NUR 2502 Exam 1: Multidimensional Care III
(MDC 3) Verified and Updated Questions and
Answers
1. A nurse is triaging victims of a mass casualty incident. A patient is found with
a respiratory rate of 34, a radial pulse of 110, and is unable to follow simple
commands. What color tag should this patient receive?
A. Red
B. Yellow
C. Green
D. Black
Answer: A
Explanation: Using the START triage method, a respiratory rate over 30, capillary refill
over 2 seconds (or weak pulse), and inability to follow commands indicates a Red tag
(Immediate).
2. A patient arrives in the ED with partial-thickness burns to the entire left arm
and the entire anterior trunk. Using the Rule of Nines, what is the total body
surface area (TBSA) percentage?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Explanation: The entire arm is 9% and the anterior trunk is 18%. 9 + 18 = 27%.
,3. The nurse is caring for a patient in the emergent phase of a burn injury.
Which electrolyte imbalance is most expected during this phase?
A. Hyperkalemia
B. Hypokalemia
C. Hyponatremia
D. Hypocalcemia
Answer: A
Explanation: In the emergent phase, cell destruction releases potassium into the
extracellular fluid, leading to hyperkalemia.
4. A patient weighs 80 kg and has 50% TBSA burns. According to the Parkland
Formula (4mL/kg/%TBSA), how many milliliters of fluid should be administered
in the first 8 hours?
A. 16,000 mL
B. 4,000 mL
C. 8,000 mL
D. 2,000 mL
Answer: C
Explanation: Total 24h fluid: 4 x 80 x 50 = 16,000 mL. Half is given in the first 8 hours:
16, = 8,000 mL.
5. Which of the following is the most sensitive early indicator of increased
intracranial pressure (ICP)?
A. Change in level of consciousness
B. Dilated pupils
C. Cushing’s Triad
D. Decerebrate posturing
Answer: A
,Explanation: A change in the level of consciousness is the earliest and most sensitive sign
of neurological deterioration.
6. The nurse observes a patient’s EKG showing a saw-tooth pattern with a
regular atrial rhythm of 300 bpm and a ventricular rate of 75 bpm. What is this
rhythm?
A. Atrial Fibrillation
B. Sinus Bradycardia
C. Ventricular Tachycardia
D. Atrial Flutter
Answer: D
Explanation: Atrial flutter is characterized by a classic ‘saw-tooth’ P-wave pattern.
7. A patient with a head injury has a Blood Pressure of 180/60, a Heart Rate of
48, and irregular respirations. What does the nurse suspect?
A. Cushing’s Triad
B. Hypovolemic Shock
C. Septic Shock
D. Autonomic Dysreflexia
Answer: A
Explanation: Cushing’s Triad (systolic hypertension with widened pulse pressure,
bradycardia, and irregular respirations) is a late sign of increased ICP.
, 8. During a primary survey of a trauma victim, the nurse notes the patient has a
deviated trachea and absent breath sounds on the right side. What is the
priority intervention?
A. Obtain a chest X-ray
B. Administration of IV fluids
C. Endotracheal intubation
D. Needle thoracostomy
Answer: D
Explanation: A deviated trachea and absent breath sounds indicate a tension
pneumothorax, which requires immediate needle decompression.
9. A patient in the ICU is being monitored for ARDS. Which of the following is a
hallmark clinical manifestation of ARDS?
A. Improvement of oxygenation with low-flow nasal cannula
B. Refractory hypoxemia
C. Increased lung compliance
D. Decreased pulmonary artery wedge pressure
Answer: B
Explanation: Refractory hypoxemia (hypoxemia that does not improve with increased
oxygen administration) is a hallmark of ARDS.
10. The nurse is caring for a patient in septic shock. Which lab value is most
indicative of inadequate tissue perfusion?
