NUR 265 Exam 2 V2 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 2) |
Galen
1. A 62-year-old male is admitted to the ICU with cardiogenic shock following an extensive
anterior wall myocardial infarction. The nurse notes the following hemodynamic parameters:
Blood Pressure 82/50 mmHg, Heart Rate 118 bpm, Central Venous Pressure (CVP) 14 mmHg,
and Pulmonary Artery Wedge Pressure (PAWP) 22 mmHg. Which intervention should the
nurse prioritize?
A. Administer a 500 mL normal saline bolus to increase preload.
B. Administer Atropine to manage the current heart rate.
C. Prepare for immediate administration of IV Furosemide to reduce CVP.
D. Initiate a Dobutamine infusion to improve myocardial contractility.
Answer: D
Rationale: In cardiogenic shock, the heart fails as a pump, leading to high filling pressures
(elevated PAWP) and low output. Dobutamine is an inotrope that increases contractility
and cardiac output without significantly increasing myocardial oxygen demand. A fluid
bolus is contraindicated as the patient is already fluid-overloaded in the pulmonary
vasculature, evidenced by the high PAWP.
2. A patient with a T3 spinal cord injury is exhibiting signs of neurogenic shock. The nurse
observes a blood pressure of 88/42 mmHg and a heart rate of 48 bpm. Which physiological
mechanism explains these findings?
A. Loss of parasympathetic tone leading to peripheral vasoconstriction.
B. Hypovolemia resulting from occult internal hemorrhage.
C. Increased systemic vascular resistance from adrenal gland overstimulation.
D. Massive vasodilation due to loss of sympathetic nervous system tone.
Answer: D
Rationale: Neurogenic shock occurs due to the loss of sympathetic tone below the level of
the spinal cord injury, leading to massive vasodilation and bradycardia. Unlike other forms
of shock, the heart rate does not increase because the sympathetic pathways to the heart
are interrupted. Management typically involves vasopressors and atropine to support
blood pressure and heart rate.
,3. A 45-year-old female patient is in the early stages of septic shock. Her blood pressure is
100/60 mmHg, heart rate 110 bpm, and respiratory rate 24 bpm. Her serum lactate level is
4.2 mmol/L. Which action is the most critical according to the Sepsis Bundle?
A. Begin broad-spectrum antibiotics within 3 hours of arrival.
B. Wait for blood culture results before starting any intravenous fluids.
C. Administer a 30 mL/kg crystalloid bolus for the elevated lactate level.
D. Insert an indwelling urinary catheter to monitor hourly output.
Answer: C
Rationale: The Surviving Sepsis Campaign guidelines recommend a 30 mL/kg crystalloid
bolus for patients with a lactate level ≥ 4 mmol/L or hypotension. This fluid resuscitation is
essential to improve tissue perfusion and mitigate the metabolic acidosis caused by cellular
hypoxia. Prompt fluid administration takes priority alongside obtaining cultures and
starting antibiotics.
4. A patient in the ICU is being treated for ARDS and is currently on mechanical ventilation
with 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. What is the most likely cause of this
change?
A. Improved lung compliance reducing the need for high PEEP.
B. Spontaneous resolution of the inflammatory process in the alveoli.
C. Development of a localized infection at the site of the endotracheal tube.
D. Increased intrathoracic pressure causing decreased venous return to the heart.
Answer: D
Rationale: High levels of Positive End-Expiratory Pressure (PEEP) increase intrathoracic
pressure, which can compress the vena cava and decrease venous return (preload) to the
right atrium. This reduction in preload results in decreased cardiac output and systemic
hypotension. The nurse must monitor hemodynamics closely when PEEP levels are
elevated.
5. A 29-year-old male was rescued from a house fire and has sustained full-thickness burns to
his entire chest, abdomen, and the front of both legs. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) affected?
A. 18%
B. 27%
C. 36%
D. 45%
, Answer: C
Rationale: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18%, and the anterior portion of both legs accounts for 18% (9% each).
Adding these together results in a total of 36% TBSA. Accurate TBSA calculation is critical
for determining fluid resuscitation needs using the Parkland formula.
6. A patient with severe acute pancreatitis develops Chvostek’s sign and Trousseau’s sign.
Which electrolyte imbalance should the nurse anticipate based on these clinical findings?
A. Hypocalcemia
B. Hyperkalemia
C. Hyponatremia
D. Hypermagnesemia
Answer: A
Rationale: Acute pancreatitis often leads to hypocalcemia because of fat necrosis, where
calcium binds to fatty acids in the retroperitoneum. Chvostek’s sign (facial twitching) and
Trousseau’s sign (carpal spasm) are classic indicators of neuromuscular irritability due to
low calcium. The nurse must be prepared to administer calcium gluconate and monitor the
patient’s cardiac rhythm.
7. The nurse is caring for a patient on a mechanical ventilator. The ‘High Pressure’ alarm
begins to sound. Which of the following conditions would most likely trigger this alarm?
A. A leak in the ventilator circuit.
B. The patient has disconnected from the ventilator.
C. Excessive secretions or a kink in the ventilator tubing.
D. The endotracheal tube cuff has become deflated.
Answer: C
Rationale: High-pressure alarms are triggered when the ventilator meets resistance while
attempting to deliver a breath, such as from secretions, coughing, or a kinked tube. Low-
pressure alarms are typically caused by disconnections or leaks in the system. The nurse
should immediately assess the patient and suction the airway if necessary.
8. A patient with Disseminated Intravascular Coagulation (DIC) is exhibiting oozing of blood
from previous IV sites and the gums. Which laboratory finding is most characteristic of DIC?
A. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT).
