NUR 265 Exam 1 V3 | NUR 265 Advanced Concepts of Medical–
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 1) |
Galen
1. A 68-year-old patient, Mr. Sterling, is admitted with a diagnosis of septic shock. His blood
pressure is 82/44 mmHg, heart rate is 122 bpm, and his serum lactate is 4.5 mmol/L. After
receiving a 30 mL/kg bolus of normal saline, his mean arterial pressure (MAP) remains at 58
mmHg. Which intervention should the nurse prioritize next?
A. Administer a second 30 mL/kg fluid bolus.
B. Administer broad-spectrum intravenous antibiotics.
C. Obtain another set of blood cultures.
D. Initiate a Norepinephrine infusion.
Answer: D
Rationale: Norepinephrine is the first-line vasopressor for septic shock when fluid
resuscitation fails to achieve a MAP of at least 65 mmHg. The Surviving Sepsis Campaign
guidelines emphasize early vasopressor use to maintain organ perfusion. Continuing fluid
boluses indefinitely in a non-responsive patient can lead to fluid overload and pulmonary
edema.
2. Mrs. O’Leary, a 45-year-old female, is brought to the emergency department after a house
fire. She has partial-thickness burns on her entire left arm, her chest, and her face. Using the
Rule of Nines, what is the estimated total body surface area (TBSA) affected?
A. 18%
B. 27%
C. 22.5%
D. 31.5%
Answer: C
Rationale: According to the Rule of Nines, the entire left arm is 9%, the anterior
chest/torso is 18% (chest specifically is 9%), and the face (half of the head) is 4.5%. Adding
9% (arm) + 9% (chest) + 4.5% (face) equals 22.5%. Precise calculation is critical for
determining fluid resuscitation needs via the Parkland formula.
3. Mr. Rodriguez is in the hypermetabolic phase of recovery following a 40% TBSA burn
injury. The nurse notes a temperature of 100.8°F, heart rate of 110 bpm, and a respiratory
rate of 24 breaths/min. What is the most appropriate nursing action?
A. Notify the provider of impending septic shock.
,B. Request a stat order for blood cultures and antibiotics.
C. Document the findings as expected during this phase.
D. Increase the IV fluid rate to prevent hypovolemia.
Answer: C
Rationale: During the hypermetabolic phase of a major burn, a low-grade fever and mild
tachycardia are common due to the massive release of catecholamines and inflammatory
mediators. These systemic responses do not necessarily indicate infection if other signs of
sepsis are absent. The nurse should continue monitoring but recognize this as a typical
pathophysiological response to the injury.
4. A patient with multiple rib fractures and a suspected hemothorax following a motor
vehicle accident (MVA) develops sudden shortness of breath and tracheal deviation to the
right. The nurse notes absent breath sounds on the left side. Which procedure should the
nurse anticipate immediately?
A. Urgent chest X-ray to confirm placement.
B. Pericardiocentesis for cardiac tamponade.
C. Intubation and mechanical ventilation.
D. Needle decompression of the left chest.
Answer: D
Rationale: Tracheal deviation away from the affected side and absent breath sounds are
classic signs of a tension pneumothorax, which is a life-threatening emergency. Needle
decompression is the immediate treatment to relieve pressure before a formal chest tube is
inserted. Delaying for an X-ray could lead to cardiovascular collapse due to decreased
venous return.
5. The nurse is caring for a 55-year-old patient who is 4 hours post-abdominal surgery. The
patient’s urinary output has been 20 mL/hour for the last two hours, heart rate is 105 bpm,
and skin is cool to the touch. What is the nurse’s priority interpretation of these findings?
A. The patient is experiencing acute renal failure.
B. The patient is showing normal postoperative inflammatory response.
C. The patient is in the compensatory stage of hypovolemic shock.
D. The patient is experiencing neurogenic shock from anesthesia.
Answer: C
Rationale: Tachycardia, cool skin, and oliguria (less than 30 mL/hr) are early signs that the
body is compensating for low intravascular volume. In the compensatory stage, blood is
shunted from non-vital organs like the skin and kidneys to the heart and brain. Recognizing
, these subtle signs allows for early intervention with fluids before the patient
decompensates.
