NUR 265 Advanced Medical-Surgical Nursing Exam 8 2026 |Galen
College
1. A nurse is caring for a patient in the emergency department who was
involved in a mass casualty incident. The patient is breathing spontaneously,
has a respiratory rate of 25, and follows commands but has a large open leg
fracture. According to the START triage system, what color tag should the nurse
assign?
A. Red (Immediate)
B. Green (Minor)
C. Yellow (Delayed)
D. Black (Deceased)
Answer: C
Rationale: Yellow tags are for victims who are stable but require medical care. This patient
follows commands and has stable respirations, but the fracture prevents them from being
‘Green’ (walking wounded).
2. A patient arrives with deep partial-thickness burns to the entire left arm and
the anterior trunk. Using the Rule of Nines, what is the estimated Total Body
Surface Area (TBSA) burned?
A. 18%
B. 36%
C. 27%
D. 45%
Answer: C
Rationale: The entire arm is 9% and the anterior trunk is 18%. 9 + 18 = 27%.
,3. Which clinical finding is most indicative of the hyperdynamic (early) phase of
septic shock?
A. Cool, clammy skin
B. Bradycardia
C. Decreased cardiac output
D. Warm, flushed skin
Answer: D
Rationale: In the early phase of septic shock, vasodilation causes the skin to be warm and
flushed despite the infection.
4. A patient with ARDS is being mechanically ventilated. The nurse notes the
high-pressure alarm is sounding. What is the most likely cause?
A. A leak in the ventilator circuit
B. The patient is biting the endotracheal tube
C. The patient has disconnected from the ventilator
D. The cuff on the ET tube has deflated
Answer: B
Rationale: High-pressure alarms are triggered by increased resistance, such as biting the
tube, secretions, or decreased lung compliance. Leaks cause low-pressure alarms.
5. What is the primary goal of applying Positive End-Expiratory Pressure (PEEP)
in a patient with ARDS?
A. To decrease the work of breathing
B. To reverse respiratory acidosis
C. To increase the fraction of inspired oxygen (FiO2)
D. To prevent alveolar collapse at the end of expiration
Answer: D
Rationale: PEEP keeps the alveoli open at the end of expiration, improving gas exchange
and oxygenation in ARDS patients.
, 6. A patient is admitted with a Glascow Coma Scale (GCS) score of 7. How should
the nurse interpret this score?
A. The patient is fully alert and oriented
B. The patient is in a coma and requires intubation
C. The patient has a moderate brain injury
D. The patient is brain dead
Answer: B
Rationale: A GCS score of 8 or less typically indicates a severe brain injury or coma,
requiring airway protection (intubation).
7. Which medication is considered the first-line treatment for a patient
experiencing anaphylactic shock?
A. Diphenhydramine
B. Methylprednisolone
C. Epinephrine
D. Albuterol
Answer: C
Rationale: Epinephrine is the gold standard for treating anaphylaxis because it causes
vasoconstriction and bronchodilation.
8. A nurse is monitoring a patient with a spinal cord injury at the T4 level. The
patient reports a sudden, severe headache and has a BP of 190/100. What is the
priority nursing action?
A. Administer PRN pain medication
B. Lower the head of the bed immediately
C. Check for bladder distention or fecal impaction
D. Perform a neurological assessment
Answer: C
College
1. A nurse is caring for a patient in the emergency department who was
involved in a mass casualty incident. The patient is breathing spontaneously,
has a respiratory rate of 25, and follows commands but has a large open leg
fracture. According to the START triage system, what color tag should the nurse
assign?
A. Red (Immediate)
B. Green (Minor)
C. Yellow (Delayed)
D. Black (Deceased)
Answer: C
Rationale: Yellow tags are for victims who are stable but require medical care. This patient
follows commands and has stable respirations, but the fracture prevents them from being
‘Green’ (walking wounded).
2. A patient arrives with deep partial-thickness burns to the entire left arm and
the anterior trunk. Using the Rule of Nines, what is the estimated Total Body
Surface Area (TBSA) burned?
A. 18%
B. 36%
C. 27%
D. 45%
Answer: C
Rationale: The entire arm is 9% and the anterior trunk is 18%. 9 + 18 = 27%.
,3. Which clinical finding is most indicative of the hyperdynamic (early) phase of
septic shock?
A. Cool, clammy skin
B. Bradycardia
C. Decreased cardiac output
D. Warm, flushed skin
Answer: D
Rationale: In the early phase of septic shock, vasodilation causes the skin to be warm and
flushed despite the infection.
4. A patient with ARDS is being mechanically ventilated. The nurse notes the
high-pressure alarm is sounding. What is the most likely cause?
A. A leak in the ventilator circuit
B. The patient is biting the endotracheal tube
C. The patient has disconnected from the ventilator
D. The cuff on the ET tube has deflated
Answer: B
Rationale: High-pressure alarms are triggered by increased resistance, such as biting the
tube, secretions, or decreased lung compliance. Leaks cause low-pressure alarms.
5. What is the primary goal of applying Positive End-Expiratory Pressure (PEEP)
in a patient with ARDS?
A. To decrease the work of breathing
B. To reverse respiratory acidosis
C. To increase the fraction of inspired oxygen (FiO2)
D. To prevent alveolar collapse at the end of expiration
Answer: D
Rationale: PEEP keeps the alveoli open at the end of expiration, improving gas exchange
and oxygenation in ARDS patients.
, 6. A patient is admitted with a Glascow Coma Scale (GCS) score of 7. How should
the nurse interpret this score?
A. The patient is fully alert and oriented
B. The patient is in a coma and requires intubation
C. The patient has a moderate brain injury
D. The patient is brain dead
Answer: B
Rationale: A GCS score of 8 or less typically indicates a severe brain injury or coma,
requiring airway protection (intubation).
7. Which medication is considered the first-line treatment for a patient
experiencing anaphylactic shock?
A. Diphenhydramine
B. Methylprednisolone
C. Epinephrine
D. Albuterol
Answer: C
Rationale: Epinephrine is the gold standard for treating anaphylaxis because it causes
vasoconstriction and bronchodilation.
8. A nurse is monitoring a patient with a spinal cord injury at the T4 level. The
patient reports a sudden, severe headache and has a BP of 190/100. What is the
priority nursing action?
A. Administer PRN pain medication
B. Lower the head of the bed immediately
C. Check for bladder distention or fecal impaction
D. Perform a neurological assessment
Answer: C
