NUR104 | NUR104 Medsurg 2 Exam 1 Version 3
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient arrives in the emergency department with a deep laceration and signs of
hypovolemic shock. What is the nurse’s first priority intervention?
A. Applying direct pressure to the wound to stop bleeding
B. Administering a broad-spectrum antibiotic
C. Inserting a foley catheter to monitor urine output
D. Obtaining a complete medical history from the family
Correct Answer: A
Expert Explanation: The first priority in hypovolemic shock caused by hemorrhage
is to stop the loss of fluid volume. Applying direct pressure is the most immediate
way to control external bleeding and prevent further hemodynamic decline. Once
the bleeding is controlled, the nurse can proceed with fluid resuscitation and other
medical interventions. Monitoring output and administering medications are
secondary to stabilizing the patient’s immediate physical threat. Effective clinical
judgment requires addressing the ‘Circulation’ aspect of the ABCs in this specific
emergency scenario.
,2. When calculating the Mean Arterial Pressure (MAP) for a patient with a blood
pressure of 90/60 mmHg, what is the result?
A. 60 mmHg
B. 75 mmHg
C. 80 mmHg
D. 70 mmHg
Correct Answer: D
Expert Explanation: Mean Arterial Pressure is calculated by the formula (Systolic
BP + 2 * Diastolic BP) / 3. For a BP of 90/60, the calculation is (90 + 120) / 3, which
equals 70 mmHg. A MAP above 65 mmHg is generally required to maintain adequate
perfusion to vital organs like the brain and kidneys. In critical care, this value is a
more reliable indicator of tissue perfusion than systolic blood pressure alone.
Nurses must monitor this value closely in patients experiencing shock or respiratory
distress.
3. Which of the following is considered an early clinical manifestation of hypoxia in a
patient with respiratory distress?
A. Restlessness and agitation
B. Bradypnea and lethargy
C. Cyanosis of the lips and nail beds
,D. Clubbing of the fingers
Correct Answer: A
Expert Explanation: Restlessness and agitation are early signs of hypoxia as the
brain is highly sensitive to declining oxygen levels. These symptoms often precede
more obvious physical changes like cyanosis, which is considered a late sign. As the
condition progresses, the patient may become increasingly confused or combative.
Recognizing these behavioral changes early allows for rapid intervention with
oxygen therapy. Early detection is critical for preventing further respiratory failure
and cardiac arrest.
4. A patient in cardiogenic shock is prescribed Dobutamine. The nurse understands
that this medication is used primarily to:
A. Increase heart rate and cause vasoconstriction
B. Improve myocardial contractility and cardiac output
C. Decrease the workload of the heart by causing vasodilation
D. Promote diuresis to reduce pulmonary edema
Correct Answer: B
Expert Explanation: Dobutamine is a positive inotropic agent that enhances the
strength of myocardial contractions. By increasing contractility, it helps improve
cardiac output in patients whose hearts are failing to pump effectively. It is
, commonly used in cardiogenic shock to support systemic perfusion without
significantly increasing the heart rate. The nurse must monitor for dysrhythmias
and changes in blood pressure during the infusion. This intervention is a standard
part of managing hemodynamics in critical cardiovascular emergencies.
5. The nurse is caring for a patient suspected of having septic shock. Which laboratory
value is most indicative of tissue hypoperfusion?
A. Elevated White Blood Cell (WBC) count
B. Serum Lactate level of 5.0 mmol/L
C. Blood Urea Nitrogen (BUN) of 25 mg/dL
D. Hemoglobin of 10 g/dL
Correct Answer: B
Expert Explanation: Lactic acid is produced when cells shift to anaerobic
metabolism due to inadequate oxygen delivery to the tissues. A serum lactate level
greater than 2 mmol/L is a significant marker for tissue hypoperfusion and cellular
hypoxia. In septic shock, high lactate levels are associated with increased mortality
and are used to guide fluid resuscitation. While WBC counts indicate infection, they
do not directly measure the adequacy of perfusion. Monitoring lactate levels is a
crucial component of the surviving sepsis campaign bundles.
