NUR 265 Exam 4 V1 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 4) |
Galen
1. A 45-year-old male patient, Mr. Henderson, is admitted to the ICU with a diagnosis of
septic shock. His current vital signs are BP 82/46 mmHg, HR 122 bpm, RR 26 bpm, and Temp
102.4 F. The nurse notes a serum lactate level of 5.2 mmol/L. Which provider order should
the nurse prioritize first?
A. Administer Norepinephrine infusion to maintain MAP > 65 mmHg.
B. Obtain two sets of blood cultures from different sites.
C. Initiate a 30 mL/kg rapid intravenous bolus of crystalloids.
D. Administer broad-spectrum antibiotics within the first hour.
Answer: C
Rationale: According to the Surviving Sepsis Campaign bundles, the initial resuscitation
for hypotension or a lactate level ≥ 4 mmol/L is a 30 mL/kg crystalloid bolus. Fluid
resuscitation is the cornerstone of managing septic shock to restore intravascular volume
and improve organ perfusion. While cultures and antibiotics are critical, they follow or
occur concurrently with the initiation of fluid resuscitation in the setting of severe
hypotension.
2. Ms. Garcia is a 32-year-old patient who sustained partial and full-thickness burns to her
entire anterior torso and the entirety of both anterior legs. Using the Rule of Nines, what is
the estimated percentage of Total Body Surface Area (TBSA) burned?
A. 27%
B. 45%
C. 36%
D. 18%
Answer: C
Rationale: In the Rule of Nines, the anterior torso (chest and abdomen) accounts for 18%
of the TBSA. Each anterior leg accounts for 9%, so both anterior legs equal 18%. Adding
these together (18% for the torso + 18% for the legs) results in a total of 36% TBSA.
,3. A patient with a history of T4 spinal cord injury presents to the emergency department
complaining of a pounding headache and blurred vision. The nurse notes the patient is
diaphoretic above the level of injury and has a blood pressure of 210/108 mmHg. What is the
nurse’s immediate priority action?
A. Perform a digital rectal exam to check for fecal impaction.
B. Administer PRN Hydralazine as ordered by the physician.
C. Place the patient in a high-Fowler’s position.
D. Catheterize the patient to relieve bladder distension.
Answer: C
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency. The first priority is to sit the patient upright (high-Fowler’s) to utilize
orthostatic pressure to help lower the blood pressure. After positioning, the nurse should
then investigate and remove the triggering stimulus, such as bladder distension or bowel
impaction.
4. Mr. Lee is receiving mechanical ventilation. The high-pressure alarm on the ventilator
begins to sound. Which of the following conditions should the nurse assess for as a potential
cause of this alarm?
A. Disconnection of the ventilator tubing from the endotracheal tube.
B. A leak in the endotracheal tube cuff.
C. The patient is biting the endotracheal tube.
D. Extubation or displacement of the airway.
Answer: C
Rationale: High-pressure alarms are triggered by increased resistance in the circuit or the
patient’s airway. Common causes include biting the tube, secretions in the airway, kinks in
the tubing, or the patient fighting the ventilator. Low-pressure alarms are typically caused
by disconnections or leaks in the system.
5. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. The ECG
shows peaked T-waves. Which medication should the nurse expect to administer first to
protect the heart from the effects of hyperkalemia?
A. Sodium Polystyrene Sulfonate (Kayexalate) orally.
B. Intravenous Calcium Gluconate.
C. Regular Insulin and 50% Dextrose IV.
D. Sodium Bicarbonate IV push.
Answer: B
, Rationale: Calcium gluconate does not lower potassium levels but is the priority because it
stabilizes the myocardial cell membrane to prevent lethal dysrhythmias. Following
stabilization, medications like insulin/D50 are used to shift potassium into the cells, and
Kayexalate or dialysis is used to remove potassium from the body. Peaked T-waves indicate
that the heart is already being affected by the potassium level.
