NURS 481 | NURS481 Final Exam: Advanced Med
Surg - WCU Updated and Latest Questions and
Correct Answers with Rationale
1. A patient with septic shock is receiving aggressive fluid resuscitation. Which assessment
finding most accurately indicates that the fluid replacement is effective?
A. Urine output of 20 mL/hr
B. Central venous pressure (CVP) of 2 mmHg
C. Heart rate of 110 beats per minute
D. Mean arterial pressure (MAP) of 70 mmHg
Correct Answer: D
Rationale: The primary goal in treating septic shock is to restore tissue perfusion through
fluid resuscitation. A mean arterial pressure (MAP) greater than 65 mmHg is a standard
indicator of adequate organ perfusion. Although CVP is monitored, a value of 2 mmHg
suggests continued hypovolemia rather than effective replacement. Urine output should
ideally be at least 0.5 mL/kg/hr, so 20 mL/hr is generally insufficient for an average adult.
Restoring the MAP helps ensure that vital organs like the kidneys and brain receive enough
oxygenated blood.
2. A client on mechanical ventilation triggers a high-pressure alarm. Which action should the
nurse perform first?
A. Auscultate the patient’s breath sounds
B. Increase the oxygen concentration
C. Check for kinks in the ventilator tubing
D. Suction the patient’s airway
Correct Answer: C
Rationale: High-pressure alarms indicate that the ventilator is meeting resistance while
trying to deliver a breath. The most common and easily corrected cause is a physical
obstruction such as a kinked tube. The nurse should always check the patient and the
circuit starting from the patient and moving toward the machine. Suctioning may be
necessary if secretions are the cause, but mechanical kinks are checked first. If the cause is
not quickly found, the nurse must manually ventilate the patient with a bag-valve mask.
3. A patient with a T6 spinal cord injury reports a sudden, severe headache and has a blood
pressure of 210/110 mmHg. What is the priority nursing intervention?
A. Place the patient in a high-Fowler’s position
B. Administer an ordered antihypertensive medication
,C. Check the patient for bladder distention
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: This patient is exhibiting classic signs of autonomic dysreflexia, which is a
medical emergency. The first action is to sit the patient upright in a high-Fowler’s position
to help lower blood pressure via orthostatic changes. After repositioning, the nurse should
then identify and alleviate the triggering stimulus, usually a distended bladder or impacted
bowel. Antihypertensives may be used if the blood pressure remains dangerously high
after the cause is addressed. Prompt intervention is necessary to prevent complications
like stroke or seizures.
4. A client with full-thickness burns over 40% of their body is in the emergent phase. Which
electrolyte imbalance is the nurse most likely to observe?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hyponatremia
Correct Answer: A
Rationale: During the emergent phase of a burn injury, massive cellular destruction
occurs. This causes potassium to leak out of the damaged cells and enter the extracellular
fluid. The nurse must monitor for hyperkalemia, which can lead to life-threatening cardiac
dysrhythmias. Additionally, sodium often shifts into the interstitial space, potentially
causing hyponatremia, but hyperkalemia is the hallmark emergent electrolyte shift.
Monitoring EKG changes and serum lab values is a critical nursing responsibility during
this phase.
5. Which clinical finding is a component of Cushing’s Triad, indicating increased intracranial
pressure?
A. Widening pulse pressure
B. Tachycardia
C. Hypotension
D. Increased respiratory rate
Correct Answer: A
Rationale: Cushing’s Triad is a late sign of increased intracranial pressure and impending
brain herniation. It consists of bradycardia, irregular respirations, and a widening pulse
pressure (increasing systolic BP with stable or decreasing diastolic BP). The body increases
systolic blood pressure to overcome intracranial pressure and maintain cerebral perfusion.
, Tachycardia and hypotension are more characteristic of shock, not increased ICP.
Recognizing these signs early allows for rapid intervention to decrease pressure and
prevent permanent damage.
6. In a patient suspected of having Disseminated Intravascular Coagulation (DIC), which
laboratory result would the nurse expect to find?
A. Decreased D-dimer levels
B. Increased fibrinogen levels
C. Prolonged prothrombin time (PT)
D. Increased platelet count
Correct Answer: C
Rationale: DIC involves both excessive clotting and excessive bleeding, leading to the
depletion of clotting factors. As a result, coagulation times such as PT and PTT are
prolonged. D-dimer levels are elevated because they indicate the breakdown of clots within
the body. Fibrinogen and platelets are consumed during the process, so their levels will be
decreased rather than increased. These laboratory findings help confirm the diagnosis and
guide the administration of blood products.
7. A patient with ARDS is being treated with mechanical ventilation and PEEP. What is the
primary purpose of adding PEEP?
A. To keep alveoli open at the end of expiration
B. To reduce the risk of ventilator-associated pneumonia
C. To prevent barotrauma from high tidal volumes
D. To decrease the patient’s work of breathing
Correct Answer: A
Rationale: Positive End-Expiratory Pressure (PEEP) is used to maintain airway pressure
above atmospheric pressure at the end of exhalation. This prevents the collapse of alveoli
and promotes better gas exchange across the alveolar-capillary membrane. In ARDS, PEEP
helps recruit collapsed alveoli, improving oxygenation and allowing for lower FiO2 levels.
High levels of PEEP can increase the risk of barotrauma, so it must be carefully titrated. It is
a fundamental component of the protective lung ventilation strategy.
8. A patient with cirrhosis and hepatic encephalopathy is prescribed lactulose. What is the
goal of this therapy?