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient arrives in the emergency department with a deep laceration and signs of
hypovolemic shock. What is the nurse’s first priority intervention?
A. Applying direct pressure to the wound to stop bleeding
B. Administering a broad-spectrum antibiotic
C. Inserting a foley catheter to monitor urine output
D. Obtaining a complete medical history from the family
Correct Answer: A
Expert Explanation: The first priority in hypovolemic shock caused by hemorrhage
is to stop the loss of fluid volume. Applying direct pressure is the most immediate
way to control external bleeding and prevent further hemodynamic decline. Once
the bleeding is controlled, the nurse can proceed with fluid resuscitation and other
medical interventions. Monitoring output and administering medications are
secondary to stabilizing the patient’s immediate physical threat. Effective clinical
judgment requires addressing the ‘Circulation’ aspect of the ABCs in this specific
emergency scenario.
,2. When calculating the Mean Arterial Pressure (MAP) for a patient with a blood
pressure of 90/60 mmHg, what is the result?
A. 60 mmHg
B. 75 mmHg
C. 80 mmHg
D. 70 mmHg
Correct Answer: D
Expert Explanation: Mean Arterial Pressure is calculated by the formula (Systolic
BP + 2 * Diastolic BP) / 3. For a BP of 90/60, the calculation is (90 + 120) / 3, which
equals 70 mmHg. A MAP above 65 mmHg is generally required to maintain adequate
perfusion to vital organs like the brain and kidneys. In critical care, this value is a
more reliable indicator of tissue perfusion than systolic blood pressure alone.
Nurses must monitor this value closely in patients experiencing shock or respiratory
distress.
3. Which of the following is considered an early clinical manifestation of hypoxia in a
patient with respiratory distress?
A. Restlessness and agitation
B. Bradypnea and lethargy
C. Cyanosis of the lips and nail beds
,D. Clubbing of the fingers
Correct Answer: A
Expert Explanation: Restlessness and agitation are early signs of hypoxia as the
brain is highly sensitive to declining oxygen levels. These symptoms often precede
more obvious physical changes like cyanosis, which is considered a late sign. As the
condition progresses, the patient may become increasingly confused or combative.
Recognizing these behavioral changes early allows for rapid intervention with
oxygen therapy. Early detection is critical for preventing further respiratory failure
and cardiac arrest.
4. A patient in cardiogenic shock is prescribed Dobutamine. The nurse understands
that this medication is used primarily to:
A. Increase heart rate and cause vasoconstriction
B. Improve myocardial contractility and cardiac output
C. Decrease the workload of the heart by causing vasodilation
D. Promote diuresis to reduce pulmonary edema
Correct Answer: B
Expert Explanation: Dobutamine is a positive inotropic agent that enhances the
strength of myocardial contractions. By increasing contractility, it helps improve
cardiac output in patients whose hearts are failing to pump effectively. It is
, commonly used in cardiogenic shock to support systemic perfusion without
significantly increasing the heart rate. The nurse must monitor for dysrhythmias
and changes in blood pressure during the infusion. This intervention is a standard
part of managing hemodynamics in critical cardiovascular emergencies.
5. The nurse is caring for a patient suspected of having septic shock. Which laboratory
value is most indicative of tissue hypoperfusion?
A. Elevated White Blood Cell (WBC) count
B. Serum Lactate level of 5.0 mmol/L
C. Blood Urea Nitrogen (BUN) of 25 mg/dL
D. Hemoglobin of 10 g/dL
Correct Answer: B
Expert Explanation: Lactic acid is produced when cells shift to anaerobic
metabolism due to inadequate oxygen delivery to the tissues. A serum lactate level
greater than 2 mmol/L is a significant marker for tissue hypoperfusion and cellular
hypoxia. In septic shock, high lactate levels are associated with increased mortality
and are used to guide fluid resuscitation. While WBC counts indicate infection, they
do not directly measure the adequacy of perfusion. Monitoring lactate levels is a
crucial component of the surviving sepsis campaign bundles.
