NUR 220 | NUR 220 Medical Surgical Nursing Exam
2 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient is admitted with suspected hypovolemic shock following a motor vehicle
accident. Which of the following should be the nurse’s first action?
A. Administering prescribed pain medication
B. Obtaining a complete medical history from family
C. Inserting a second large-bore IV catheter
D. Sending a urine sample for toxicology
Correct Answer: C
Expert Explanation: In hypovolemic shock, the priority is to restore circulating
volume as quickly as possible. Large-bore IV access is essential for the rapid
administration of fluids and blood products. While pain management is important, it
is secondary to hemodynamic stabilization. Obtaining a history and toxicology
screening are diagnostic but do not address the immediate life-threatening crisis.
The nurse must focus on interventions that prevent further circulatory collapse.
2. Which clinical finding is considered an early sign of hypoxia in a patient
experiencing circulatory compromise?
A. Cyanosis of the lips and nail beds
,B. Bradycardia and hypotension
C. Restlessness and agitation
D. Decreased deep tendon reflexes
Correct Answer: C
Expert Explanation: The brain is highly sensitive to changes in oxygen delivery,
making neurological changes an early indicator. Restlessness, agitation, and
confusion often precede physical signs like cyanosis. Cyanosis is actually a late sign
of severe hypoxia and should not be relied upon for early detection. Bradycardia is
also a late finding in adults, as the heart initially compensates with tachycardia.
Recognizing early mental status changes allows for prompt intervention to improve
oxygenation.
3. A nurse is monitoring a patient in septic shock. Which Mean Arterial Pressure (MAP)
value indicates adequate tissue perfusion?
A. 50 mmHg
B. 55 mmHg
C. 40 mmHg
D. 65 mmHg
Correct Answer: D
,Expert Explanation: Mean Arterial Pressure (MAP) is a critical indicator of organ
perfusion during shock states. A MAP of at least 65 mmHg is generally required to
ensure that vital organs receive enough blood. Values below this threshold can lead
to acute kidney injury and other organ failures. If the MAP remains low despite fluid
resuscitation, vasopressors may be initiated. Titrating therapy to achieve this target
is a primary nursing responsibility in the ICU.
4. During the compensatory stage of shock, the nurse expects to see which of the
following physiological responses?
A. Increased heart rate and cool, clammy skin
B. Decreased heart rate and warm, dry skin
C. Respiratory rate decrease and hypotension
D. Increased urine output and hypertension
Correct Answer: A
Expert Explanation: In the compensatory stage, the body activates the sympathetic
nervous system to maintain cardiac output. This results in tachycardia and
peripheral vasoconstriction, leading to cool and clammy skin. Blood is shunted away
from non-essential organs like the skin and GI tract to prioritize the heart and brain.
Urine output typically decreases as the kidneys attempt to conserve water. These
, compensatory mechanisms are temporary and will fail if the underlying cause is not
treated.
5. A patient receiving a blood transfusion develops hives, itching, and wheezing. What
is the nurse’s immediate priority?
A. Slow the infusion rate and call the doctor
B. Stop the transfusion and disconnect the tubing
C. Administer diphenhydramine and continue monitoring
D. Check the patient’s temperature and vital signs
Correct Answer: B
Expert Explanation: Any sign of an adverse reaction during a blood transfusion
requires the immediate cessation of the infusion. Disconnecting the tubing ensures
that no further blood or allergen enters the patient’s circulation. Simply slowing the
rate is insufficient and dangerous if a severe allergic reaction is occurring. After
stopping the blood, the nurse should maintain the IV line with normal saline using
new tubing. These actions prioritize patient safety and minimize the severity of the
reaction.
6. Which type of shock is characterized by bradycardia rather than tachycardia?
A. Hypovolemic shock
B. Cardiogenic shock
2 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient is admitted with suspected hypovolemic shock following a motor vehicle
accident. Which of the following should be the nurse’s first action?
A. Administering prescribed pain medication
B. Obtaining a complete medical history from family
C. Inserting a second large-bore IV catheter
D. Sending a urine sample for toxicology
Correct Answer: C
Expert Explanation: In hypovolemic shock, the priority is to restore circulating
volume as quickly as possible. Large-bore IV access is essential for the rapid
administration of fluids and blood products. While pain management is important, it
is secondary to hemodynamic stabilization. Obtaining a history and toxicology
screening are diagnostic but do not address the immediate life-threatening crisis.
The nurse must focus on interventions that prevent further circulatory collapse.
2. Which clinical finding is considered an early sign of hypoxia in a patient
experiencing circulatory compromise?
A. Cyanosis of the lips and nail beds
,B. Bradycardia and hypotension
C. Restlessness and agitation
D. Decreased deep tendon reflexes
Correct Answer: C
Expert Explanation: The brain is highly sensitive to changes in oxygen delivery,
making neurological changes an early indicator. Restlessness, agitation, and
confusion often precede physical signs like cyanosis. Cyanosis is actually a late sign
of severe hypoxia and should not be relied upon for early detection. Bradycardia is
also a late finding in adults, as the heart initially compensates with tachycardia.
Recognizing early mental status changes allows for prompt intervention to improve
oxygenation.
3. A nurse is monitoring a patient in septic shock. Which Mean Arterial Pressure (MAP)
value indicates adequate tissue perfusion?
A. 50 mmHg
B. 55 mmHg
C. 40 mmHg
D. 65 mmHg
Correct Answer: D
,Expert Explanation: Mean Arterial Pressure (MAP) is a critical indicator of organ
perfusion during shock states. A MAP of at least 65 mmHg is generally required to
ensure that vital organs receive enough blood. Values below this threshold can lead
to acute kidney injury and other organ failures. If the MAP remains low despite fluid
resuscitation, vasopressors may be initiated. Titrating therapy to achieve this target
is a primary nursing responsibility in the ICU.
4. During the compensatory stage of shock, the nurse expects to see which of the
following physiological responses?
A. Increased heart rate and cool, clammy skin
B. Decreased heart rate and warm, dry skin
C. Respiratory rate decrease and hypotension
D. Increased urine output and hypertension
Correct Answer: A
Expert Explanation: In the compensatory stage, the body activates the sympathetic
nervous system to maintain cardiac output. This results in tachycardia and
peripheral vasoconstriction, leading to cool and clammy skin. Blood is shunted away
from non-essential organs like the skin and GI tract to prioritize the heart and brain.
Urine output typically decreases as the kidneys attempt to conserve water. These
, compensatory mechanisms are temporary and will fail if the underlying cause is not
treated.
5. A patient receiving a blood transfusion develops hives, itching, and wheezing. What
is the nurse’s immediate priority?
A. Slow the infusion rate and call the doctor
B. Stop the transfusion and disconnect the tubing
C. Administer diphenhydramine and continue monitoring
D. Check the patient’s temperature and vital signs
Correct Answer: B
Expert Explanation: Any sign of an adverse reaction during a blood transfusion
requires the immediate cessation of the infusion. Disconnecting the tubing ensures
that no further blood or allergen enters the patient’s circulation. Simply slowing the
rate is insufficient and dangerous if a severe allergic reaction is occurring. After
stopping the blood, the nurse should maintain the IV line with normal saline using
new tubing. These actions prioritize patient safety and minimize the severity of the
reaction.
6. Which type of shock is characterized by bradycardia rather than tachycardia?
A. Hypovolemic shock
B. Cardiogenic shock
