NURS 481 | NURS481 Exam 4: Advanced Med Surg -
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient suspected of having sepsis. Which of the following
interventions is the highest priority within the first hour of recognition?
A. Administering a vasopressor to maintain MAP > 65 mmHg.
B. Obtaining blood cultures before administering broad-spectrum antibiotics.
C. Starting a 500 mL bolus of 5% Albumin.
D. Inserting an indwelling urinary catheter to monitor output.
Correct Answer: B
Rationale: The priority action in the initial sepsis bundle is obtaining blood cultures prior
to antibiotic administration. Identifying the causative organism allows for targeted therapy
later in the treatment course. Antibiotics must still be started within the first hour even if
cultures are delayed. This sequence is vital for preventing the progression of infection to
septic shock. Early intervention directly correlates with improved patient survival rates in
high-acuity settings.
2. A patient in septic shock remains hypotensive after receiving a 30 mL/kg bolus of
crystalloids. Which medication should the nurse prepare to administer first?
A. Dobutamine
B. Norepinephrine
C. Nitroglycerin
D. Amiodarone
Correct Answer: B
Rationale: Norepinephrine is the first-line vasopressor of choice for patients in septic
shock who are fluid-resuscitated but remain hypotensive. It works primarily by increasing
systemic vascular resistance through alpha-adrenergic stimulation. Maintaining a Mean
Arterial Pressure (MAP) of at least 65 mmHg is the therapeutic goal. Vasopressors should
only be started after adequate fluid volume has been restored to the intravascular space.
The nurse must monitor the infusion site closely for signs of extravasation and tissue
necrosis.
3. When assessing a trauma patient using the primary survey, which action is performed
during the ‘C’ (Circulation) phase?
A. Assessing the Glasgow Coma Scale score.
B. Checking for bilateral breath sounds.
,C. Applying direct pressure to obvious external bleeding.
D. Removing all clothing to inspect for hidden injuries.
Correct Answer: C
Rationale: The circulation phase of the primary survey focuses on assessing pulses and
controlling hemorrhage. Controlling external bleeding with direct pressure is a critical step
in maintaining hemodynamic stability. The nurse should also assess skin color,
temperature, and capillary refill during this stage. If the patient is pulseless, advanced life
support protocols must be initiated immediately. Circulation management ensures that
vital organs receive adequate perfusion during the initial trauma response.
4. A patient with multiple organ dysfunction syndrome (MODS) is experiencing failure of the
renal system. Which clinical finding most likely indicates this progression?
A. Serum Creatinine of 0.8 mg/dL
B. Serum Potassium of 6.2 mEq/L
C. Urine output of 50 mL/hr
D. Blood Urea Nitrogen (BUN) of 15 mg/dL
Correct Answer: B
Rationale: Hyperkalemia is a common indicator of acute renal failure within the context of
MODS. When the kidneys fail, they can no longer effectively excrete potassium or urea from
the bloodstream. A potassium level of 6.2 mEq/L represents a significant risk for cardiac
arrhythmias. The nurse must monitor for ECG changes and prepare for interventions like
dialysis or CRRT. This finding highlights the multisystem impact of critical illness on
electrolyte balance.
5. The nurse is caring for a trauma patient with a suspected tension pneumothorax. Which
clinical manifestation is a hallmark sign of this condition?
A. Hyperresonance on the unaffected side
B. Tracheal deviation toward the affected side
C. Increased blood pressure and bradycardia
D. Absent breath sounds on the affected side
Correct Answer: D
Rationale: Absent breath sounds on the affected side combined with respiratory distress is
a classic sign of tension pneumothorax. In this condition, air enters the pleural space but
cannot escape, causing lung collapse and mediastinal shift. Tracheal deviation actually
occurs toward the unaffected side as pressure builds. This is a life-threatening emergency
that requires immediate needle decompression. Rapid assessment and intervention are
essential to restore cardiac output and ventilation.
, 6. A patient is admitted with a serum lactate level of 5.2 mmol/L. How should the nurse
interpret this finding in the context of sepsis?
A. The patient is experiencing adequate tissue perfusion.
B. The patient is recovering well from an inflammatory response.
C. The patient has metabolic alkalosis from hyperventilation.
D. The patient is showing signs of anaerobic metabolism and tissue hypoxia.
Correct Answer: D
Rationale: Elevated lactate levels (typically >2 mmol/L) indicate that tissues are not
receiving enough oxygen, leading to anaerobic metabolism. In sepsis, high lactate levels are
a strong predictor of morbidity and mortality. This lab value guides the intensity of fluid
resuscitation and the urgency of medical intervention. The goal is to clear the lactate
through improved oxygen delivery and hemodynamic support. Frequent monitoring of
lactate helps evaluate the effectiveness of the treatment plan.
7. Which phase of the trauma survey involves the ‘Full set of vitals’ and ‘Family presence’ (F)?
A. Primary Survey
B. Triage Phase
C. Tertiary Survey
D. Secondary Survey
Correct Answer: D
Rationale: The secondary survey begins after the primary survey is completed and life-
threatening conditions are stabilized. The ‘F’ component stands for obtaining a full set of
vital signs and facilitating family presence. Including family can provide comfort to the
patient and essential medical history to the team. This phase also includes comfort
measures and a head-to-toe assessment. It is a systematic approach to ensure no injuries
are missed during the initial chaos.
8. A patient in the ICU is diagnosed with Disseminated Intravascular Coagulation (DIC)
secondary to sepsis. Which lab result is most consistent with this diagnosis?
A. Elevated Platelet count
B. Decreased D-dimer levels
C. Increased Fibrinogen levels
D. Prolonged Prothrombin Time (PT)
Correct Answer: D
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a patient suspected of having sepsis. Which of the following
interventions is the highest priority within the first hour of recognition?
