NUR 265 Exam 1: Advanced MedSurg - Galen College of
Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A patient in septic shock has a blood pressure of 82/46 mmHg after receiving a 3-liter fluid bolus. Which
medication should the nurse anticipate administering next?
A. Dopamine
B. Atropine
C. Furosemide
D. Norepinephrine
Correct Answer: D
Rationale: Norepinephrine is the first-line vasopressor used for septic shock when fluid resuscitation
fails to restore blood pressure. It works by increasing systemic vascular resistance through
vasoconstriction. The nurse must monitor the patient’s mean arterial pressure to ensure adequate organ
perfusion. Fluid resuscitation should always precede the use of vasopressors in distributive shock. This
intervention is critical to prevent the progression of multiple organ dysfunction syndrome.
2. A client with full-thickness burns over 40% of the body is in the emergent phase. What is the priority
nursing diagnosis?
A. Impaired Physical Mobility
B. Risk for Infection
C. Deficient Fluid Volume
D. Acute Pain
Correct Answer: C
,Rationale: During the emergent phase of a burn injury, massive fluid shifts occur from the intravascular
to the interstitial space. This results in hypovolemia and potential burn shock which can be fatal. The
nurse must prioritize fluid resuscitation to maintain cardiac output and renal function. Although infection
and pain are significant concerns, they are not the immediate threat to life. Addressing the fluid volume
deficit is the most critical intervention in the first 24 to 48 hours.
3. The nurse is caring for a patient on a mechanical ventilator who is fighting the machine. Which ventilator
alarm should the nurse expect to hear?
A. Low pressure alarm
B. Low exhaled volume alarm
C. High pressure alarm
D. Apnea alarm
Correct Answer: C
Rationale: High pressure alarms are triggered when the ventilator meets resistance while trying to
deliver a breath. Common causes include the patient biting the tube, coughing, or experiencing
bronchospasm. The nurse should assess the patient’s respiratory status and check for tube obstructions
immediately. If the patient is ‘fighting’ the vent, it indicates asynchronous breathing with the machine’s
settings. Suctioning may be required to clear secretions and reduce the airway pressure.
4. A patient with a spinal cord injury at T6 suddenly develops a headache and a blood pressure of 200/110
mmHg. What is the nurse’s first action?
A. Administer an antihypertensive medication
B. Lower the head of the bed to a flat position
C. Check for a full bladder or fecal impaction
, D. Call a Code Blue immediately
Correct Answer: C
Rationale: Autonomic dysreflexia is a life-threatening condition occurring in patients with spinal cord
injuries above T6. It is often triggered by noxious stimuli such as a distended bladder or bowel. The nurse
must first identify and remove the cause to stop the sympathetic surge. Raising the head of the bed to 45
degrees or higher is also a priority to help lower blood pressure. Failing to treat this promptly can lead to
seizures, stroke, or myocardial infarction.
5. The nurse observes the following ABG results: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the
nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Rationale: The pH of 7.30 indicates acidosis because it is below the normal range of 7.35 to 7.45. The
PaCO2 of 52 mmHg is elevated, which signifies a respiratory cause for the acidity. Since the bicarbonate
level is normal, there is currently no compensation taking place. This condition is often seen in patients
with hypoventilation or chronic obstructive pulmonary disease. The nurse should focus on improving the
patient’s ventilation to blow off excess carbon dioxide.
6. During the resuscitation phase of a burn injury, which laboratory finding should the nurse expect?
A. Hypernatremia
B. Hyperkalemia
Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A patient in septic shock has a blood pressure of 82/46 mmHg after receiving a 3-liter fluid bolus. Which
medication should the nurse anticipate administering next?
A. Dopamine
B. Atropine
C. Furosemide
D. Norepinephrine
Correct Answer: D
Rationale: Norepinephrine is the first-line vasopressor used for septic shock when fluid resuscitation
fails to restore blood pressure. It works by increasing systemic vascular resistance through
vasoconstriction. The nurse must monitor the patient’s mean arterial pressure to ensure adequate organ
perfusion. Fluid resuscitation should always precede the use of vasopressors in distributive shock. This
intervention is critical to prevent the progression of multiple organ dysfunction syndrome.
2. A client with full-thickness burns over 40% of the body is in the emergent phase. What is the priority
nursing diagnosis?
A. Impaired Physical Mobility
B. Risk for Infection
C. Deficient Fluid Volume
D. Acute Pain
Correct Answer: C
,Rationale: During the emergent phase of a burn injury, massive fluid shifts occur from the intravascular
to the interstitial space. This results in hypovolemia and potential burn shock which can be fatal. The
nurse must prioritize fluid resuscitation to maintain cardiac output and renal function. Although infection
and pain are significant concerns, they are not the immediate threat to life. Addressing the fluid volume
deficit is the most critical intervention in the first 24 to 48 hours.
3. The nurse is caring for a patient on a mechanical ventilator who is fighting the machine. Which ventilator
alarm should the nurse expect to hear?
A. Low pressure alarm
B. Low exhaled volume alarm
C. High pressure alarm
D. Apnea alarm
Correct Answer: C
Rationale: High pressure alarms are triggered when the ventilator meets resistance while trying to
deliver a breath. Common causes include the patient biting the tube, coughing, or experiencing
bronchospasm. The nurse should assess the patient’s respiratory status and check for tube obstructions
immediately. If the patient is ‘fighting’ the vent, it indicates asynchronous breathing with the machine’s
settings. Suctioning may be required to clear secretions and reduce the airway pressure.
4. A patient with a spinal cord injury at T6 suddenly develops a headache and a blood pressure of 200/110
mmHg. What is the nurse’s first action?
A. Administer an antihypertensive medication
B. Lower the head of the bed to a flat position
C. Check for a full bladder or fecal impaction
, D. Call a Code Blue immediately
Correct Answer: C
Rationale: Autonomic dysreflexia is a life-threatening condition occurring in patients with spinal cord
injuries above T6. It is often triggered by noxious stimuli such as a distended bladder or bowel. The nurse
must first identify and remove the cause to stop the sympathetic surge. Raising the head of the bed to 45
degrees or higher is also a priority to help lower blood pressure. Failing to treat this promptly can lead to
seizures, stroke, or myocardial infarction.
5. The nurse observes the following ABG results: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the
nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Rationale: The pH of 7.30 indicates acidosis because it is below the normal range of 7.35 to 7.45. The
PaCO2 of 52 mmHg is elevated, which signifies a respiratory cause for the acidity. Since the bicarbonate
level is normal, there is currently no compensation taking place. This condition is often seen in patients
with hypoventilation or chronic obstructive pulmonary disease. The nurse should focus on improving the
patient’s ventilation to blow off excess carbon dioxide.
6. During the resuscitation phase of a burn injury, which laboratory finding should the nurse expect?
A. Hypernatremia
B. Hyperkalemia