6. The nurse is caring for a patient who is in the compensatory stage of shock. Which clinical
finding is consistent with this stage?
A. Anuria and metabolic acidosis.
B. Lethargy and mottled skin.
C. Cool, clammy skin and increased heart rate.
D. Systolic blood pressure below 80 mmHg.
Answer: C
Rationale: In the compensatory stage of shock, the body’s sympathetic nervous system is
activated to maintain cardiac output and blood pressure. Signs include tachycardia,
tachypnea, and cool/clammy skin due to peripheral vasoconstriction (shunting blood to
vital organs). Anuria and profound hypotension are characteristic of the progressive and
refractory stages.
7. An 18-year-old female, Sarah, is brought to the ED with Diabetic Ketoacidosis (DKA). Her
blood glucose is 550 mg/dL, and her arterial pH is 7.15. The nurse has started an insulin drip.
What is the nurse’s primary concern when the blood glucose reaches 250 mg/dL?
A. Stopping the insulin infusion immediately.
B. Switching the IV fluid to include 5% Dextrose.
C. Administering IV bicarbonate to correct the pH.
D. Increasing the insulin rate to clear ketones faster.
Answer: B
Rationale: When blood glucose levels drop to approximately 250 mg/dL in a DKA patient,
dextrose is added to the IV fluids (e.g., D5 0.45% NS). This prevents hypoglycemia and
allows for the continued administration of insulin needed to resolve the ketosis and
metabolic acidosis. The insulin drip is usually continued until the anion gap closes and the
patient can transition to subcutaneous insulin.
8. The nurse is monitoring a patient with a traumatic brain injury (TBI). Which set of vital
signs indicates Cushing’s Triad, a sign of increased intracranial pressure?
A. BP 90/50 mmHg, HR 120 bpm, RR 24 bpm.
B. BP 170/60 mmHg, HR 50 bpm, irregular respirations.
C. BP 120/80 mmHg, HR 80 bpm, RR 16 bpm.
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 4) |
Galen
1. A 45-year-old male patient, Mr. Henderson, is admitted to the ICU with a diagnosis of
septic shock. His current vital signs are BP 82/46 mmHg, HR 122 bpm, RR 26 bpm, and Temp
102.4 F. The nurse notes a serum lactate level of 5.2 mmol/L. Which provider order should
the nurse prioritize first?
A. Administer Norepinephrine infusion to maintain MAP > 65 mmHg.
B. Obtain two sets of blood cultures from different sites.
C. Initiate a 30 mL/kg rapid intravenous bolus of crystalloids.
D. Administer broad-spectrum antibiotics within the first hour.
Answer: C
Rationale: According to the Surviving Sepsis Campaign bundles, the initial resuscitation
for hypotension or a lactate level ≥ 4 mmol/L is a 30 mL/kg crystalloid bolus. Fluid
resuscitation is the cornerstone of managing septic shock to restore intravascular volume
and improve organ perfusion. While cultures and antibiotics are critical, they follow or
occur concurrently with the initiation of fluid resuscitation in the setting of severe
hypotension.
2. Ms. Garcia is a 32-year-old patient who sustained partial and full-thickness burns to her
entire anterior torso and the entirety of both anterior legs. Using the Rule of Nines, what is
the estimated percentage of Total Body Surface Area (TBSA) burned?
A. 27%
B. 45%
C. 36%
D. 18%
Answer: C
Rationale: In the Rule of Nines, the anterior torso (chest and abdomen) accounts for 18%
of the TBSA. Each anterior leg accounts for 9%, so both anterior legs equal 18%. Adding
these together (18% for the torso + 18% for the legs) results in a total of 36% TBSA.
,3. A patient with a history of T4 spinal cord injury presents to the emergency department
complaining of a pounding headache and blurred vision. The nurse notes the patient is
diaphoretic above the level of injury and has a blood pressure of 210/108 mmHg. What is the
nurse’s immediate priority action?