6. Which laboratory result would most strongly support a diagnosis of Disseminated
Intravascular Coagulation (DIC) in a patient with multi-organ dysfunction?
A. Elevated D-dimer and decreased Fibrinogen levels.
B. Decreased D-dimer and increased Prothrombin Time (PT).
C. Increased platelet count and decreased fibrinogen.
D. Decreased Partial Thromboplastin Time (PTT).
Answer: A
Rationale: DIC is characterized by systemic clotting which consumes clotting factors and
platelets, followed by excessive bleeding. An elevated D-dimer indicates significant
fibrinolysis, while decreased fibrinogen indicates that clotting factors are being exhausted.
Together, these labs reflect the simultaneous clotting and bleeding paradox of DIC.
7. Mr. Thompson, weighing 176 lbs (80 kg), is admitted with 50% TBSA burns. Using the
Parkland formula (4 mL/kg/% TBSA), calculate the volume of Lactated Ringer’s solution the
nurse should administer in the first 8 hours.
A. 4,000 mL
B. 16,000 mL
C. 8,000 mL
D. 32,000 mL
Answer: C
Rationale: The total 24-hour fluid requirement is 4 mL x 80 kg x 50% = 16,000 mL.
According to the Parkland formula, half of the total volume (8,000 mL) must be
administered within the first 8 hours from the time of injury. The remaining half is given
over the subsequent 16 hours.
8. The nurse is managing a patient on a mechanical ventilator for ARDS. The PEEP has been
increased to 15 cm H2O. Which hemodynamic change should the nurse monitor for most
closely?
A. Increased Cardiac Output.
B. Increased Stroke Volume.
C. Decreased Central Venous Pressure.
D. Decreased Blood Pressure.
Answer: D
Surgical Nursing | Actual Q&A with Rationale (NUR 265 Exam 1) |
Galen
1. A 68-year-old patient, Mr. Sterling, is admitted with a diagnosis of septic shock. His blood
pressure is 82/44 mmHg, heart rate is 122 bpm, and his serum lactate is 4.5 mmol/L. After
receiving a 30 mL/kg bolus of normal saline, his mean arterial pressure (MAP) remains at 58
mmHg. Which intervention should the nurse prioritize next?
A. Administer a second 30 mL/kg fluid bolus.
B. Administer broad-spectrum intravenous antibiotics.
C. Obtain another set of blood cultures.
D. Initiate a Norepinephrine infusion.
Answer: D
Rationale: Norepinephrine is the first-line vasopressor for septic shock when fluid
resuscitation fails to achieve a MAP of at least 65 mmHg. The Surviving Sepsis Campaign
guidelines emphasize early vasopressor use to maintain organ perfusion. Continuing fluid
boluses indefinitely in a non-responsive patient can lead to fluid overload and pulmonary
edema.
2. Mrs. O’Leary, a 45-year-old female, is brought to the emergency department after a house
fire. She has partial-thickness burns on her entire left arm, her chest, and her face. Using the
Rule of Nines, what is the estimated total body surface area (TBSA) affected?
A. 18%
B. 27%
C. 22.5%
D. 31.5%
Answer: C
Rationale: According to the Rule of Nines, the entire left arm is 9%, the anterior
chest/torso is 18% (chest specifically is 9%), and the face (half of the head) is 4.5%. Adding
9% (arm) + 9% (chest) + 4.5% (face) equals 22.5%. Precise calculation is critical for
determining fluid resuscitation needs via the Parkland formula.
3. Mr. Rodriguez is in the hypermetabolic phase of recovery following a 40% TBSA burn
injury. The nurse notes a temperature of 100.8°F, heart rate of 110 bpm, and a respiratory
rate of 24 breaths/min. What is the most appropriate nursing action?
