NURS 211L | NURS211L Exam 4: Med Surg 2 - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A patient is admitted with suspected sepsis. Which of the following is the priority action
within the first hour of care according to the Surviving Sepsis Campaign bundle?
A. Administer broad-spectrum antibiotics after blood cultures are obtained.
B. Insert an indwelling urinary catheter to monitor hourly output.
C. Administer a 500 mL bolus of normal saline over 4 hours.
D. Wait for the white blood cell count result before starting fluids.
Correct Answer: A
Rationale: Prompt administration of antibiotics is critical in reducing mortality rates
associated with sepsis. Blood cultures must be drawn before starting antibiotics to ensure
accurate identification of the pathogen. Fluids should be administered rapidly at 30 mL/kg
for hypotension or high lactate rather than at a slow rate. Delays in therapy significantly
increase the risk of progression to septic shock. Continuous monitoring of the patient’s
response to these initial interventions is a nursing priority.
2. A patient in the ICU is diagnosed with Acute Respiratory Distress Syndrome (ARDS). The
nurse understands that prone positioning is used primarily for what purpose?
A. To improve oxygenation by recruitment of posterior lung segments.
B. To decrease the patient’s work of breathing and prevent fatigue.
C. To facilitate easier suctioning of thick pulmonary secretions.
D. To prevent the development of hospital-acquired pneumonia.
Correct Answer: A
Rationale: Prone positioning shifts the weight of the heart and abdominal contents away
from the posterior lung fields. This allows previously collapsed alveoli in the dorsal regions
to reopen and participate in gas exchange. It is typically reserved for patients with severe
ARDS who remain hypoxemic despite high levels of oxygen and PEEP. The nurse must
monitor for complications such as pressure ulcers and endotracheal tube displacement
during the turn. Improved ventilation-perfusion matching is the primary physiological goal
of this intervention.
3. Which clinical manifestation would the nurse expect to find in a patient experiencing the
compensatory stage of shock?
A. Mean arterial pressure (MAP) less than 60 mmHg.
B. Tachycardia and narrowed pulse pressure.
,C. Cold, clammy skin and metabolic acidosis.
D. Anuria and lethargy.
Correct Answer: B
Rationale: During the compensatory stage, the body activates the sympathetic nervous
system to maintain cardiac output. Tachycardia occurs as the heart beats faster to
compensate for a decrease in stroke volume. The peripheral vasculature constricts, which
may lead to a narrowed pulse pressure even if the systolic blood pressure remains near
normal. If interventions are successful at this stage, the patient can often recover without
permanent organ damage. Metabolic acidosis and cold skin are more characteristic of the
progressive stage of shock.
4. A patient is suspected of developing Disseminated Intravascular Coagulation (DIC). Which
laboratory finding most strongly supports this diagnosis?
A. Decreased serum potassium and calcium.
B. Increased platelet count and decreased PT/PTT.
C. Elevated hemoglobin and hematocrit.
D. Elevated D-dimer levels and decreased fibrinogen.
Correct Answer: D
Rationale: DIC involves the paradoxical systemic activation of coagulation followed by a
depletion of clotting factors. Elevated D-dimer levels indicate that fibrinolysis is occurring
rapidly due to excessive clot formation. Fibrinogen is consumed during the clotting
process, leading to the low levels seen in DIC patients. Platelet counts typically drop
significantly as they are used up in microthrombi throughout the body. Monitoring these
trends is essential for the nurse to anticipate bleeding or ischemic complications.
5. The nurse is caring for a patient with cardiogenic shock following an acute myocardial
infarction. What is the primary goal of using an Intra-Aortic Balloon Pump (IABP)?
A. To increase the heart rate and systemic vascular resistance.
B. To provide permanent circulatory support for the failing heart.
C. To decrease myocardial oxygen demand and increase coronary perfusion.
D. To bypass the left ventricle and oxygenate the blood externally.
Correct Answer: C
Rationale: The IABP inflates during diastole to increase pressure in the aorta, which
pushes blood into the coronary arteries. It deflates just before systole, which creates a
vacuum effect that reduces afterload and myocardial work. This temporary mechanical
device helps stabilize patients while they await more definitive treatment like surgery or
PCI. It does not replace the heart’s function but rather assists the failing ventricle to
, recover. Careful monitoring of the insertion site for bleeding and limb ischemia is a vital
nursing responsibility.
