NUR 265 – EXAM 4 | Questions and
Answers | 2026 Update | 100% Correct –
Galen.
1. A patient in septic shock has a serum lactate of 4.8 mmol/L and a MAP of
58 mmHg despite a 30 mL/kg fluid bolus. Norepinephrine is started.
According to the Surviving Sepsis Campaign guidelines, what is the nurse's
priority action?
• A. Add vasopressin as a second-line vasopressor.
• B. Obtain blood cultures if they have not been drawn.
• C. Start intravenous hydrocortisone.
• D. Assess for and eliminate the source of infection.
Correct ,,,,answer,,,,: D
Rationale: While fluid resuscitation, antibiotics, and vasopressors are critical in
sepsis management, the guidelines emphasize that source control—identifying and
eliminating the infection source (e.g., removing an infected line, draining an
abscess)—is a cornerstone of care and should be a priority. Vasopressin is typically
added as a second-line agent, and steroids are considered only in refractory shock.
2. A patient with Acute Kidney Injury (AKI) has a urine output of 0.3
mL/kg/hr for 18 hours, a rising BUN and creatinine, and hyperkalemia. The
nurse recognizes this as which phase of AKI?
• A. Diuretic phase
• B. Oliguric phase
• C. Recovery phase
• D. Initiation phase
,Correct ,,,,answer,,,,: B
Rationale: The oliguric phase of AKI is defined by a urine output of less than 0.5
mL/kg/hr for 6 to 12 hours. This phase is characterized by fluid overload, a rising
BUN and creatinine, and electrolyte imbalances, including hyperkalemia and
hyperphosphatemia.
3. A patient with increased intracranial pressure (ICP) has an ICP of 28
mmHg and a Cerebral Perfusion Pressure (CPP) of 52 mmHg. Which
intervention should the nurse implement first?
• A. Administer mannitol 0.5–1 g/kg IV.
• B. Elevate the head of the bed (HOB) to 30–45 degrees and maintain neutral
head alignment.
• C. Hyperventilate the patient to a PaCO₂ of 25 mmHg.
• D. Initiate a propofol infusion for sedation.
Correct ,,,,answer,,,,: B
Rationale: First-line, non-pharmacologic measures to reduce ICP include
elevating the HOB to 30-45 degrees and maintaining the head in a neutral, midline
position to promote venous drainage. Osmotic diuretics and brief hyperventilation
are used for acute herniation emergencies.
4. The nurse is caring for a patient with a suspected anaphylactic reaction.
Which of the following findings should the nurse anticipate first?
• A. Hypotension and tachycardia
• B. Wheezing and stridor
• C. Urticaria and angioedema
• D. Anxiety and a feeling of impending doom
Correct ,,,,answer,,,,: C
Rationale: While all are signs of anaphylaxis, the initial findings are often
cutaneous, such as urticaria (hives), flushing, and angioedema (swelling of lips,
, tongue, or face). Respiratory and cardiovascular symptoms can develop rapidly
after.
5. A nurse is caring for a client who had a lung transplant 10 days ago. It
would be a priority for the nurse to notify the healthcare provider if the client
has which finding?
• A. Reports of incisional pain.
• B. A temperature of 99.2°F (37.3°C).
• C. Developed sputum that is yellow-tinged.
• D. A heart rate of 88 beats per minute.
Correct ,,,,answer,,,,: C
Rationale: A lung transplant patient is highly susceptible to infection and
rejection. The development of yellow-tinged sputum is a key sign of a potential
infection, which is a priority to report.
Section 2: Renal and Endocrine Disorders (16-30)
6. A patient with Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
would most likely exhibit which set of findings?
• A. Serum Na 148 mEq/L, dilute urine, high serum osmolality
• B. Serum Na 118 mEq/L, concentrated urine, low serum osmolality
• C. Serum Na 165 mEq/L, polyuria, low urine osmolality
• D. Serum Na 135 mEq/L, normal urine, normal osmolality
Correct ,,,,answer,,,,: B
Rationale: SIADH is characterized by excessive ADH, leading to water retention,
dilutional hyponatremia (low serum sodium), and concentrated urine. The serum
osmolality will be low, while urine osmolality will be high.
