NUR 209/NUR209 Exam 4 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient with ARDS is being treated with mechanical ventilation using high PEEP. Which
assessment finding should the nurse prioritize as a potential complication?
A. Increased cardiac output
B. Respiratory alkalosis on ABG
C. Subcutaneous emphysema and decreased breath sounds
D. Decrease in peak inspiratory pressure
Correct Answer: C
Expert Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase the
risk of barotrauma, which can lead to a pneumothorax. Subcutaneous emphysema and
decreased breath sounds are classic indicators of air escaping into the pleural space or
tissues. The nurse must monitor these signs closely to ensure patient safety and immediate
intervention if a tension pneumothorax develops.
2. The nurse is interpreting an ABG for a patient with COPD: pH 7.32, PaCO2 58 mmHg, HCO3
30 mEq/L. How should the nurse classify this result?
A. Uncompensated respiratory acidosis
B. Fully compensated metabolic alkalosis
,C. Partially compensated respiratory acidosis
D. Normal ABG for a COPD patient
Correct Answer: C
Expert Explanation: The pH is below normal (7.35-7.45), indicating acidosis, while the
PaCO2 is elevated, indicating a respiratory cause. The HCO3 is also elevated above normal
(22-26 mEq/L), suggesting the kidneys are attempting to compensate by retaining base.
Because the pH has not yet returned to the normal range, the condition is considered
partially compensated.
3. A patient is admitted with a high-level spinal cord injury (C4). Which of the following is the
priority nursing diagnosis?
A. Impaired physical mobility
B. Urinary retention
C. Risk for autonomic dysreflexia
D. Ineffective breathing pattern
Correct Answer: D
Expert Explanation: Injuries at or above the C4 level affect the phrenic nerve, which
controls the diaphragm and primary respiratory function. Maintaining a patent airway and
adequate ventilation is the highest priority following the ABC (Airway, Breathing,
Circulation) framework. While the other diagnoses are relevant to spinal cord injury, they
do not pose an immediate threat to life like respiratory failure does.
,4. A patient in the ICU develops a ‘High Pressure’ alarm on the mechanical ventilator. What is
the first action the nurse should take?
A. Check for a leak in the ventilator circuit
B. Increase the oxygen concentration (FiO2)
C. Turn off the alarm to prevent patient anxiety
D. Assess the patient’s need for suctioning
Correct Answer: D
Expert Explanation: A high-pressure alarm indicates that the ventilator is meeting
resistance when trying to deliver a breath, often caused by secretions, biting the tube, or
kinks. Assessing the patient for the need to suction or identifying obstructions is the
standard first response. If the cause is not immediately found or the patient is in distress,
the nurse should manually ventilate with a bag-valve-mask.
5. Which clinical manifestation is indicative of the ‘cold phase’ (hypodynamic) of septic
shock?
A. Flushed, warm skin
B. Increased cardiac output
C. Mottled, cool extremities and oliguria
D. Bounding peripheral pulses
Correct Answer: C
, Expert Explanation: The cold phase of septic shock occurs as the body’s compensatory
mechanisms fail and cardiac output drops significantly. Clinical signs include cool, pale, or
mottled skin, weak pulses, and decreased urine output due to poor renal perfusion. This
late stage indicates a worsening prognosis and the need for aggressive hemodynamic
support.
6. A burn patient is in the emergent phase of injury. Using the Parkland formula (4mL x kg x
%TBSA), calculate the total fluid for a 70kg patient with 40% burns.
A. 5,600 mL
B. 22,400 mL
C. 2,800 mL
D. 11,200 mL
Correct Answer: D
Expert Explanation: The Parkland formula is calculated as 4 mL multiplied by the
patient’s weight in kilograms and the percentage of total body surface area burned (4 x 70
x 40 = 11,200). Half of this total volume is administered in the first 8 hours post-injury, and
the remaining half over the next 16 hours. Accurate calculation and administration are vital
to prevent hypovolemic shock in the emergent phase.
7. A patient is displaying V-fib on the monitor. What is the immediate priority intervention?
A. Administer an IV bolus of Amiodarone
B. Initiate CPR and prepare for defibrillation
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient with ARDS is being treated with mechanical ventilation using high PEEP. Which
assessment finding should the nurse prioritize as a potential complication?