6. A patient with a high-level spinal cord injury (T2) is at risk for neurogenic shock. Which
hemodynamic assessment finding is classic for this condition?
A. Hypotension and bradycardia.
B. Hypertension and tachycardia.
C. Hypotension and tachycardia.
D. Hyperthermia and vasoconstriction.
Correct Answer: A
Rationale: Neurogenic shock results from the loss of sympathetic tone, leading to massive
vasodilation and hypotension. Unlike other forms of shock, the heart cannot compensate
with tachycardia because the sympathetic pathways are disrupted. This results in the
hallmark combination of low blood pressure and a slow heart rate. Patients also lose the
ability to thermoregulate, often becoming poikilothermic and taking on the environment’s
temperature. Treatment involves cautious fluid resuscitation and vasopressors to restore
vascular tone.
7. A patient is admitted with multiple trauma and is at risk for Multiple Organ Dysfunction
Syndrome (MODS). Which organ system is usually the first to show signs of failure?
A. Respiratory system.
B. Renal system.
C. Hepatic system.
D. Gastrointestinal system.
Correct Answer: A
Rationale: The lungs are highly sensitive to systemic inflammation and are often the first
organ to fail in MODS. This usually manifests as Acute Respiratory Distress Syndrome
(ARDS) with severe hypoxemia and pulmonary infiltrates. Following lung failure, other
systems like the renal and hepatic systems may begin to decline. Early detection of
respiratory distress is critical to prevent the cascade of multi-organ failure. Management is
largely supportive and focuses on treating the underlying cause of the initial insult.
8. The nurse is managing a patient on a mechanical ventilator. The high-pressure alarm
sounds. Which of the following is the most likely cause?
A. A leak in the ventilator circuit.
B. Excessive secretions in the airway.
C. The patient has disconnected the tubing.
Updated and Latest Questions and Correct
Answers with Rationale
1. A patient is admitted with suspected sepsis. Which of the following is the priority action
within the first hour of care according to the Surviving Sepsis Campaign bundle?
A. Administer broad-spectrum antibiotics after blood cultures are obtained.
B. Insert an indwelling urinary catheter to monitor hourly output.
C. Administer a 500 mL bolus of normal saline over 4 hours.
D. Wait for the white blood cell count result before starting fluids.
Correct Answer: A
Rationale: Prompt administration of antibiotics is critical in reducing mortality rates
associated with sepsis. Blood cultures must be drawn before starting antibiotics to ensure
accurate identification of the pathogen. Fluids should be administered rapidly at 30 mL/kg
for hypotension or high lactate rather than at a slow rate. Delays in therapy significantly
increase the risk of progression to septic shock. Continuous monitoring of the patient’s
response to these initial interventions is a nursing priority.
2. A patient in the ICU is diagnosed with Acute Respiratory Distress Syndrome (ARDS). The
nurse understands that prone positioning is used primarily for what purpose?
A. To improve oxygenation by recruitment of posterior lung segments.
B. To decrease the patient’s work of breathing and prevent fatigue.
C. To facilitate easier suctioning of thick pulmonary secretions.
D. To prevent the development of hospital-acquired pneumonia.
Correct Answer: A
Rationale: Prone positioning shifts the weight of the heart and abdominal contents away
from the posterior lung fields. This allows previously collapsed alveoli in the dorsal regions
to reopen and participate in gas exchange. It is typically reserved for patients with severe
ARDS who remain hypoxemic despite high levels of oxygen and PEEP. The nurse must
monitor for complications such as pressure ulcers and endotracheal tube displacement
during the turn. Improved ventilation-perfusion matching is the primary physiological goal
of this intervention.
3. Which clinical manifestation would the nurse expect to find in a patient experiencing the
compensatory stage of shock?
A. Mean arterial pressure (MAP) less than 60 mmHg.
B. Tachycardia and narrowed pulse pressure.
,C. Cold, clammy skin and metabolic acidosis.
