NUR 265 Final Exam V3 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Final Exam) |
Galen
1. Mr. Miller, a 58-year-old patient admitted with septic shock, has received 3 liters of normal
saline. His current vitals are BP 82/44 mmHg, HR 122 bpm, and CVP 12 mmHg. Which
intervention should the nurse anticipate next based on the Surviving Sepsis Campaign
guidelines?
A. Administration of a 500 mL bolus of 5% albumin
B. Increasing the IV maintenance rate to 200 mL/hr
C. Starting a dobutamine infusion to increase contractility
D. Initiation of a norepinephrine (Levophed) infusion
Answer: D
Rationale: Norepinephrine is the first-line vasopressor for septic shock when fluid
resuscitation (CVP 8-12 mmHg) fails to maintain a mean arterial pressure (MAP) of at least
65 mmHg. The patient’s MAP is currently approximately 56 mmHg despite adequate fluid
volume as indicated by the CVP. Vasopressors are necessary to restore systemic vascular
resistance and improve perfusion to vital organs.
2. A 42-year-old patient, Sarah, is admitted to the burn unit with partial and full-thickness
burns to her chest, abdomen, and both anterior legs. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) burned?
A. 27%
B. 54%
C. 45%
D. 36%
Answer: D
Rationale: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18% of TBSA. Each anterior leg accounts for 9%, totaling 18% for both
anterior legs. Therefore, 18% (trunk) + 18% (legs) equals 36% TBSA, which is critical for
calculating fluid resuscitation needs.
3. James is a 28-year-old male who suffered a T4 spinal cord injury (SCI) three weeks ago. He
suddenly reports a severe, pounding headache and nasal congestion. The nurse notes his BP
is 188/96 mmHg and HR is 52 bpm. What is the nurse’s priority action?
A. Place the patient in a high-Fowler’s position
,B. Assess the patient for bladder distension or fecal impaction
C. Administer the prescribed PRN hydralazine intravenously
D. Perform a neurological assessment to check for increased intracranial pressure
Answer: A
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
common in SCI at or above T6. The immediate priority is to sit the patient up (high-
Fowler’s) to utilize orthostatic changes to lower blood pressure. Following this, the nurse
should identify and remove the triggering stimulus, such as a full bladder or impacted
bowel.
4. Ms. Thompson is being treated for Acute Respiratory Distress Syndrome (ARDS) and is on
mechanical ventilation with a PEEP of 15 cm H2O. The nurse notes a sudden drop in SpO2,
tracheal deviation to the right, and absent breath sounds on the left. Which complication
does the nurse suspect?
A. Development of a left-sided tension pneumothorax
B. Displacement of the endotracheal tube into the right mainstem bronchus
C. Severe pulmonary edema and alveolar collapse
D. Acute pulmonary embolism
Answer: A
Rationale: High levels of PEEP increase the risk of barotrauma, which can lead to a
pneumothorax. Tracheal deviation away from the affected side and absent breath sounds
are classic indicators of a tension pneumothorax. This is a life-threatening emergency
requiring immediate needle decompression or chest tube insertion.
5. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L and the
ECG shows peaked T waves. Which medication should the nurse expect to administer first to
protect the heart?
A. Intravenous Calcium Gluconate
B. Sodium Polystyrene Sulfonate (Kayexalate) orally
C. Intravenous Regular Insulin and Dextrose 50%
D. Sodium Bicarbonate intravenous push
Answer: A
Rationale: Calcium gluconate does not lower potassium, but it stabilizes the myocardial
cell membrane to prevent lethal dysrhythmias in the setting of hyperkalemia. Insulin and
Dextrose are used next to shift potassium into the cells. Kayexalate is used for the actual
removal of potassium from the body but takes longer to act.
, 6. Mr. Rodriguez is admitted with Diabetic Ketoacidosis (DKA). His blood glucose is 450 mg/dL
and his potassium is 3.3 mEq/L. The provider orders an insulin drip. What is the nurse’s most
appropriate action?
A. Start the insulin drip immediately as ordered
B. Administer 20 mEq of potassium chloride orally before starting insulin
C. Hold the insulin and notify the provider about the potassium level
D. Bolus the patient with 1 liter of Normal Saline and then start insulin
Answer: C
Rationale: Insulin causes potassium to shift into the intracellular space, which will further
lower the serum potassium level. If insulin is started when potassium is already low (< 3.3
mEq/L), it can cause life-threatening hypokalemia. The nurse must ensure potassium
replacement is initiated before or alongside insulin therapy.
7. An 80-year-old patient, Mrs. Gable, is in the ICU with a pulmonary artery catheter. The
nurse notes a Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg and a Cardiac Index of
1.8 L/min/m2. Which condition is most consistent with these findings?
A. Hypovolemic Shock
B. Cardiogenic Shock
C. Septic Shock
D. Anaphylactic Shock
Answer: B
Rationale: Cardiogenic shock is characterized by a low Cardiac Index (< 2.2 L/min/m2)
and an elevated PAWP (> 18 mmHg) due to pump failure and fluid backing up into the
lungs. In hypovolemic shock, both pressures would be low. In septic shock, the Cardiac
Index is often high initially and the PAWP is low to normal.
8. The nurse is caring for a patient, Linda, who is 48 hours post-craniotomy for a brain tumor.
She has an intracranial pressure (ICP) monitor. The ICP is currently 22 mmHg. Which nursing
intervention is appropriate?
