NU 185 Exam 4: Med-Surg II - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient who has been diagnosed with systemic inflammatory response syndrome
(SIRS). Which of the following clinical findings would the nurse expect to observe?
A. Temperature of 37.0°C (98.6°F) and heart rate of 70 bpm
B. Temperature of 38.5°C (101.3°F) and respiratory rate of 24 breaths/min
C. White blood cell count of 8,000/mm³ and PaCO2 of 45 mmHg
D. Blood pressure of 140/90 mmHg and heart rate of 60 bpm
Correct Answer: B
Rationale: SIRS criteria include a temperature greater than 38°C or less than 36°C. It also includes a
heart rate over 90 beats per minute and a respiratory rate over 20 breaths per minute. This specific
patient meets the temperature and respiratory rate criteria for a SIRS diagnosis. Early identification is
crucial to prevent the progression to sepsis or multiple organ dysfunction syndrome. Nurses must
monitor these vital signs closely in critically ill adults to ensure timely intervention.
2. A patient in the ICU is suspected of developing Multiple Organ Dysfunction Syndrome (MODS). Which
organ system is usually the first to show signs of dysfunction in this condition?
A. Respiratory system
B. Hepatic system
C. Renal system
D. Cardiovascular system
Correct Answer: A
,Rationale: In MODS, the respiratory system is typically the first to demonstrate clinical signs of failure.
Patients often progress to Acute Respiratory Distress Syndrome (ARDS) due to inflammatory damage to
the alveolar-capillary membrane. This early failure requires aggressive ventilation and oxygenation
strategies to stabilize the patient. Monitoring for hypoxemia and increased work of breathing is a priority
assessment for the nurse. Understanding the sequence of organ failure helps in prioritizing collaborative
care interventions.
3. A patient with full-thickness burns over 40% of their body is in the emergent phase. What is the primary
nursing priority during this initial 24- to 48-hour period?
A. Managing severe pain with high-dose opioids
B. Providing high-calorie nutritional support
C. Preventing infection of the burn wounds
D. Maintaining a patent airway and fluid resuscitation
Correct Answer: D
Rationale: The emergent phase of burn care focuses primarily on stabilizing the patient’s airway and
circulation. Fluid shifts during this phase can lead to hypovolemic shock, making aggressive fluid
resuscitation essential. Airway management is critical if inhalation injury is suspected due to potential
edema. While pain management and infection control are important, they are secondary to life-saving
stabilization. Collaborative care involves monitoring urine output to evaluate the effectiveness of the fluid
volume replaced.
4. A patient is admitted with a diagnosis of Septic Shock. The nurse notes a Mean Arterial Pressure (MAP) of
55 mmHg despite fluid resuscitation. Which medication should the nurse expect to administer next?
A. Nitroglycerin
B. Furosemide
,C. Norepinephrine
D. Atropine
Correct Answer: C
Rationale: Norepinephrine is the first-line vasopressor used in septic shock when fluid resuscitation fails
to maintain adequate perfusion. A MAP of at least 65 mmHg is generally required to ensure sufficient
organ perfusion. This medication works by increasing systemic vascular resistance through alpha-
adrenergic stimulation. The nurse must monitor the infusion site closely for extravasation and assess
peripheral pulses. Maintaining hemodynamic stability is a key component of multisystem disorder
management.
5. Which lab result is most indicative of Disseminated Intravascular Coagulation (DIC) in a critically ill
patient?
A. Elevated D-dimer levels
B. Increased platelet count
C. Decreased Prothrombin Time (PT)
D. Decreased Fibrin Degradation Products (FDPs)
Correct Answer: A
Rationale: An elevated D-dimer level is a hallmark indicator of the fibrinolysis that occurs during DIC.
This condition involves both excessive clotting and subsequent bleeding as clotting factors are depleted.
Laboratory findings typically show prolonged PT/PTT and decreased platelet counts. DIC is often a
secondary complication of severe conditions like sepsis or trauma. Management focuses on treating the
underlying cause while replacing depleted blood components as needed.
, 6. The nurse is caring for a patient with HIV whose CD4+ T-cell count has dropped below 200 cells/mm³. This
finding indicates that the patient has reached which stage of the infection?
A. Acute infection stage
B. Clinical latency stage
C. Window period
D. AIDS (Stage 3)
Correct Answer: D
Rationale: A CD4+ T-cell count of less than 200 cells/mm³ is the diagnostic threshold for AIDS. At this
stage, the immune system is severely compromised, making the patient highly susceptible to
opportunistic infections. The nurse must implement strict infection control measures and monitor for
signs of secondary illness. Antiretroviral therapy is essential to prevent further immune decline and
improve survival rates. This stage represents the most advanced phase of the HIV infection spectrum.
7. A patient is experiencing an anaphylactic reaction after an IV antibiotic infusion. What is the nurse’s first
action?
A. Administer diphenhydramine intramuscularly
B. Apply oxygen via non-rebreather mask
C. Stop the antibiotic infusion immediately
D. Elevate the patient’s legs to treat hypotension
Correct Answer: C
Rationale: The first priority when an adverse reaction is suspected is to remove the offending agent.
Stopping the infusion prevents further allergen exposure and limits the severity of the response.
