NURS 481 | NURS481 Exam 3: Advanced Med Surg -
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A patient with a head injury presents with a Widening Pulse Pressure, Bradycardia, and
Irregular Respirations. What should the nurse immediately suspect?
A. Hypovolemic shock
B. Cushing’s Triad indicating increased ICP
C. Autonomic dysreflexia
D. Pulmonary embolism
Correct Answer: B
Rationale: Cushing’s Triad is a late sign of increased intracranial pressure and impending
brain herniation. It consists of systemic hypertension with a widening pulse pressure,
bradycardia, and irregular respiratory patterns. This clinical manifestation requires
immediate medical intervention to reduce intracranial pressure. Hypovolemic shock would
typically present with tachycardia and hypotension instead. Monitoring for these specific
changes is critical in patients following a traumatic brain injury.
2. Which lab result is most specific for diagnosing acute pancreatitis?
A. Elevated Serum Amylase
B. Elevated Serum Lipase
C. Decreased Blood Urea Nitrogen
D. Elevated White Blood Cell Count
Correct Answer: B
Rationale: Serum lipase is more specific to the pancreas than amylase and stays elevated
longer. While amylase levels rise quickly, they may return to normal within 48 to 72 hours.
Lipase levels remain elevated for up to 7 to 14 days following an acute event. Leukocytosis
is common but is a non-specific indicator of general inflammation. Accurate diagnosis relies
on the combination of clinical symptoms and these specific enzyme elevations.
3. A patient with Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L. Which
medication is the priority to protect the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin and Dextrose
C. Calcium Gluconate
,D. Furosemide (Lasix)
Correct Answer: C
Rationale: Calcium gluconate is administered intravenously to stabilize the myocardial cell
membrane during severe hyperkalemia. It does not lower the serum potassium level but
prevents life-threatening arrhythmias. Following stabilization, other treatments like insulin
and dextrose are used to shift potassium into cells. Kayexalate may be used to eventually
remove potassium from the body through the stool. The nurse must prioritize cardiac
stability when potassium exceeds critical thresholds.
4. A patient with a T6 spinal cord injury reports a severe pounding headache and is found to
have a BP of 210/110 mmHg. What is the nurse’s first action?
A. Administer PRN Hydralazine
B. Check for bladder distention or a kinked catheter
C. Place the patient in a High-Fowler’s position
D. Call the physician immediately
Correct Answer: C
Rationale: Placing the patient in a sitting position (High-Fowler’s) is the immediate
priority to help lower blood pressure via orthostatic changes. Autonomic dysreflexia is a
medical emergency that occurs in patients with spinal injuries at T6 or above. After
repositioning, the nurse should quickly assess for the triggering cause, such as a full
bladder. Identifying and removing the stimulus is the definitive treatment for this
condition. Failure to manage this rapidly can lead to a stroke or seizure.
5. What is the primary purpose of administering Lactulose to a patient with Cirrhosis and
hepatic encephalopathy?
A. To decrease serum bilirubin levels
B. To prevent constipation from inactivity
C. To reduce ammonia levels via the bowel
D. To increase serum protein levels
Correct Answer: C
Rationale: Lactulose works by pulling ammonia from the blood into the colon to be
excreted. High ammonia levels are the primary cause of neurological decline in hepatic
encephalopathy. The drug also acts as an osmotic laxative, producing 2-3 soft stools per
day. Monitoring the patient’s mental status is the best way to evaluate the drug’s
effectiveness. Dehydration should be avoided while ensuring the ammonia is being
successfully cleared.
, 6. A patient is receiving Peritoneal Dialysis. The outflow drainage is noted to be cloudy. What
is the nurse’s priority action?
A. Continue the next cycle of dialysis
B. Irrigate the catheter with saline
C. Notify the provider and obtain a culture of the drainage
D. Slow the infusion rate for the next cycle
Correct Answer: C
Rationale: Cloudy dialysate drainage is the earliest sign of peritonitis in a patient
undergoing peritoneal dialysis. The nurse must obtain a sample for culture and sensitivity
to identify the pathogen. Other signs may include abdominal pain, fever, and rebound
tenderness. Prompt antibiotic therapy is necessary to prevent systemic infection and
catheter loss. Clear or straw-colored drainage is the expected finding for a normal dialysis
cycle.
7. Which clinical finding is an absolute contraindication for the administration of tissue
plasminogen activator (tPA) in an ischemic stroke patient?
A. Blood pressure of 160/90 mmHg
B. Symptom onset 2 hours prior to arrival
C. Age older than 65 years
D. Active internal bleeding
Correct Answer: D
Rationale: Active internal bleeding poses a high risk of catastrophic hemorrhage if
thrombolytics are administered. tPA is used to dissolve clots but cannot distinguish
between pathologic and protective clots. The blood pressure must be carefully managed
and generally kept below 185/110 mmHg for tPA. Onset of symptoms must usually be
within a 3 to 4.5-hour window. Assessing the patient’s medical history for recent surgeries
or trauma is a vital nursing priority.
8. A nurse is caring for a patient with Acute Kidney Injury (AKI) in the oliguric phase. What
should the nurse expect to find?