A. To decrease serum potassium levels
B. To reduce the production of stomach acid
C. To improve the absorption of fat-soluble vitamins
Surg - WCU Updated and Latest Questions and
Correct Answers with Rationale
1. A patient with septic shock is receiving aggressive fluid resuscitation. Which assessment
finding most accurately indicates that the fluid replacement is effective?
A. Urine output of 20 mL/hr
B. Central venous pressure (CVP) of 2 mmHg
C. Heart rate of 110 beats per minute
D. Mean arterial pressure (MAP) of 70 mmHg
Correct Answer: D
Rationale: The primary goal in treating septic shock is to restore tissue perfusion through
fluid resuscitation. A mean arterial pressure (MAP) greater than 65 mmHg is a standard
indicator of adequate organ perfusion. Although CVP is monitored, a value of 2 mmHg
suggests continued hypovolemia rather than effective replacement. Urine output should
ideally be at least 0.5 mL/kg/hr, so 20 mL/hr is generally insufficient for an average adult.
Restoring the MAP helps ensure that vital organs like the kidneys and brain receive enough
oxygenated blood.
2. A client on mechanical ventilation triggers a high-pressure alarm. Which action should the
nurse perform first?
A. Auscultate the patient’s breath sounds
B. Increase the oxygen concentration
C. Check for kinks in the ventilator tubing
D. Suction the patient’s airway
Correct Answer: C
Rationale: High-pressure alarms indicate that the ventilator is meeting resistance while
trying to deliver a breath. The most common and easily corrected cause is a physical
obstruction such as a kinked tube. The nurse should always check the patient and the
circuit starting from the patient and moving toward the machine. Suctioning may be
necessary if secretions are the cause, but mechanical kinks are checked first. If the cause is
not quickly found, the nurse must manually ventilate the patient with a bag-valve mask.
3. A patient with a T6 spinal cord injury reports a sudden, severe headache and has a blood
pressure of 210/110 mmHg. What is the priority nursing intervention?
A. Place the patient in a high-Fowler’s position
B. Administer an ordered antihypertensive medication
,C. Check the patient for bladder distention
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: This patient is exhibiting classic signs of autonomic dysreflexia, which is a
medical emergency. The first action is to sit the patient upright in a high-Fowler’s position
to help lower blood pressure via orthostatic changes. After repositioning, the nurse should
then identify and alleviate the triggering stimulus, usually a distended bladder or impacted
bowel. Antihypertensives may be used if the blood pressure remains dangerously high
after the cause is addressed. Prompt intervention is necessary to prevent complications
like stroke or seizures.
4. A client with full-thickness burns over 40% of their body is in the emergent phase. Which
electrolyte imbalance is the nurse most likely to observe?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hyponatremia
Correct Answer: A
Rationale: During the emergent phase of a burn injury, massive cellular destruction
occurs. This causes potassium to leak out of the damaged cells and enter the extracellular
fluid. The nurse must monitor for hyperkalemia, which can lead to life-threatening cardiac
dysrhythmias. Additionally, sodium often shifts into the interstitial space, potentially
causing hyponatremia, but hyperkalemia is the hallmark emergent electrolyte shift.
Monitoring EKG changes and serum lab values is a critical nursing responsibility during
this phase.
5. Which clinical finding is a component of Cushing’s Triad, indicating increased intracranial
pressure?
A. Widening pulse pressure
B. Tachycardia
C. Hypotension
D. Increased respiratory rate
Correct Answer: A
Rationale: Cushing’s Triad is a late sign of increased intracranial pressure and impending
brain herniation. It consists of bradycardia, irregular respirations, and a widening pulse
pressure (increasing systolic BP with stable or decreasing diastolic BP). The body increases
systolic blood pressure to overcome intracranial pressure and maintain cerebral perfusion.
, Tachycardia and hypotension are more characteristic of shock, not increased ICP.
Recognizing these signs early allows for rapid intervention to decrease pressure and
prevent permanent damage.
6. In a patient suspected of having Disseminated Intravascular Coagulation (DIC), which
laboratory result would the nurse expect to find?
A. Decreased D-dimer levels
B. Increased fibrinogen levels
C. Prolonged prothrombin time (PT)
D. Increased platelet count
Correct Answer: C
Rationale: DIC involves both excessive clotting and excessive bleeding, leading to the
depletion of clotting factors. As a result, coagulation times such as PT and PTT are
prolonged. D-dimer levels are elevated because they indicate the breakdown of clots within
the body. Fibrinogen and platelets are consumed during the process, so their levels will be
decreased rather than increased. These laboratory findings help confirm the diagnosis and
guide the administration of blood products.
7. A patient with ARDS is being treated with mechanical ventilation and PEEP. What is the
primary purpose of adding PEEP?
A. To keep alveoli open at the end of expiration
B. To reduce the risk of ventilator-associated pneumonia
C. To prevent barotrauma from high tidal volumes
D. To decrease the patient’s work of breathing
Correct Answer: A
Rationale: Positive End-Expiratory Pressure (PEEP) is used to maintain airway pressure
above atmospheric pressure at the end of exhalation. This prevents the collapse of alveoli
and promotes better gas exchange across the alveolar-capillary membrane. In ARDS, PEEP
helps recruit collapsed alveoli, improving oxygenation and allowing for lower FiO2 levels.
High levels of PEEP can increase the risk of barotrauma, so it must be carefully titrated. It is
a fundamental component of the protective lung ventilation strategy.
8. A patient with cirrhosis and hepatic encephalopathy is prescribed lactulose. What is the
goal of this therapy?
A. To decrease serum potassium levels
B. To reduce the production of stomach acid
C. To improve the absorption of fat-soluble vitamins
