain organ perfusion and stabilize the patient’s
hemodynamic status.
2. Mrs. Rodriguez is a 68-year-old female diagnosed with Septic Shock. Despite receiving 30
mL/kg of crystalloid fluids, her Mean Arterial Pressure (MAP) remains at 58 mmHg, and her
serum lactate is 4.2 mmol/L. Which medication should the nurse anticipate administering
next to maintain a MAP of 65 mmHg or greater?
A. Nitroprusside
B. Amiodarone
C. Norepinephrine
D. Furosemide
Answer: C
Rationale: Norepinephrine is the first-line vasopressor recommended in the Surviving
Sepsis Guidelines for patients who remain hypotensive despite adequate fluid
resuscitation. It acts primarily on alpha-1 receptors to cause vasoconstriction and increase
systemic vascular resistance. The goal is to maintain a MAP above 65 mmHg to ensure
adequate end-organ perfusion.
,3. A patient with a T4 spinal cord injury, Mr. Davis, reports a sudden, pounding headache and
nasal congestion. The nurse observes the patient is flushed above the level of injury and has a
blood pressure of 210/110 mmHg. What is the nurse’s first action?
A. Elevate the head of the bed to a sitting position.
B. Check the patient’s bladder for distention or catheter kinks.
C. Administer the ordered PRN dose of hydralazine.
D. Assess the patient for a possible fecal impaction.
Answer: A
Rationale: Autonomic dysreflexia is a medical emergency that can occur in patients with
spinal cord injuries at or above T6. The immediate priority is to sit the patient upright to
lower blood pressure through postural hypotension. Once the patient is positioned safely,
the nurse should then identify and remove the triggering stimulus, such as a full bladder or
impacted bowel.
4. A 55-year-old male, Mr. Henderson, is on mechanical ventilation for Acute Respiratory
Distress Syndrome (ARDS). The ventilator settings include a PEEP of 15 cm H2O. The nurse
notices the patient’s blood pressure has dropped from 120/80 to 90/60 mmHg over the last
30 minutes. Which pathophysiological mechanism best explains this change?
A. Increased PEEP leads to decreased venous return and cardiac output.
B. ARDS causes a systemic inflammatory response leading to vasodilation.
C. High levels of PEEP increase coronary artery perfusion pressure.
D. The patient is experiencing a secondary pneumothorax from barotrauma.
Answer: A
Rationale: Positive End-Expiratory Pressure (PEEP) is essential in ARDS to keep alveoli
open and improve oxygenation. However, high levels of PEEP increase intrathoracic
pressure, which can compress the vena cava and decrease venous return to the right heart.
This reduction in preload leads to a decrease in cardiac output and systemic blood
pressure.
5. A patient in the Intensive Care Unit is suspected of developing Disseminated Intravascular
Coagulation (DIC) secondary to Gram-negative sepsis. Which laboratory finding most strongly
supports this diagnosis?
A. Increased Platelet count
B. Decreased D-dimer levels
C. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT)
D. Elevated Fibrinogen levels
, Answer: C
Rationale: DIC is characterized by the systemic activation of the coagulation cascade,
leading to the depletion of clotting factors and platelets. Laboratory results typically show
prolonged PT and PTT due to the consumption of factors, as well as elevated D-dimer levels
reflecting fibrinolysis. Platelets and fibrinogen levels are generally decreased as they are
consumed in the formation of microthrombi.
6. During a mass casualty incident triage, the nurse assesses a 30-year-old victim who has a
respiratory rate of 34 breaths per minute, a capillary refill of 4 seconds, and is unable to
follow simple commands. Using the START triage system, how should this patient be tagged?
A. Green (Minor)
B. Red (Immediate)
C. Yellow (Delayed)
D. Black (Deceased)
Answer: B
Rationale: According to the START (Simple Triage and Rapid Treatment) algorithm, a
patient is tagged Red (Immediate) if they meet any of the following criteria: Respirations >
30, absent radial pulse or capillary refill > 2 seconds, or inability to follow simple
commands. This patient meets all three criteria, indicating a life-threatening condition that
requires immediate intervention. Triage ensures that resources are allocated to those most
likely to survive with prompt care.
7. Mr. Kelly is receiving an infusion of Magnesium Sulfate for the management of pre-
eclampsia with severe features. Upon assessment, the nurse finds the patient is lethargic, has
a respiratory rate of 8 breaths per minute, and absent deep tendon reflexes. Which
medication should the nurse have immediately available?
A. Naloxone
B. Calcium Gluconate
C. Protamine Sulfate
D. Vitamin K
Answer: B
Rationale: Magnesium toxicity is characterized by respiratory depression, loss of deep
tendon reflexes, and altered mental status. Calcium Gluconate is the specific antagonist for
magnesium sulfate and should be readily available whenever magnesium is being infused.
The nurse must stop the infusion immediately and administer the reversal agent to prevent
cardiac arrest.