A. Notify the provider of impending septic shock.
,B. Request a stat order for blood cultures and antibiotics.
C. Document the findings as expected during this phase.
D. Increase the IV fluid rate to prevent hypovolemia.
Answer: C
Rationale: During the hypermetabolic phase of a major burn, a low-grade fever and mild
tachycardia are common due to the massive release of catecholamines and inflammatory
mediators. These systemic responses do not necessarily indicate infection if other signs of
sepsis are absent. The nurse should continue monitoring but recognize this as a typical
pathophysiological response to the injury.
4. A patient with multiple rib fractures and a suspected hemothorax following a motor
vehicle accident (MVA) develops sudden shortness of breath and tracheal deviation to the
right. The nurse notes absent breath sounds on the left side. Which procedure should the
nurse anticipate immediately?
A. Urgent chest X-ray to confirm placement.
B. Pericardiocentesis for cardiac tamponade.
C. Intubation and mechanical ventilation.
D. Needle decompression of the left chest.
Answer: D
Rationale: Tracheal deviation away from the affected side and absent breath sounds are
classic signs of a tension pneumothorax, which is a life-threatening emergency. Needle
decompression is the immediate treatment to relieve pressure before a formal chest tube is
inserted. Delaying for an X-ray could lead to cardiovascular collapse due to decreased
venous return.
5. The nurse is caring for a 55-year-old patient who is 4 hours post-abdominal surgery. The
patient’s urinary output has been 20 mL/hour for the last two hours, heart rate is 105 bpm,
and skin is cool to the touch. What is the nurse’s priority interpretation of these findings?
A. The patient is experiencing acute renal failure.
B. The patient is showing normal postoperative inflammatory response.
C. The patient is in the compensatory stage of hypovolemic shock.
D. The patient is experiencing neurogenic shock from anesthesia.
Answer: C
Rationale: Tachycardia, cool skin, and oliguria (less than 30 mL/hr) are early signs that the
body is compensating for low intravascular volume. In the compensatory stage, blood is
shunted from non-vital organs like the skin and kidneys to the heart and brain. Recognizing
, these subtle signs allows for early intervention with fluids before the patient
decompensates.
6. Which laboratory result would most strongly support a diagnosis of Disseminated
Intravascular Coagulation (DIC) in a patient with multi-organ dysfunction?
A. Elevated D-dimer and decreased Fibrinogen levels.
B. Decreased D-dimer and increased Prothrombin Time (PT).
C. Increased platelet count and decreased fibrinogen.
D. Decreased Partial Thromboplastin Time (PTT).
Answer: A
Rationale: DIC is characterized by systemic clotting which consumes clotting factors and
platelets, followed by excessive bleeding. An elevated D-dimer indicates significant
fibrinolysis, while decreased fibrinogen indicates that clotting factors are being exhausted.
Together, these labs reflect the simultaneous clotting and bleeding paradox of DIC.
7. Mr. Thompson, weighing 176 lbs (80 kg), is admitted with 50% TBSA burns. Using the
Parkland formula (4 mL/kg/% TBSA), calculate the volume of Lactated Ringer’s solution the
nurse should administer in the first 8 hours.
A. 4,000 mL
B. 16,000 mL
C. 8,000 mL
D. 32,000 mL
Answer: C
Rationale: The total 24-hour fluid requirement is 4 mL x 80 kg x 50% = 16,000 mL.
According to the Parkland formula, half of the total volume (8,000 mL) must be
administered within the first 8 hours from the time of injury. The remaining half is given
over the subsequent 16 hours.
8. The nurse is managing a patient on a mechanical ventilator for ARDS. The PEEP has been
increased to 15 cm H2O. Which hemodynamic change should the nurse monitor for most
closely?
A. Increased Cardiac Output.
B. Increased Stroke Volume.
C. Decreased Central Venous Pressure.
D. Decreased Blood Pressure.
Answer: D
