NUR242 Exam 4 V3 | NUR 242 Med-Surg Exam
Q&A | Galen College of Nursing
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This comprehensive exam-style preparation material is designed to support students preparing
for advanced medical-surgical nursing assessments involving critical care, complex
multisystem disorders, and specialized nursing interventions. The content focuses on
integrating nursing knowledge into high-level clinical decision-making scenarios.
The questions are structured to closely mirror actual course assessments while reinforcing
analytical reasoning, prioritization, and safe nursing interventions. Detailed expert explanations
are included to improve comprehension and academic performance.
════════════════════════════════════
The Exam Covers:
• Advanced adult assessment
• Disaster preparedness nursing
• Pharmacological management in critical care
• Specialized adult nursing procedures
• Leadership in nursing practice
• Cultural considerations in adult care
• Complex patient prioritization
• Comprehensive medical-surgical review
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1. During a mass casualty incident, a patient arrives with a sucking chest wound and
significant respiratory distress. Which triage category should the nurse assign to this patient?
A. Red (Immediate)
B. Yellow (Delayed)
C. Green (Minor)
,D. Black (Expectant)
Correct Answer: A
Expert Explanation: A sucking chest wound indicates a life-threatening compromise to the
respiratory system that requires immediate intervention to ensure survival. Red tags are
reserved for patients who have ABC (Airway, Breathing, Circulation) issues that are
treatable if addressed right away. This categorization is essential for maximizing the
number of lives saved during a disaster response.
2. A nurse is caring for a patient in the emergent phase of a major burn injury. Which
electrolyte imbalance is the most critical priority to monitor for during this phase?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypercalcemia
Correct Answer: B
Expert Explanation: In the emergent phase of a burn, massive cell destruction causes
intracellular potassium to leak into the extracellular fluid. Hyperkalemia can lead to
dangerous cardiac dysrhythmias and requires close monitoring and potential intervention.
This electrolyte shift occurs rapidly alongside fluid shifts that characterize the first 24 to 48
hours of burn management.
,3. A patient with a T6 spinal cord injury reports a sudden, throbbing headache and has a
blood pressure of 190/100 mmHg. What is the nurse’s first action?
A. Administer prescribed antihypertensive medication.
B. Check the patient’s bladder for distention.
C. Elevate the head of the bed to 45 degrees or higher.
D. Place the patient in a supine position.
Correct Answer: C
Expert Explanation: The patient is exhibiting classic signs of autonomic dysreflexia, which
is a medical emergency in spinal cord injury patients. The first priority is to sit the patient
up to help lower the blood pressure through orthostatic changes. After elevating the head
of the bed, the nurse should then identify and remove the triggering stimulus, such as a full
bladder or impacted bowel.
4. A patient is being treated for Septic Shock. Which clinical finding indicates that the patient
is responding positively to the initial fluid resuscitation?
A. Urine output of 0.2 mL/kg/hr.
B. A heart rate increase to 110 beats per minute.
C. A central venous pressure (CVP) of 2 mmHg.
D. A Mean Arterial Pressure (MAP) of 65 mmHg or higher.
Correct Answer: D
, Expert Explanation: The goal of fluid resuscitation in sepsis is to restore tissue perfusion,
and a MAP of at least 65 mmHg is the standard target for adequate organ perfusion.
Improving MAP suggests that the circulating volume is increasing and vascular resistance
is being supported. Other signs of success include improved mental status and urine output
of at least 0.5 mL/kg/hr.
5. While monitoring a patient on mechanical ventilation, the high-pressure alarm sounds.
Which action should the nurse take first?
A. Check the tubing for kinks or condensation.
B. Auscultate the patient’s breath sounds.
C. Disconnect the ventilator and manually bag the patient.
D. Increase the oxygen concentration to 100%.
Correct Answer: B
Expert Explanation: The nurse must first assess the patient to determine the cause of the
high-pressure alarm, such as secretions, bronchospasm, or pneumothorax. Auscultation
provides immediate clinical data on whether the patient’s airway is obstructed or if breath
sounds are absent. Only after assessing the patient and the circuit should the nurse proceed
to interventions like suctioning or manual ventilation if necessary.
6. Which of the following patients should the nurse triage as ‘Yellow’ (Delayed) during a
disaster?