Following this, the nurse should assess the airway and prepare to administer epinephrine. Collaborative
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient who has been diagnosed with systemic inflammatory response syndrome
(SIRS). Which of the following clinical findings would the nurse expect to observe?
A. Temperature of 37.0°C (98.6°F) and heart rate of 70 bpm
B. Temperature of 38.5°C (101.3°F) and respiratory rate of 24 breaths/min
C. White blood cell count of 8,000/mm³ and PaCO2 of 45 mmHg
D. Blood pressure of 140/90 mmHg and heart rate of 60 bpm
Correct Answer: B
Rationale: SIRS criteria include a temperature greater than 38°C or less than 36°C. It also includes a
heart rate over 90 beats per minute and a respiratory rate over 20 breaths per minute. This specific
patient meets the temperature and respiratory rate criteria for a SIRS diagnosis. Early identification is
crucial to prevent the progression to sepsis or multiple organ dysfunction syndrome. Nurses must
monitor these vital signs closely in critically ill adults to ensure timely intervention.
2. A patient in the ICU is suspected of developing Multiple Organ Dysfunction Syndrome (MODS). Which
organ system is usually the first to show signs of dysfunction in this condition?
A. Respiratory system
B. Hepatic system
C. Renal system
D. Cardiovascular system
Correct Answer: A
,Rationale: In MODS, the respiratory system is typically the first to demonstrate clinical signs of failure.
Patients often progress to Acute Respiratory Distress Syndrome (ARDS) due to inflammatory damage to
the alveolar-capillary membrane. This early failure requires aggressive ventilation and oxygenation
strategies to stabilize the patient. Monitoring for hypoxemia and increased work of breathing is a priority
assessment for the nurse. Understanding the sequence of organ failure helps in prioritizing collaborative
care interventions.
3. A patient with full-thickness burns over 40% of their body is in the emergent phase. What is the primary
nursing priority during this initial 24- to 48-hour period?
A. Managing severe pain with high-dose opioids
B. Providing high-calorie nutritional support
C. Preventing infection of the burn wounds
D. Maintaining a patent airway and fluid resuscitation
Correct Answer: D
Rationale: The emergent phase of burn care focuses primarily on stabilizing the patient’s airway and
circulation. Fluid shifts during this phase can lead to hypovolemic shock, making aggressive fluid
resuscitation essential. Airway management is critical if inhalation injury is suspected due to potential
edema. While pain management and infection control are important, they are secondary to life-saving
stabilization. Collaborative care involves monitoring urine output to evaluate the effectiveness of the fluid
volume replaced.
4. A patient is admitted with a diagnosis of Septic Shock. The nurse notes a Mean Arterial Pressure (MAP) of
55 mmHg despite fluid resuscitation. Which medication should the nurse expect to administer next?
A. Nitroglycerin
B. Furosemide
,C. Norepinephrine
D. Atropine
Correct Answer: C
Rationale: Norepinephrine is the first-line vasopressor used in septic shock when fluid resuscitation fails
to maintain adequate perfusion. A MAP of at least 65 mmHg is generally required to ensure sufficient
organ perfusion. This medication works by increasing systemic vascular resistance through alpha-
adrenergic stimulation. The nurse must monitor the infusion site closely for extravasation and assess
peripheral pulses. Maintaining hemodynamic stability is a key component of multisystem disorder
management.
5. Which lab result is most indicative of Disseminated Intravascular Coagulation (DIC) in a critically ill
patient?
A. Elevated D-dimer levels
B. Increased platelet count
C. Decreased Prothrombin Time (PT)
D. Decreased Fibrin Degradation Products (FDPs)
Correct Answer: A
Rationale: An elevated D-dimer level is a hallmark indicator of the fibrinolysis that occurs during DIC.
This condition involves both excessive clotting and subsequent bleeding as clotting factors are depleted.
Laboratory findings typically show prolonged PT/PTT and decreased platelet counts. DIC is often a
secondary complication of severe conditions like sepsis or trauma. Management focuses on treating the
underlying cause while replacing depleted blood components as needed.
, 6. The nurse is caring for a patient with HIV whose CD4+ T-cell count has dropped below 200 cells/mm³. This
finding indicates that the patient has reached which stage of the infection?
A. Acute infection stage
B. Clinical latency stage
C. Window period
D. AIDS (Stage 3)
Correct Answer: D
Rationale: A CD4+ T-cell count of less than 200 cells/mm³ is the diagnostic threshold for AIDS. At this
stage, the immune system is severely compromised, making the patient highly susceptible to
opportunistic infections. The nurse must implement strict infection control measures and monitor for
signs of secondary illness. Antiretroviral therapy is essential to prevent further immune decline and
improve survival rates. This stage represents the most advanced phase of the HIV infection spectrum.
7. A patient is experiencing an anaphylactic reaction after an IV antibiotic infusion. What is the nurse’s first
action?
A. Administer diphenhydramine intramuscularly
B. Apply oxygen via non-rebreather mask
C. Stop the antibiotic infusion immediately
D. Elevate the patient’s legs to treat hypotension
Correct Answer: C
Rationale: The first priority when an adverse reaction is suspected is to remove the offending agent.
Stopping the infusion prevents further allergen exposure and limits the severity of the response.
Following this, the nurse should assess the airway and prepare to administer epinephrine. Collaborative