A. Encourage the patient to perform coughing and deep breathing exercises
B. Cluster nursing activities to allow for longer rest periods
C. Maintain the head of the bed at 30 to 45 degrees with the head in a neutral position
D. Perform vigorous endotracheal suctioning every 2 hours
Answer: C
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Final Exam) |
Galen
1. Mr. Miller, a 58-year-old patient admitted with septic shock, has received 3 liters of normal
saline. His current vitals are BP 82/44 mmHg, HR 122 bpm, and CVP 12 mmHg. Which
intervention should the nurse anticipate next based on the Surviving Sepsis Campaign
guidelines?
A. Administration of a 500 mL bolus of 5% albumin
B. Increasing the IV maintenance rate to 200 mL/hr
C. Starting a dobutamine infusion to increase contractility
D. Initiation of a norepinephrine (Levophed) infusion
Answer: D
Rationale: Norepinephrine is the first-line vasopressor for septic shock when fluid
resuscitation (CVP 8-12 mmHg) fails to maintain a mean arterial pressure (MAP) of at least
65 mmHg. The patient’s MAP is currently approximately 56 mmHg despite adequate fluid
volume as indicated by the CVP. Vasopressors are necessary to restore systemic vascular
resistance and improve perfusion to vital organs.
2. A 42-year-old patient, Sarah, is admitted to the burn unit with partial and full-thickness
burns to her chest, abdomen, and both anterior legs. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) burned?
A. 27%
B. 54%
C. 45%
D. 36%
Answer: D
Rationale: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18% of TBSA. Each anterior leg accounts for 9%, totaling 18% for both
anterior legs. Therefore, 18% (trunk) + 18% (legs) equals 36% TBSA, which is critical for
calculating fluid resuscitation needs.
3. James is a 28-year-old male who suffered a T4 spinal cord injury (SCI) three weeks ago. He
suddenly reports a severe, pounding headache and nasal congestion. The nurse notes his BP
is 188/96 mmHg and HR is 52 bpm. What is the nurse’s priority action?
A. Place the patient in a high-Fowler’s position
,B. Assess the patient for bladder distension or fecal impaction
C. Administer the prescribed PRN hydralazine intravenously
D. Perform a neurological assessment to check for increased intracranial pressure
Answer: A
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a medical emergency
common in SCI at or above T6. The immediate priority is to sit the patient up (high-
Fowler’s) to utilize orthostatic changes to lower blood pressure. Following this, the nurse
should identify and remove the triggering stimulus, such as a full bladder or impacted
bowel.
4. Ms. Thompson is being treated for Acute Respiratory Distress Syndrome (ARDS) and is on
mechanical ventilation with a PEEP of 15 cm H2O. The nurse notes a sudden drop in SpO2,
tracheal deviation to the right, and absent breath sounds on the left. Which complication
does the nurse suspect?
A. Development of a left-sided tension pneumothorax
B. Displacement of the endotracheal tube into the right mainstem bronchus
C. Severe pulmonary edema and alveolar collapse
D. Acute pulmonary embolism
Answer: A
Rationale: High levels of PEEP increase the risk of barotrauma, which can lead to a
pneumothorax. Tracheal deviation away from the affected side and absent breath sounds
are classic indicators of a tension pneumothorax. This is a life-threatening emergency
requiring immediate needle decompression or chest tube insertion.
5. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L and the
ECG shows peaked T waves. Which medication should the nurse expect to administer first to
protect the heart?
A. Intravenous Calcium Gluconate
B. Sodium Polystyrene Sulfonate (Kayexalate) orally
C. Intravenous Regular Insulin and Dextrose 50%
D. Sodium Bicarbonate intravenous push
Answer: A
Rationale: Calcium gluconate does not lower potassium, but it stabilizes the myocardial
cell membrane to prevent lethal dysrhythmias in the setting of hyperkalemia. Insulin and
Dextrose are used next to shift potassium into the cells. Kayexalate is used for the actual
removal of potassium from the body but takes longer to act.
, 6. Mr. Rodriguez is admitted with Diabetic Ketoacidosis (DKA). His blood glucose is 450 mg/dL
and his potassium is 3.3 mEq/L. The provider orders an insulin drip. What is the nurse’s most
appropriate action?
A. Start the insulin drip immediately as ordered
B. Administer 20 mEq of potassium chloride orally before starting insulin
C. Hold the insulin and notify the provider about the potassium level
D. Bolus the patient with 1 liter of Normal Saline and then start insulin
Answer: C
Rationale: Insulin causes potassium to shift into the intracellular space, which will further
lower the serum potassium level. If insulin is started when potassium is already low (< 3.3
mEq/L), it can cause life-threatening hypokalemia. The nurse must ensure potassium
replacement is initiated before or alongside insulin therapy.
7. An 80-year-old patient, Mrs. Gable, is in the ICU with a pulmonary artery catheter. The
nurse notes a Pulmonary Artery Wedge Pressure (PAWP) of 22 mmHg and a Cardiac Index of
1.8 L/min/m2. Which condition is most consistent with these findings?
A. Hypovolemic Shock
B. Cardiogenic Shock
C. Septic Shock
D. Anaphylactic Shock
Answer: B
Rationale: Cardiogenic shock is characterized by a low Cardiac Index (< 2.2 L/min/m2)
and an elevated PAWP (> 18 mmHg) due to pump failure and fluid backing up into the
lungs. In hypovolemic shock, both pressures would be low. In septic shock, the Cardiac
Index is often high initially and the PAWP is low to normal.
8. The nurse is caring for a patient, Linda, who is 48 hours post-craniotomy for a brain tumor.
She has an intracranial pressure (ICP) monitor. The ICP is currently 22 mmHg. Which nursing
intervention is appropriate?
A. Encourage the patient to perform coughing and deep breathing exercises
B. Cluster nursing activities to allow for longer rest periods
C. Maintain the head of the bed at 30 to 45 degrees with the head in a neutral position
D. Perform vigorous endotracheal suctioning every 2 hours
Answer: C