A. Urine output greater than 1 liter per day
B. Decreased Serum Creatinine
C. Metabolic Acidosis
D. Hypokalemia
Correct Answer: C
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A patient with a head injury presents with a Widening Pulse Pressure, Bradycardia, and
Irregular Respirations. What should the nurse immediately suspect?
A. Hypovolemic shock
B. Cushing’s Triad indicating increased ICP
C. Autonomic dysreflexia
D. Pulmonary embolism
Correct Answer: B
Rationale: Cushing’s Triad is a late sign of increased intracranial pressure and impending
brain herniation. It consists of systemic hypertension with a widening pulse pressure,
bradycardia, and irregular respiratory patterns. This clinical manifestation requires
immediate medical intervention to reduce intracranial pressure. Hypovolemic shock would
typically present with tachycardia and hypotension instead. Monitoring for these specific
changes is critical in patients following a traumatic brain injury.
2. Which lab result is most specific for diagnosing acute pancreatitis?
A. Elevated Serum Amylase
B. Elevated Serum Lipase
C. Decreased Blood Urea Nitrogen
D. Elevated White Blood Cell Count
Correct Answer: B
Rationale: Serum lipase is more specific to the pancreas than amylase and stays elevated
longer. While amylase levels rise quickly, they may return to normal within 48 to 72 hours.
Lipase levels remain elevated for up to 7 to 14 days following an acute event. Leukocytosis
is common but is a non-specific indicator of general inflammation. Accurate diagnosis relies
on the combination of clinical symptoms and these specific enzyme elevations.
3. A patient with Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L. Which
medication is the priority to protect the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin and Dextrose
C. Calcium Gluconate
,D. Furosemide (Lasix)
Correct Answer: C
Rationale: Calcium gluconate is administered intravenously to stabilize the myocardial cell
membrane during severe hyperkalemia. It does not lower the serum potassium level but
prevents life-threatening arrhythmias. Following stabilization, other treatments like insulin
and dextrose are used to shift potassium into cells. Kayexalate may be used to eventually
remove potassium from the body through the stool. The nurse must prioritize cardiac
stability when potassium exceeds critical thresholds.
4. A patient with a T6 spinal cord injury reports a severe pounding headache and is found to
have a BP of 210/110 mmHg. What is the nurse’s first action?
A. Administer PRN Hydralazine
B. Check for bladder distention or a kinked catheter
C. Place the patient in a High-Fowler’s position
D. Call the physician immediately
Correct Answer: C
Rationale: Placing the patient in a sitting position (High-Fowler’s) is the immediate
priority to help lower blood pressure via orthostatic changes. Autonomic dysreflexia is a
medical emergency that occurs in patients with spinal injuries at T6 or above. After
repositioning, the nurse should quickly assess for the triggering cause, such as a full
bladder. Identifying and removing the stimulus is the definitive treatment for this
condition. Failure to manage this rapidly can lead to a stroke or seizure.
5. What is the primary purpose of administering Lactulose to a patient with Cirrhosis and
hepatic encephalopathy?
A. To decrease serum bilirubin levels
B. To prevent constipation from inactivity
C. To reduce ammonia levels via the bowel
D. To increase serum protein levels
Correct Answer: C
Rationale: Lactulose works by pulling ammonia from the blood into the colon to be
excreted. High ammonia levels are the primary cause of neurological decline in hepatic
encephalopathy. The drug also acts as an osmotic laxative, producing 2-3 soft stools per
day. Monitoring the patient’s mental status is the best way to evaluate the drug’s
effectiveness. Dehydration should be avoided while ensuring the ammonia is being
successfully cleared.
, 6. A patient is receiving Peritoneal Dialysis. The outflow drainage is noted to be cloudy. What
is the nurse’s priority action?
A. Continue the next cycle of dialysis
B. Irrigate the catheter with saline
C. Notify the provider and obtain a culture of the drainage
D. Slow the infusion rate for the next cycle
Correct Answer: C
Rationale: Cloudy dialysate drainage is the earliest sign of peritonitis in a patient
undergoing peritoneal dialysis. The nurse must obtain a sample for culture and sensitivity
to identify the pathogen. Other signs may include abdominal pain, fever, and rebound
tenderness. Prompt antibiotic therapy is necessary to prevent systemic infection and
catheter loss. Clear or straw-colored drainage is the expected finding for a normal dialysis
cycle.
7. Which clinical finding is an absolute contraindication for the administration of tissue
plasminogen activator (tPA) in an ischemic stroke patient?
A. Blood pressure of 160/90 mmHg
B. Symptom onset 2 hours prior to arrival
C. Age older than 65 years
D. Active internal bleeding
Correct Answer: D
Rationale: Active internal bleeding poses a high risk of catastrophic hemorrhage if
thrombolytics are administered. tPA is used to dissolve clots but cannot distinguish
between pathologic and protective clots. The blood pressure must be carefully managed
and generally kept below 185/110 mmHg for tPA. Onset of symptoms must usually be
within a 3 to 4.5-hour window. Assessing the patient’s medical history for recent surgeries
or trauma is a vital nursing priority.
8. A nurse is caring for a patient with Acute Kidney Injury (AKI) in the oliguric phase. What
should the nurse expect to find?
A. Urine output greater than 1 liter per day
B. Decreased Serum Creatinine
C. Metabolic Acidosis
D. Hypokalemia
Correct Answer: C