A. Perform a digital rectal exam to check for fecal impaction.
B. Administer PRN Hydralazine as ordered by the physician.
C. Place the patient in a high-Fowler’s position.
D. Catheterize the patient to relieve bladder distension.
Answer: C
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a medical
emergency. The first priority is to sit the patient upright (high-Fowler’s) to utilize
orthostatic pressure to help lower the blood pressure. After positioning, the nurse should
then investigate and remove the triggering stimulus, such as bladder distension or bowel
impaction.
4. Mr. Lee is receiving mechanical ventilation. The high-pressure alarm on the ventilator
begins to sound. Which of the following conditions should the nurse assess for as a potential
cause of this alarm?
A. Disconnection of the ventilator tubing from the endotracheal tube.
B. A leak in the endotracheal tube cuff.
C. The patient is biting the endotracheal tube.
D. Extubation or displacement of the airway.
Answer: C
Rationale: High-pressure alarms are triggered by increased resistance in the circuit or the
patient’s airway. Common causes include biting the tube, secretions in the airway, kinks in
the tubing, or the patient fighting the ventilator. Low-pressure alarms are typically caused
by disconnections or leaks in the system.
5. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. The ECG
shows peaked T-waves. Which medication should the nurse expect to administer first to
protect the heart from the effects of hyperkalemia?
A. Sodium Polystyrene Sulfonate (Kayexalate) orally.
B. Intravenous Calcium Gluconate.
C. Regular Insulin and 50% Dextrose IV.
D. Sodium Bicarbonate IV push.
Answer: B
, Rationale: Calcium gluconate does not lower potassium levels but is the priority because it
stabilizes the myocardial cell membrane to prevent lethal dysrhythmias. Following
stabilization, medications like insulin/D50 are used to shift potassium into the cells, and
Kayexalate or dialysis is used to remove potassium from the body. Peaked T-waves indicate
that the heart is already being affected by the potassium level.
6. The nurse is caring for a patient who is in the compensatory stage of shock. Which clinical
finding is consistent with this stage?
A. Anuria and metabolic acidosis.
B. Lethargy and mottled skin.
C. Cool, clammy skin and increased heart rate.
D. Systolic blood pressure below 80 mmHg.
Answer: C
Rationale: In the compensatory stage of shock, the body’s sympathetic nervous system is
activated to maintain cardiac output and blood pressure. Signs include tachycardia,
tachypnea, and cool/clammy skin due to peripheral vasoconstriction (shunting blood to
vital organs). Anuria and profound hypotension are characteristic of the progressive and
refractory stages.
7. An 18-year-old female, Sarah, is brought to the ED with Diabetic Ketoacidosis (DKA). Her
blood glucose is 550 mg/dL, and her arterial pH is 7.15. The nurse has started an insulin drip.
What is the nurse’s primary concern when the blood glucose reaches 250 mg/dL?
A. Stopping the insulin infusion immediately.
B. Switching the IV fluid to include 5% Dextrose.
C. Administering IV bicarbonate to correct the pH.
D. Increasing the insulin rate to clear ketones faster.
Answer: B
Rationale: When blood glucose levels drop to approximately 250 mg/dL in a DKA patient,
dextrose is added to the IV fluids (e.g., D5 0.45% NS). This prevents hypoglycemia and
allows for the continued administration of insulin needed to resolve the ketosis and
metabolic acidosis. The insulin drip is usually continued until the anion gap closes and the
patient can transition to subcutaneous insulin.
8. The nurse is monitoring a patient with a traumatic brain injury (TBI). Which set of vital
signs indicates Cushing’s Triad, a sign of increased intracranial pressure?
A. BP 90/50 mmHg, HR 120 bpm, RR 24 bpm.
B. BP 170/60 mmHg, HR 50 bpm, irregular respirations.
C. BP 120/80 mmHg, HR 80 bpm, RR 16 bpm.