A. Elevated Creatinine
B. Elevated White Blood Cell count
C. Decreased Hemoglobin
D. Elevated Lactate level
Answer: D
(MDC 3) Verified and Updated Questions and
Answers
1. A nurse is triaging victims of a mass casualty incident. A patient is found with
a respiratory rate of 34, a radial pulse of 110, and is unable to follow simple
commands. What color tag should this patient receive?
A. Red
B. Yellow
C. Green
D. Black
Answer: A
Explanation: Using the START triage method, a respiratory rate over 30, capillary refill
over 2 seconds (or weak pulse), and inability to follow commands indicates a Red tag
(Immediate).
2. A patient arrives in the ED with partial-thickness burns to the entire left arm
and the entire anterior trunk. Using the Rule of Nines, what is the total body
surface area (TBSA) percentage?
A. 18%
B. 45%
C. 36%
D. 27%
Answer: D
Explanation: The entire arm is 9% and the anterior trunk is 18%. 9 + 18 = 27%.
,3. The nurse is caring for a patient in the emergent phase of a burn injury.
Which electrolyte imbalance is most expected during this phase?
A. Hyperkalemia
B. Hypokalemia
C. Hyponatremia
D. Hypocalcemia
Answer: A
Explanation: In the emergent phase, cell destruction releases potassium into the
extracellular fluid, leading to hyperkalemia.
4. A patient weighs 80 kg and has 50% TBSA burns. According to the Parkland
Formula (4mL/kg/%TBSA), how many milliliters of fluid should be administered
in the first 8 hours?
A. 16,000 mL
B. 4,000 mL
C. 8,000 mL
D. 2,000 mL
Answer: C
Explanation: Total 24h fluid: 4 x 80 x 50 = 16,000 mL. Half is given in the first 8 hours:
16, = 8,000 mL.
5. Which of the following is the most sensitive early indicator of increased
intracranial pressure (ICP)?
A. Change in level of consciousness
B. Dilated pupils
C. Cushing’s Triad
D. Decerebrate posturing
Answer: A
,Explanation: A change in the level of consciousness is the earliest and most sensitive sign
of neurological deterioration.
6. The nurse observes a patient’s EKG showing a saw-tooth pattern with a
regular atrial rhythm of 300 bpm and a ventricular rate of 75 bpm. What is this
rhythm?
A. Atrial Fibrillation
B. Sinus Bradycardia
C. Ventricular Tachycardia
D. Atrial Flutter
Answer: D
Explanation: Atrial flutter is characterized by a classic ‘saw-tooth’ P-wave pattern.
7. A patient with a head injury has a Blood Pressure of 180/60, a Heart Rate of
48, and irregular respirations. What does the nurse suspect?
A. Cushing’s Triad
B. Hypovolemic Shock
C. Septic Shock
D. Autonomic Dysreflexia
Answer: A
Explanation: Cushing’s Triad (systolic hypertension with widened pulse pressure,
bradycardia, and irregular respirations) is a late sign of increased ICP.
, 8. During a primary survey of a trauma victim, the nurse notes the patient has a
deviated trachea and absent breath sounds on the right side. What is the
priority intervention?
A. Obtain a chest X-ray
B. Administration of IV fluids
C. Endotracheal intubation
D. Needle thoracostomy
Answer: D
Explanation: A deviated trachea and absent breath sounds indicate a tension
pneumothorax, which requires immediate needle decompression.
9. A patient in the ICU is being monitored for ARDS. Which of the following is a
hallmark clinical manifestation of ARDS?
A. Improvement of oxygenation with low-flow nasal cannula
B. Refractory hypoxemia
C. Increased lung compliance
D. Decreased pulmonary artery wedge pressure
Answer: B
Explanation: Refractory hypoxemia (hypoxemia that does not improve with increased
oxygen administration) is a hallmark of ARDS.
10. The nurse is caring for a patient in septic shock. Which lab value is most
indicative of inadequate tissue perfusion?
A. Elevated Creatinine
B. Elevated White Blood Cell count
C. Decreased Hemoglobin
D. Elevated Lactate level
Answer: D