B. Increased platelet count.
C. Decreased D-dimer levels.
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 2) |
Galen
1. A 62-year-old male is admitted to the ICU with cardiogenic shock following an extensive
anterior wall myocardial infarction. The nurse notes the following hemodynamic parameters:
Blood Pressure 82/50 mmHg, Heart Rate 118 bpm, Central Venous Pressure (CVP) 14 mmHg,
and Pulmonary Artery Wedge Pressure (PAWP) 22 mmHg. Which intervention should the
nurse prioritize?
A. Administer a 500 mL normal saline bolus to increase preload.
B. Administer Atropine to manage the current heart rate.
C. Prepare for immediate administration of IV Furosemide to reduce CVP.
D. Initiate a Dobutamine infusion to improve myocardial contractility.
Answer: D
Rationale: In cardiogenic shock, the heart fails as a pump, leading to high filling pressures
(elevated PAWP) and low output. Dobutamine is an inotrope that increases contractility
and cardiac output without significantly increasing myocardial oxygen demand. A fluid
bolus is contraindicated as the patient is already fluid-overloaded in the pulmonary
vasculature, evidenced by the high PAWP.
2. A patient with a T3 spinal cord injury is exhibiting signs of neurogenic shock. The nurse
observes a blood pressure of 88/42 mmHg and a heart rate of 48 bpm. Which physiological
mechanism explains these findings?
A. Loss of parasympathetic tone leading to peripheral vasoconstriction.
B. Hypovolemia resulting from occult internal hemorrhage.
C. Increased systemic vascular resistance from adrenal gland overstimulation.
D. Massive vasodilation due to loss of sympathetic nervous system tone.
Answer: D
Rationale: Neurogenic shock occurs due to the loss of sympathetic tone below the level of
the spinal cord injury, leading to massive vasodilation and bradycardia. Unlike other forms
of shock, the heart rate does not increase because the sympathetic pathways to the heart
are interrupted. Management typically involves vasopressors and atropine to support
blood pressure and heart rate.
,3. A 45-year-old female patient is in the early stages of septic shock. Her blood pressure is
100/60 mmHg, heart rate 110 bpm, and respiratory rate 24 bpm. Her serum lactate level is
4.2 mmol/L. Which action is the most critical according to the Sepsis Bundle?
A. Begin broad-spectrum antibiotics within 3 hours of arrival.
B. Wait for blood culture results before starting any intravenous fluids.
C. Administer a 30 mL/kg crystalloid bolus for the elevated lactate level.
D. Insert an indwelling urinary catheter to monitor hourly output.
Answer: C
Rationale: The Surviving Sepsis Campaign guidelines recommend a 30 mL/kg crystalloid
bolus for patients with a lactate level ≥ 4 mmol/L or hypotension. This fluid resuscitation is
essential to improve tissue perfusion and mitigate the metabolic acidosis caused by cellular
hypoxia. Prompt fluid administration takes priority alongside obtaining cultures and
starting antibiotics.
4. A patient in the ICU is being treated for ARDS and is currently on mechanical ventilation
with 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. What is the most likely cause of this
change?
A. Improved lung compliance reducing the need for high PEEP.
B. Spontaneous resolution of the inflammatory process in the alveoli.
C. Development of a localized infection at the site of the endotracheal tube.
D. Increased intrathoracic pressure causing decreased venous return to the heart.
Answer: D
Rationale: High levels of Positive End-Expiratory Pressure (PEEP) increase intrathoracic
pressure, which can compress the vena cava and decrease venous return (preload) to the
right atrium. This reduction in preload results in decreased cardiac output and systemic
hypotension. The nurse must monitor hemodynamics closely when PEEP levels are
elevated.
5. A 29-year-old male was rescued from a house fire and has sustained full-thickness burns to
his entire chest, abdomen, and the front of both legs. Using the Rule of Nines, what is the
estimated Total Body Surface Area (TBSA) affected?
A. 18%
B. 27%
C. 36%
D. 45%
, Answer: C
Rationale: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18%, and the anterior portion of both legs accounts for 18% (9% each).
Adding these together results in a total of 36% TBSA. Accurate TBSA calculation is critical
for determining fluid resuscitation needs using the Parkland formula.
6. A patient with severe acute pancreatitis develops Chvostek’s sign and Trousseau’s sign.
Which electrolyte imbalance should the nurse anticipate based on these clinical findings?
A. Hypocalcemia
B. Hyperkalemia
C. Hyponatremia
D. Hypermagnesemia
Answer: A
Rationale: Acute pancreatitis often leads to hypocalcemia because of fat necrosis, where
calcium binds to fatty acids in the retroperitoneum. Chvostek’s sign (facial twitching) and
Trousseau’s sign (carpal spasm) are classic indicators of neuromuscular irritability due to
low calcium. The nurse must be prepared to administer calcium gluconate and monitor the
patient’s cardiac rhythm.
7. The nurse is caring for a patient on a mechanical ventilator. The ‘High Pressure’ alarm
begins to sound. Which of the following conditions would most likely trigger this alarm?
A. A leak in the ventilator circuit.
B. The patient has disconnected from the ventilator.
C. Excessive secretions or a kink in the ventilator tubing.
D. The endotracheal tube cuff has become deflated.
Answer: C
Rationale: High-pressure alarms are triggered when the ventilator meets resistance while
attempting to deliver a breath, such as from secretions, coughing, or a kinked tube. Low-
pressure alarms are typically caused by disconnections or leaks in the system. The nurse
should immediately assess the patient and suction the airway if necessary.
8. A patient with Disseminated Intravascular Coagulation (DIC) is exhibiting oozing of blood
from previous IV sites and the gums. Which laboratory finding is most characteristic of DIC?
A. Prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT).
B. Increased platelet count.
C. Decreased D-dimer levels.