A. A patient with a simple closed fracture of the radius.
Q&A | Galen College of Nursing
────────────────────────────────────
This comprehensive exam-style preparation material is designed to support students preparing
for advanced medical-surgical nursing assessments involving critical care, complex
multisystem disorders, and specialized nursing interventions. The content focuses on
integrating nursing knowledge into high-level clinical decision-making scenarios.
The questions are structured to closely mirror actual course assessments while reinforcing
analytical reasoning, prioritization, and safe nursing interventions. Detailed expert explanations
are included to improve comprehension and academic performance.
════════════════════════════════════
The Exam Covers:
• Advanced adult assessment
• Disaster preparedness nursing
• Pharmacological management in critical care
• Specialized adult nursing procedures
• Leadership in nursing practice
• Cultural considerations in adult care
• Complex patient prioritization
• Comprehensive medical-surgical review
════════════════════════════════════
1. During a mass casualty incident, a patient arrives with a sucking chest wound and
significant respiratory distress. Which triage category should the nurse assign to this patient?
A. Red (Immediate)
B. Yellow (Delayed)
C. Green (Minor)
,D. Black (Expectant)
Correct Answer: A
Expert Explanation: A sucking chest wound indicates a life-threatening compromise to the
respiratory system that requires immediate intervention to ensure survival. Red tags are
reserved for patients who have ABC (Airway, Breathing, Circulation) issues that are
treatable if addressed right away. This categorization is essential for maximizing the
number of lives saved during a disaster response.
2. A nurse is caring for a patient in the emergent phase of a major burn injury. Which
electrolyte imbalance is the most critical priority to monitor for during this phase?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypercalcemia
Correct Answer: B
Expert Explanation: In the emergent phase of a burn, massive cell destruction causes
intracellular potassium to leak into the extracellular fluid. Hyperkalemia can lead to
dangerous cardiac dysrhythmias and requires close monitoring and potential intervention.
This electrolyte shift occurs rapidly alongside fluid shifts that characterize the first 24 to 48
hours of burn management.
,3. A patient with a T6 spinal cord injury reports a sudden, throbbing headache and has a
blood pressure of 190/100 mmHg. What is the nurse’s first action?
A. Administer prescribed antihypertensive medication.
B. Check the patient’s bladder for distention.
C. Elevate the head of the bed to 45 degrees or higher.
D. Place the patient in a supine position.
Correct Answer: C
Expert Explanation: The patient is exhibiting classic signs of autonomic dysreflexia, which
is a medical emergency in spinal cord injury patients. The first priority is to sit the patient
up to help lower the blood pressure through orthostatic changes. After elevating the head
of the bed, the nurse should then identify and remove the triggering stimulus, such as a full
bladder or impacted bowel.
4. A patient is being treated for Septic Shock. Which clinical finding indicates that the patient
is responding positively to the initial fluid resuscitation?
A. Urine output of 0.2 mL/kg/hr.
B. A heart rate increase to 110 beats per minute.
C. A central venous pressure (CVP) of 2 mmHg.
D. A Mean Arterial Pressure (MAP) of 65 mmHg or higher.
Correct Answer: D
, Expert Explanation: The goal of fluid resuscitation in sepsis is to restore tissue perfusion,
and a MAP of at least 65 mmHg is the standard target for adequate organ perfusion.
Improving MAP suggests that the circulating volume is increasing and vascular resistance
is being supported. Other signs of success include improved mental status and urine output
of at least 0.5 mL/kg/hr.
5. While monitoring a patient on mechanical ventilation, the high-pressure alarm sounds.
Which action should the nurse take first?
A. Check the tubing for kinks or condensation.
B. Auscultate the patient’s breath sounds.
C. Disconnect the ventilator and manually bag the patient.
D. Increase the oxygen concentration to 100%.
Correct Answer: B
Expert Explanation: The nurse must first assess the patient to determine the cause of the
high-pressure alarm, such as secretions, bronchospasm, or pneumothorax. Auscultation
provides immediate clinical data on whether the patient’s airway is obstructed or if breath
sounds are absent. Only after assessing the patient and the circuit should the nurse proceed
to interventions like suctioning or manual ventilation if necessary.
6. Which of the following patients should the nurse triage as ‘Yellow’ (Delayed) during a
disaster?
A. A patient with a simple closed fracture of the radius.
