BSN 266 HESI MED SURG PRACTICE
EXAM VERSION 2 QUESTIONS AND
ANSWERS
1. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg and a
mean arterial pressure (MAP) of 70 mmHg. Which action should the nurse take first?
A. Administer a PRN dose of morphine sulphate
B. Notify the healthcare provider of the cerebral perfusion pressure
C. Increase the rate of the maintenance intravenous fluids
D. Elevate the head of the bed to 45 degrees
Answer: B
Conceptual Explanation: Cerebral Perfusion Pressure (CPP) = MAP - ICP. In this case, 70 -
22 = 48 mmHg. The normal CPP is 60-100 mmHg. A CPP below 50 mmHg is associated with
ischemia and neuronal death. This is a critical value that must be reported immediately.
2. The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. The
high-pressure alarm sounds. Which action should the nurse perform first?
A. Check for a disconnection between the tube and ventilator
,B. Suction the patient’s airway for secretions
C. Assess for a kink in the ventilator tubing
D. Manually ventilate the patient with an Ambu bag
Answer: C
Conceptual Explanation: The first action for a high-pressure alarm is to check for
obstructions like kinks in the tubing. If no obstruction is found and the patient is in distress,
manual ventilation is indicated, but assessment for simple obstructions is the priority step
for this specific alarm.
3. A client with full-thickness burns over 40% of the body is in the emergent phase. The client
weighs 80 kg. Using the Parkland formula, calculate the total fluid volume to be administered
in the first 8 hours.
A. 12,800 mL
B. 6,400 mL
C. 3,200 mL
D. 9,600 mL
Answer: B
Conceptual Explanation: Parkland formula: 4 mL x weight(kg) x % TBSA. Total for 24
hours: 4 x 80 x 40 = 12,800 mL. Half of the total (6,400 mL) must be given in the first 8
hours.
, 4. Which clinical manifestation should the nurse expect to find in a patient experiencing an
Addisonian crisis?
A. Severe hypertension and bradycardia
B. Hyperglycemia and metabolic alkalosis
C. Profound hypotension and hyperkalemia
D. Hypokalemia and fluid volume excess
Answer: C
Conceptual Explanation: Addisonian crisis is an acute adrenal insufficiency. It is
characterized by severe hypotension (due to lack of cortisol and aldosterone),
hyponatremia, hyperkalemia, and hypoglycemia.
5. A patient with Type 1 Diabetes is admitted with Diabetic Ketoacidosis (DKA). The nurse
notes a blood glucose of 600 mg/dL and a potassium level of 3.2 mEq/L. Which order should
the nurse implement first?
A. Start an insulin drip at 0.1 units/kg/hr
B. Infuse 1 liter of 0.9% Normal Saline over 1 hour
C. Administer 40 mEq of potassium chloride IV
D. Obtain an arterial blood gas (ABG) sample
Answer: B
EXAM VERSION 2 QUESTIONS AND
ANSWERS
1. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg and a
mean arterial pressure (MAP) of 70 mmHg. Which action should the nurse take first?
A. Administer a PRN dose of morphine sulphate
B. Notify the healthcare provider of the cerebral perfusion pressure
C. Increase the rate of the maintenance intravenous fluids
D. Elevate the head of the bed to 45 degrees
Answer: B
Conceptual Explanation: Cerebral Perfusion Pressure (CPP) = MAP - ICP. In this case, 70 -
22 = 48 mmHg. The normal CPP is 60-100 mmHg. A CPP below 50 mmHg is associated with
ischemia and neuronal death. This is a critical value that must be reported immediately.
2. The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. The
high-pressure alarm sounds. Which action should the nurse perform first?
A. Check for a disconnection between the tube and ventilator
,B. Suction the patient’s airway for secretions
C. Assess for a kink in the ventilator tubing
D. Manually ventilate the patient with an Ambu bag
Answer: C
Conceptual Explanation: The first action for a high-pressure alarm is to check for
obstructions like kinks in the tubing. If no obstruction is found and the patient is in distress,
manual ventilation is indicated, but assessment for simple obstructions is the priority step
for this specific alarm.
3. A client with full-thickness burns over 40% of the body is in the emergent phase. The client
weighs 80 kg. Using the Parkland formula, calculate the total fluid volume to be administered
in the first 8 hours.
A. 12,800 mL
B. 6,400 mL
C. 3,200 mL
D. 9,600 mL
Answer: B
Conceptual Explanation: Parkland formula: 4 mL x weight(kg) x % TBSA. Total for 24
hours: 4 x 80 x 40 = 12,800 mL. Half of the total (6,400 mL) must be given in the first 8
hours.
, 4. Which clinical manifestation should the nurse expect to find in a patient experiencing an
Addisonian crisis?
A. Severe hypertension and bradycardia
B. Hyperglycemia and metabolic alkalosis
C. Profound hypotension and hyperkalemia
D. Hypokalemia and fluid volume excess
Answer: C
Conceptual Explanation: Addisonian crisis is an acute adrenal insufficiency. It is
characterized by severe hypotension (due to lack of cortisol and aldosterone),
hyponatremia, hyperkalemia, and hypoglycemia.
5. A patient with Type 1 Diabetes is admitted with Diabetic Ketoacidosis (DKA). The nurse
notes a blood glucose of 600 mg/dL and a potassium level of 3.2 mEq/L. Which order should
the nurse implement first?
A. Start an insulin drip at 0.1 units/kg/hr
B. Infuse 1 liter of 0.9% Normal Saline over 1 hour
C. Administer 40 mEq of potassium chloride IV
D. Obtain an arterial blood gas (ABG) sample
Answer: B
