NUR 220 | NUR 220 Medical Surgical Nursing Exam
1 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient is experiencing an acute inflammatory response following a surgical
incision. Which physiological process explains the redness and heat at the site?
A. Vasoconstriction of local capillaries to prevent blood loss
B. Increased vascular permeability leading to protein leakage
C. Vasodilation resulting in increased blood flow to the injured area
D. The migration of neutrophils to the site of injury
Correct Answer: C
Expert Explanation: Inflammation begins with a vascular stage characterized by
immediate vasodilation of the local vessels. This increase in blood flow causes the
classic signs of erythema and localized heat. Chemical mediators like histamine and
bradykinin are released to trigger this physiological change. Nursing assessment
focuses on monitoring these signs to differentiate normal healing from early
infection. Understanding the vascular phase is essential for predicting subsequent
tissue swelling and edema.
,2. During the General Adaptation Syndrome (GAS), which hormone is primarily
responsible for increasing blood glucose levels to provide energy during the stress
response?
A. Insulin
B. Cortisol
C. Antidiuretic hormone (ADH)
D. Aldosterone
Correct Answer: B
Expert Explanation: Cortisol is a glucocorticoid released by the adrenal cortex
during the resistance stage of stress. It promotes gluconeogenesis in the liver to
ensure the body has sufficient fuel for the ‘fight or flight’ response. Prolonged
elevation of cortisol can lead to immunosuppression and delayed wound healing in
surgical patients. Nurses must monitor blood glucose levels in stressed patients
even if they are not diabetic. This hormonal regulation is a key component of
cellular homeostasis under external pressure.
3. A nurse is caring for a patient with a wound that is healing by secondary intention.
Which characteristic should the nurse expect to observe?
A. Surgical sutures holding the edges in close proximity
B. Minimal tissue loss and a fine scar
,C. A large gap between wound edges that fills with granulation tissue
D. Rapid healing within 4 to 7 days
Correct Answer: C
Expert Explanation: Healing by secondary intention occurs when there is
significant tissue loss or when wound edges cannot be approximated. These wounds
must heal from the bottom up through the formation of granulation tissue. This
process takes longer than primary intention and typically results in a larger, more
prominent scar. Nurses must prioritize infection control and moisture balance in
these complex wounds. Proper documentation of the size and color of granulation
tissue is vital for tracking progress.
4. A patient presents with signs of an IgE-mediated hypersensitivity reaction after
receiving a dose of penicillin. Which condition is the patient experiencing?
A. Type III Hypersensitivity
B. Type II Hypersensitivity
C. Type I Hypersensitivity
D. Type IV Hypersensitivity
Correct Answer: C
, Expert Explanation: Type I hypersensitivity involves the binding of an allergen to
IgE antibodies on mast cells and basophils. This triggers the rapid release of
inflammatory mediators like histamine, which can cause anaphylaxis. The onset is
typically immediate, ranging from minutes to hours after exposure. Nurses must be
prepared to administer epinephrine and maintain the airway in these emergency
situations. Patient education must focus on strict avoidance of the identified
allergen to prevent future occurrences.
5. Which laboratory finding is most indicative of a ‘shift to the left’ in a patient with a
severe bacterial infection?
A. Increased levels of mature segmented neutrophils
B. Decreased total white blood cell count (leukopenia)
C. Elevation of eosinophils and basophils
D. Increased percentage of immature band neutrophils
Correct Answer: D
Expert Explanation: A ‘shift to the left’ refers to an increase in immature
neutrophils, known as bands, in the bloodstream. This occurs when the bone
marrow releases young cells prematurely to fight an overwhelming infection. It is a
critical indicator that the body’s inflammatory demand is exceeding its supply of
mature cells. Nurses should interpret this as a sign of worsening systemic infection
1 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient is experiencing an acute inflammatory response following a surgical
incision. Which physiological process explains the redness and heat at the site?
A. Vasoconstriction of local capillaries to prevent blood loss
B. Increased vascular permeability leading to protein leakage
C. Vasodilation resulting in increased blood flow to the injured area
D. The migration of neutrophils to the site of injury
Correct Answer: C
Expert Explanation: Inflammation begins with a vascular stage characterized by
immediate vasodilation of the local vessels. This increase in blood flow causes the
classic signs of erythema and localized heat. Chemical mediators like histamine and
bradykinin are released to trigger this physiological change. Nursing assessment
focuses on monitoring these signs to differentiate normal healing from early
infection. Understanding the vascular phase is essential for predicting subsequent
tissue swelling and edema.
,2. During the General Adaptation Syndrome (GAS), which hormone is primarily
responsible for increasing blood glucose levels to provide energy during the stress
response?
A. Insulin
B. Cortisol
C. Antidiuretic hormone (ADH)
D. Aldosterone
Correct Answer: B
Expert Explanation: Cortisol is a glucocorticoid released by the adrenal cortex
during the resistance stage of stress. It promotes gluconeogenesis in the liver to
ensure the body has sufficient fuel for the ‘fight or flight’ response. Prolonged
elevation of cortisol can lead to immunosuppression and delayed wound healing in
surgical patients. Nurses must monitor blood glucose levels in stressed patients
even if they are not diabetic. This hormonal regulation is a key component of
cellular homeostasis under external pressure.
3. A nurse is caring for a patient with a wound that is healing by secondary intention.
Which characteristic should the nurse expect to observe?
A. Surgical sutures holding the edges in close proximity
B. Minimal tissue loss and a fine scar
,C. A large gap between wound edges that fills with granulation tissue
D. Rapid healing within 4 to 7 days
Correct Answer: C
Expert Explanation: Healing by secondary intention occurs when there is
significant tissue loss or when wound edges cannot be approximated. These wounds
must heal from the bottom up through the formation of granulation tissue. This
process takes longer than primary intention and typically results in a larger, more
prominent scar. Nurses must prioritize infection control and moisture balance in
these complex wounds. Proper documentation of the size and color of granulation
tissue is vital for tracking progress.
4. A patient presents with signs of an IgE-mediated hypersensitivity reaction after
receiving a dose of penicillin. Which condition is the patient experiencing?
A. Type III Hypersensitivity
B. Type II Hypersensitivity
C. Type I Hypersensitivity
D. Type IV Hypersensitivity
Correct Answer: C
, Expert Explanation: Type I hypersensitivity involves the binding of an allergen to
IgE antibodies on mast cells and basophils. This triggers the rapid release of
inflammatory mediators like histamine, which can cause anaphylaxis. The onset is
typically immediate, ranging from minutes to hours after exposure. Nurses must be
prepared to administer epinephrine and maintain the airway in these emergency
situations. Patient education must focus on strict avoidance of the identified
allergen to prevent future occurrences.
5. Which laboratory finding is most indicative of a ‘shift to the left’ in a patient with a
severe bacterial infection?
A. Increased levels of mature segmented neutrophils
B. Decreased total white blood cell count (leukopenia)
C. Elevation of eosinophils and basophils
D. Increased percentage of immature band neutrophils
Correct Answer: D
Expert Explanation: A ‘shift to the left’ refers to an increase in immature
neutrophils, known as bands, in the bloodstream. This occurs when the bone
marrow releases young cells prematurely to fight an overwhelming infection. It is a
critical indicator that the body’s inflammatory demand is exceeding its supply of
mature cells. Nurses should interpret this as a sign of worsening systemic infection