Answers | 2026 Update | 100% Correct –
Galen.
1. A patient in septic shock has a serum lactate of 4.8 mmol/L and a MAP of
58 mmHg despite a 30 mL/kg fluid bolus. Norepinephrine is started.
According to the Surviving Sepsis Campaign guidelines, what is the nurse's
priority action?
• A. Add vasopressin as a second-line vasopressor.
• B. Obtain blood cultures if they have not been drawn.
• C. Start intravenous hydrocortisone.
• D. Assess for and eliminate the source of infection.
Correct ,,,,answer,,,,: D
Rationale: While fluid resuscitation, antibiotics, and vasopressors are critical in
sepsis management, the guidelines emphasize that source control—identifying and
eliminating the infection source (e.g., removing an infected line, draining an
abscess)—is a cornerstone of care and should be a priority. Vasopressin is typically
added as a second-line agent, and steroids are considered only in refractory shock.
2. A patient with Acute Kidney Injury (AKI) has a urine output of 0.3
mL/kg/hr for 18 hours, a rising BUN and creatinine, and hyperkalemia. The
nurse recognizes this as which phase of AKI?
• A. Diuretic phase
• B. Oliguric phase
• C. Recovery phase
• D. Initiation phase
,Correct ,,,,answer,,,,: B
Rationale: The oliguric phase of AKI is defined by a urine output of less than 0.5
mL/kg/hr for 6 to 12 hours. This phase is characterized by fluid overload, a rising
BUN and creatinine, and electrolyte imbalances, including hyperkalemia and
hyperphosphatemia.
3. A patient with increased intracranial pressure (ICP) has an ICP of 28
mmHg and a Cerebral Perfusion Pressure (CPP) of 52 mmHg. Which
intervention should the nurse implement first?
• A. Administer mannitol 0.5–1 g/kg IV.
• B. Elevate the head of the bed (HOB) to 30–45 degrees and maintain neutral
head alignment.
• C. Hyperventilate the patient to a PaCO₂ of 25 mmHg.
• D. Initiate a propofol infusion for sedation.
Correct ,,,,answer,,,,: B
Rationale: First-line, non-pharmacologic measures to reduce ICP include
elevating the HOB to 30-45 degrees and maintaining the head in a neutral, midline
position to promote venous drainage. Osmotic diuretics and brief hyperventilation
are used for acute herniation emergencies.
4. The nurse is caring for a patient with a suspected anaphylactic reaction.
Which of the following findings should the nurse anticipate first?
• A. Hypotension and tachycardia
• B. Wheezing and stridor
• C. Urticaria and angioedema
• D. Anxiety and a feeling of impending doom
Correct ,,,,answer,,,,: C
Rationale: While all are signs of anaphylaxis, the initial findings are often
cutaneous, such as urticaria (hives), flushing, and angioedema (swelling of lips,
, tongue, or face). Respiratory and cardiovascular symptoms can develop rapidly
after.
5. A nurse is caring for a client who had a lung transplant 10 days ago. It
would be a priority for the nurse to notify the healthcare provider if the client
has which finding?
• A. Reports of incisional pain.
• B. A temperature of 99.2°F (37.3°C).
• C. Developed sputum that is yellow-tinged.
• D. A heart rate of 88 beats per minute.
Correct ,,,,answer,,,,: C
Rationale: A lung transplant patient is highly susceptible to infection and
rejection. The development of yellow-tinged sputum is a key sign of a potential
infection, which is a priority to report.
Section 2: Renal and Endocrine Disorders (16-30)
6. A patient with Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
would most likely exhibit which set of findings?
• A. Serum Na 148 mEq/L, dilute urine, high serum osmolality
• B. Serum Na 118 mEq/L, concentrated urine, low serum osmolality
• C. Serum Na 165 mEq/L, polyuria, low urine osmolality
• D. Serum Na 135 mEq/L, normal urine, normal osmolality
Correct ,,,,answer,,,,: B
Rationale: SIADH is characterized by excessive ADH, leading to water retention,
dilutional hyponatremia (low serum sodium), and concentrated urine. The serum
osmolality will be low, while urine osmolality will be high.