A. Increased cardiac output
B. Respiratory alkalosis on ABG
C. Subcutaneous emphysema and decreased breath sounds
D. Decrease in peak inspiratory pressure
Correct Answer: C
Expert Explanation: High levels of Positive End-Expiratory Pressure (PEEP) increase the
risk of barotrauma, which can lead to a pneumothorax. Subcutaneous emphysema and
decreased breath sounds are classic indicators of air escaping into the pleural space or
tissues. The nurse must monitor these signs closely to ensure patient safety and immediate
intervention if a tension pneumothorax develops.
2. The nurse is interpreting an ABG for a patient with COPD: pH 7.32, PaCO2 58 mmHg, HCO3
30 mEq/L. How should the nurse classify this result?
A. Uncompensated respiratory acidosis
B. Fully compensated metabolic alkalosis
,C. Partially compensated respiratory acidosis
D. Normal ABG for a COPD patient
Correct Answer: C
Expert Explanation: The pH is below normal (7.35-7.45), indicating acidosis, while the
PaCO2 is elevated, indicating a respiratory cause. The HCO3 is also elevated above normal
(22-26 mEq/L), suggesting the kidneys are attempting to compensate by retaining base.
Because the pH has not yet returned to the normal range, the condition is considered
partially compensated.
3. A patient is admitted with a high-level spinal cord injury (C4). Which of the following is the
priority nursing diagnosis?
A. Impaired physical mobility
B. Urinary retention
C. Risk for autonomic dysreflexia
D. Ineffective breathing pattern
Correct Answer: D
Expert Explanation: Injuries at or above the C4 level affect the phrenic nerve, which
controls the diaphragm and primary respiratory function. Maintaining a patent airway and
adequate ventilation is the highest priority following the ABC (Airway, Breathing,
Circulation) framework. While the other diagnoses are relevant to spinal cord injury, they
do not pose an immediate threat to life like respiratory failure does.
,4. A patient in the ICU develops a ‘High Pressure’ alarm on the mechanical ventilator. What is
the first action the nurse should take?
A. Check for a leak in the ventilator circuit
B. Increase the oxygen concentration (FiO2)
C. Turn off the alarm to prevent patient anxiety
D. Assess the patient’s need for suctioning
Correct Answer: D
Expert Explanation: A high-pressure alarm indicates that the ventilator is meeting
resistance when trying to deliver a breath, often caused by secretions, biting the tube, or
kinks. Assessing the patient for the need to suction or identifying obstructions is the
standard first response. If the cause is not immediately found or the patient is in distress,
the nurse should manually ventilate with a bag-valve-mask.
5. Which clinical manifestation is indicative of the ‘cold phase’ (hypodynamic) of septic
shock?
A. Flushed, warm skin
B. Increased cardiac output
C. Mottled, cool extremities and oliguria
D. Bounding peripheral pulses
Correct Answer: C
, Expert Explanation: The cold phase of septic shock occurs as the body’s compensatory
mechanisms fail and cardiac output drops significantly. Clinical signs include cool, pale, or
mottled skin, weak pulses, and decreased urine output due to poor renal perfusion. This
late stage indicates a worsening prognosis and the need for aggressive hemodynamic
support.
6. A burn patient is in the emergent phase of injury. Using the Parkland formula (4mL x kg x
%TBSA), calculate the total fluid for a 70kg patient with 40% burns.
A. 5,600 mL
B. 22,400 mL
C. 2,800 mL
D. 11,200 mL
Correct Answer: D
Expert Explanation: The Parkland formula is calculated as 4 mL multiplied by the
patient’s weight in kilograms and the percentage of total body surface area burned (4 x 70
x 40 = 11,200). Half of this total volume is administered in the first 8 hours post-injury, and
the remaining half over the next 16 hours. Accurate calculation and administration are vital
to prevent hypovolemic shock in the emergent phase.
7. A patient is displaying V-fib on the monitor. What is the immediate priority intervention?
A. Administer an IV bolus of Amiodarone
B. Initiate CPR and prepare for defibrillation
