NUR 209/NUR209 Exam 4 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which of the following initial assessment findings is most characteristic of this condition?
A. Hypercapnia resulting in respiratory alkalosis.
B. Hypoxemia that does not respond to supplemental oxygen.
C. Increased pulmonary artery wedge pressure (PAWP).
D. Presence of a dry, non-productive cough.
Correct Answer: B
Expert Explanation: Refractory hypoxemia is the hallmark sign of ARDS, where the
patient’s oxygen saturation remains low despite increasing levels of FiO2. This occurs due
to the severe shunting caused by alveolar collapse and fluid accumulation. The nurse must
monitor for this clinical deterioration early in the course of the disease.
2. The nurse is caring for a patient on mechanical ventilation. The high-pressure alarm
sounds. Which action should the nurse take first?
A. Check for leaks in the ventilator circuit.
B. Manually ventilate the patient with an Ambu bag.
C. Increase the alarm limit threshold.
,D. Assess the patient’s need for suctioning.
Correct Answer: D
Expert Explanation: High-pressure alarms are triggered by increased resistance in the
system, often caused by secretions, biting the tube, or kinks. Suctioning the patient
removes obstructions that increase airway pressure and is a standard first intervention. If
the patient is in distress and the cause is not immediately found, manual ventilation would
then be appropriate.
3. A patient arrives at the emergency department with full-thickness burns to the chest and
abdomen. Using the Rule of Nines, what percentage of the body is affected?
A. 18%
B. 9%
C. 27%
D. 36%
Correct Answer: A
Expert Explanation: According to the Rule of Nines, the entire anterior trunk (chest and
abdomen) accounts for 18% of the total body surface area. The chest alone is 9%, and the
abdomen alone is 9%. Accurate calculation is essential for determining the fluid
resuscitation requirements in the emergent phase.
, 4. The nurse is monitoring a patient in the emergent phase of burn care. Which laboratory
result is most consistent with this phase?
A. Hypokalemia
B. Hyperkalemia
C. Decreased Hematocrit
D. Metabolic Alkalosis
Correct Answer: B
Expert Explanation: Hyperkalemia occurs during the emergent phase because potassium
is released from damaged cells into the extracellular fluid. Additionally, metabolic acidosis
is common due to tissue hypoperfusion and lactic acid buildup. The nurse should closely
monitor cardiac rhythm for changes related to high potassium levels.
5. A patient with a T4 spinal cord injury suddenly reports a severe headache and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer PRN antihypertensive medication.
B. Place the patient in a flat, supine position.
C. Palpate the bladder for distention.
D. Notify the healthcare provider immediately.
Correct Answer: C
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which of the following initial assessment findings is most characteristic of this condition?
A. Hypercapnia resulting in respiratory alkalosis.
B. Hypoxemia that does not respond to supplemental oxygen.
C. Increased pulmonary artery wedge pressure (PAWP).
D. Presence of a dry, non-productive cough.
Correct Answer: B
Expert Explanation: Refractory hypoxemia is the hallmark sign of ARDS, where the
patient’s oxygen saturation remains low despite increasing levels of FiO2. This occurs due
to the severe shunting caused by alveolar collapse and fluid accumulation. The nurse must
monitor for this clinical deterioration early in the course of the disease.
2. The nurse is caring for a patient on mechanical ventilation. The high-pressure alarm
sounds. Which action should the nurse take first?
A. Check for leaks in the ventilator circuit.
B. Manually ventilate the patient with an Ambu bag.
C. Increase the alarm limit threshold.
,D. Assess the patient’s need for suctioning.
Correct Answer: D
Expert Explanation: High-pressure alarms are triggered by increased resistance in the
system, often caused by secretions, biting the tube, or kinks. Suctioning the patient
removes obstructions that increase airway pressure and is a standard first intervention. If
the patient is in distress and the cause is not immediately found, manual ventilation would
then be appropriate.
3. A patient arrives at the emergency department with full-thickness burns to the chest and
abdomen. Using the Rule of Nines, what percentage of the body is affected?
A. 18%
B. 9%
C. 27%
D. 36%
Correct Answer: A
Expert Explanation: According to the Rule of Nines, the entire anterior trunk (chest and
abdomen) accounts for 18% of the total body surface area. The chest alone is 9%, and the
abdomen alone is 9%. Accurate calculation is essential for determining the fluid
resuscitation requirements in the emergent phase.
, 4. The nurse is monitoring a patient in the emergent phase of burn care. Which laboratory
result is most consistent with this phase?
A. Hypokalemia
B. Hyperkalemia
C. Decreased Hematocrit
D. Metabolic Alkalosis
Correct Answer: B
Expert Explanation: Hyperkalemia occurs during the emergent phase because potassium
is released from damaged cells into the extracellular fluid. Additionally, metabolic acidosis
is common due to tissue hypoperfusion and lactic acid buildup. The nurse should closely
monitor cardiac rhythm for changes related to high potassium levels.
5. A patient with a T4 spinal cord injury suddenly reports a severe headache and has a blood
pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer PRN antihypertensive medication.
B. Place the patient in a flat, supine position.
C. Palpate the bladder for distention.
D. Notify the healthcare provider immediately.
Correct Answer: C