A. Administering a vasopressor to maintain MAP > 65 mmHg.
B. Obtaining blood cultures before administering broad-spectrum antibiotics.
C. Starting a 500 mL bolus of 5% Albumin.
D. Inserting an indwelling urinary catheter to monitor output.
Correct Answer: B
Rationale: The priority action in the initial sepsis bundle is obtaining blood cultures prior
to antibiotic administration. Identifying the causative organism allows for targeted therapy
later in the treatment course. Antibiotics must still be started within the first hour even if
cultures are delayed. This sequence is vital for preventing the progression of infection to
septic shock. Early intervention directly correlates with improved patient survival rates in
high-acuity settings.
2. A patient in septic shock remains hypotensive after receiving a 30 mL/kg bolus of
crystalloids. Which medication should the nurse prepare to administer first?
A. Dobutamine
B. Norepinephrine
C. Nitroglycerin
D. Amiodarone
Correct Answer: B
Rationale: Norepinephrine is the first-line vasopressor of choice for patients in septic
shock who are fluid-resuscitated but remain hypotensive. It works primarily by increasing
systemic vascular resistance through alpha-adrenergic stimulation. Maintaining a Mean
Arterial Pressure (MAP) of at least 65 mmHg is the therapeutic goal. Vasopressors should
only be started after adequate fluid volume has been restored to the intravascular space.
The nurse must monitor the infusion site closely for signs of extravasation and tissue
necrosis.
3. When assessing a trauma patient using the primary survey, which action is performed
during the ‘C’ (Circulation) phase?
A. Assessing the Glasgow Coma Scale score.
B. Checking for bilateral breath sounds.
,C. Applying direct pressure to obvious external bleeding.
D. Removing all clothing to inspect for hidden injuries.
Correct Answer: C
Rationale: The circulation phase of the primary survey focuses on assessing pulses and
controlling hemorrhage. Controlling external bleeding with direct pressure is a critical step
in maintaining hemodynamic stability. The nurse should also assess skin color,
temperature, and capillary refill during this stage. If the patient is pulseless, advanced life
support protocols must be initiated immediately. Circulation management ensures that
vital organs receive adequate perfusion during the initial trauma response.
4. A patient with multiple organ dysfunction syndrome (MODS) is experiencing failure of the
renal system. Which clinical finding most likely indicates this progression?
A. Serum Creatinine of 0.8 mg/dL
B. Serum Potassium of 6.2 mEq/L
C. Urine output of 50 mL/hr
D. Blood Urea Nitrogen (BUN) of 15 mg/dL
Correct Answer: B
Rationale: Hyperkalemia is a common indicator of acute renal failure within the context of
MODS. When the kidneys fail, they can no longer effectively excrete potassium or urea from
the bloodstream. A potassium level of 6.2 mEq/L represents a significant risk for cardiac
arrhythmias. The nurse must monitor for ECG changes and prepare for interventions like
dialysis or CRRT. This finding highlights the multisystem impact of critical illness on
electrolyte balance.
5. The nurse is caring for a trauma patient with a suspected tension pneumothorax. Which
clinical manifestation is a hallmark sign of this condition?
A. Hyperresonance on the unaffected side
B. Tracheal deviation toward the affected side
C. Increased blood pressure and bradycardia
D. Absent breath sounds on the affected side
Correct Answer: D
Rationale: Absent breath sounds on the affected side combined with respiratory distress is
a classic sign of tension pneumothorax. In this condition, air enters the pleural space but
cannot escape, causing lung collapse and mediastinal shift. Tracheal deviation actually
occurs toward the unaffected side as pressure builds. This is a life-threatening emergency
that requires immediate needle decompression. Rapid assessment and intervention are
essential to restore cardiac output and ventilation.
, 6. A patient is admitted with a serum lactate level of 5.2 mmol/L. How should the nurse
interpret this finding in the context of sepsis?
A. The patient is experiencing adequate tissue perfusion.
B. The patient is recovering well from an inflammatory response.
C. The patient has metabolic alkalosis from hyperventilation.
D. The patient is showing signs of anaerobic metabolism and tissue hypoxia.
Correct Answer: D
Rationale: Elevated lactate levels (typically >2 mmol/L) indicate that tissues are not
receiving enough oxygen, leading to anaerobic metabolism. In sepsis, high lactate levels are
a strong predictor of morbidity and mortality. This lab value guides the intensity of fluid
resuscitation and the urgency of medical intervention. The goal is to clear the lactate
through improved oxygen delivery and hemodynamic support. Frequent monitoring of
lactate helps evaluate the effectiveness of the treatment plan.
7. Which phase of the trauma survey involves the ‘Full set of vitals’ and ‘Family presence’ (F)?
A. Primary Survey
B. Triage Phase
C. Tertiary Survey
D. Secondary Survey
Correct Answer: D
Rationale: The secondary survey begins after the primary survey is completed and life-
threatening conditions are stabilized. The ‘F’ component stands for obtaining a full set of
vital signs and facilitating family presence. Including family can provide comfort to the
patient and essential medical history to the team. This phase also includes comfort
measures and a head-to-toe assessment. It is a systematic approach to ensure no injuries
are missed during the initial chaos.
8. A patient in the ICU is diagnosed with Disseminated Intravascular Coagulation (DIC)
secondary to sepsis. Which lab result is most consistent with this diagnosis?
A. Elevated Platelet count
B. Decreased D-dimer levels
C. Increased Fibrinogen levels
D. Prolonged Prothrombin Time (PT)
Correct Answer: D