D. Anuria and lethargy.
Correct Answer: B
Rationale: During the compensatory stage, the body activates the sympathetic nervous
system to maintain cardiac output. Tachycardia occurs as the heart beats faster to
compensate for a decrease in stroke volume. The peripheral vasculature constricts, which
may lead to a narrowed pulse pressure even if the systolic blood pressure remains near
normal. If interventions are successful at this stage, the patient can often recover without
permanent organ damage. Metabolic acidosis and cold skin are more characteristic of the
progressive stage of shock.
4. A patient is suspected of developing Disseminated Intravascular Coagulation (DIC). Which
laboratory finding most strongly supports this diagnosis?
A. Decreased serum potassium and calcium.
B. Increased platelet count and decreased PT/PTT.
C. Elevated hemoglobin and hematocrit.
D. Elevated D-dimer levels and decreased fibrinogen.
Correct Answer: D
Rationale: DIC involves the paradoxical systemic activation of coagulation followed by a
depletion of clotting factors. Elevated D-dimer levels indicate that fibrinolysis is occurring
rapidly due to excessive clot formation. Fibrinogen is consumed during the clotting
process, leading to the low levels seen in DIC patients. Platelet counts typically drop
significantly as they are used up in microthrombi throughout the body. Monitoring these
trends is essential for the nurse to anticipate bleeding or ischemic complications.
5. The nurse is caring for a patient with cardiogenic shock following an acute myocardial
infarction. What is the primary goal of using an Intra-Aortic Balloon Pump (IABP)?
A. To increase the heart rate and systemic vascular resistance.
B. To provide permanent circulatory support for the failing heart.
C. To decrease myocardial oxygen demand and increase coronary perfusion.
D. To bypass the left ventricle and oxygenate the blood externally.
Correct Answer: C
Rationale: The IABP inflates during diastole to increase pressure in the aorta, which
pushes blood into the coronary arteries. It deflates just before systole, which creates a
vacuum effect that reduces afterload and myocardial work. This temporary mechanical
device helps stabilize patients while they await more definitive treatment like surgery or
PCI. It does not replace the heart’s function but rather assists the failing ventricle to
, recover. Careful monitoring of the insertion site for bleeding and limb ischemia is a vital
nursing responsibility.
6. A patient with a high-level spinal cord injury (T2) is at risk for neurogenic shock. Which
hemodynamic assessment finding is classic for this condition?
A. Hypotension and bradycardia.
B. Hypertension and tachycardia.
C. Hypotension and tachycardia.
D. Hyperthermia and vasoconstriction.
Correct Answer: A
Rationale: Neurogenic shock results from the loss of sympathetic tone, leading to massive
vasodilation and hypotension. Unlike other forms of shock, the heart cannot compensate
with tachycardia because the sympathetic pathways are disrupted. This results in the
hallmark combination of low blood pressure and a slow heart rate. Patients also lose the
ability to thermoregulate, often becoming poikilothermic and taking on the environment’s
temperature. Treatment involves cautious fluid resuscitation and vasopressors to restore
vascular tone.
7. A patient is admitted with multiple trauma and is at risk for Multiple Organ Dysfunction
Syndrome (MODS). Which organ system is usually the first to show signs of failure?
A. Respiratory system.
B. Renal system.
C. Hepatic system.
D. Gastrointestinal system.
Correct Answer: A
Rationale: The lungs are highly sensitive to systemic inflammation and are often the first
organ to fail in MODS. This usually manifests as Acute Respiratory Distress Syndrome
(ARDS) with severe hypoxemia and pulmonary infiltrates. Following lung failure, other
systems like the renal and hepatic systems may begin to decline. Early detection of
respiratory distress is critical to prevent the cascade of multi-organ failure. Management is
largely supportive and focuses on treating the underlying cause of the initial insult.
8. The nurse is managing a patient on a mechanical ventilator. The high-pressure alarm
sounds. Which of the following is the most likely cause?
A. A leak in the ventilator circuit.
B. Excessive secretions in the airway.
C. The patient has disconnected the tubing.
