NUR 265 Advanced Medical-Surgical Nursing Exam 1 2026 |Galen
College
1. During a mass casualty incident, a patient is found with a respiratory rate of
32, a capillary refill of 4 seconds, and is unable to follow simple commands.
Which color tag should the nurse assign?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: Red tags are for immediate priority patients who have life-threatening injuries
but a high chance of survival if treated immediately. Criteria include RR > 30, cap refill > 2
seconds, or inability to follow commands.
2. A patient has sustained deep partial-thickness burns to the front of both legs
and the entire perineum. Using the Rule of Nines, calculate the Total Body
Surface Area (TBSA) affected.
A. 18%
B. 37%
C. 19%
D. 9%
Answer: C
Rationale: The front of one leg is 9%. For two legs (front only), it is 18%. The perineum is
1%. 18% + 1% = 19%.
,3. Which clinical manifestation is a hallmark sign of the compensatory stage of
shock?
A. Mean Arterial Pressure (MAP) decrease of 20 mmHg from baseline
B. Cold, clammy skin and metabolic acidosis
C. Increased heart rate and narrowed pulse pressure
D. Anuria and lethargy
Answer: C
Rationale: In the compensatory stage, the body attempts to maintain homeostasis.
Common signs include tachycardia, increased respiratory rate, and narrowed pulse
pressure while maintaining a near-normal blood pressure.
4. A 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. Hypocalcemia
D. Hypernatremia
Answer: A
Rationale: In the emergent phase, massive cell destruction releases potassium into the
extracellular fluid, leading to hyperkalemia. Hyponatremia is also common as sodium
follows water into the interstitial space.
5. A patient with a T6 spinal cord injury presents with a BP of 82/40, HR of 48,
and skin that is warm and dry. The nurse suspects which type of shock?
A. Hypovolemic shock
B. Cardiogenic shock
C. Neurogenic shock
D. Septic shock
Answer: C
, Rationale: Neurogenic shock is characterized by the triad of hypotension, bradycardia, and
warm/dry skin due to the loss of sympathetic nervous system tone, typically occurring
with injuries at or above T6.
6. Using the Parkland formula (4mL x kg x %TBSA), calculate the total fluid
volume needed in the first 24 hours for a 70kg patient with a 50% TBSA burn.
A. 14,000 mL
B. 7,000 mL
C. 28,000 mL
D. 10,500 mL
Answer: A
Rationale: 4mL x 70kg x 50% = 14,000 mL. Half of this (7,000 mL) is given in the first 8
hours.
7. Which assessment finding in a patient with a chest injury suggests a tension
pneumothorax?
A. Paradoxical chest wall movement
B. Crepitus around the injury site
C. Dullness upon percussion of the affected side
D. Tracheal deviation to the unaffected side
Answer: D
Rationale: Tension pneumothorax causes air to be trapped in the pleural space, increasing
pressure and shifting the mediastinum and trachea toward the unaffected side.
8. What is the primary goal of the emergent phase of burn care?
A. Infection prevention
B. Fluid resuscitation
C. Wound grafting
D. Physical therapy
Answer: B
College
1. During a mass casualty incident, a patient is found with a respiratory rate of
32, a capillary refill of 4 seconds, and is unable to follow simple commands.
Which color tag should the nurse assign?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: Red tags are for immediate priority patients who have life-threatening injuries
but a high chance of survival if treated immediately. Criteria include RR > 30, cap refill > 2
seconds, or inability to follow commands.
2. A patient has sustained deep partial-thickness burns to the front of both legs
and the entire perineum. Using the Rule of Nines, calculate the Total Body
Surface Area (TBSA) affected.
A. 18%
B. 37%
C. 19%
D. 9%
Answer: C
Rationale: The front of one leg is 9%. For two legs (front only), it is 18%. The perineum is
1%. 18% + 1% = 19%.
,3. Which clinical manifestation is a hallmark sign of the compensatory stage of
shock?
A. Mean Arterial Pressure (MAP) decrease of 20 mmHg from baseline
B. Cold, clammy skin and metabolic acidosis
C. Increased heart rate and narrowed pulse pressure
D. Anuria and lethargy
Answer: C
Rationale: In the compensatory stage, the body attempts to maintain homeostasis.
Common signs include tachycardia, increased respiratory rate, and narrowed pulse
pressure while maintaining a near-normal blood pressure.
4. A 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. Hypocalcemia
D. Hypernatremia
Answer: A
Rationale: In the emergent phase, massive cell destruction releases potassium into the
extracellular fluid, leading to hyperkalemia. Hyponatremia is also common as sodium
follows water into the interstitial space.
5. A patient with a T6 spinal cord injury presents with a BP of 82/40, HR of 48,
and skin that is warm and dry. The nurse suspects which type of shock?
A. Hypovolemic shock
B. Cardiogenic shock
C. Neurogenic shock
D. Septic shock
Answer: C
, Rationale: Neurogenic shock is characterized by the triad of hypotension, bradycardia, and
warm/dry skin due to the loss of sympathetic nervous system tone, typically occurring
with injuries at or above T6.
6. Using the Parkland formula (4mL x kg x %TBSA), calculate the total fluid
volume needed in the first 24 hours for a 70kg patient with a 50% TBSA burn.
A. 14,000 mL
B. 7,000 mL
C. 28,000 mL
D. 10,500 mL
Answer: A
Rationale: 4mL x 70kg x 50% = 14,000 mL. Half of this (7,000 mL) is given in the first 8
hours.
7. Which assessment finding in a patient with a chest injury suggests a tension
pneumothorax?
A. Paradoxical chest wall movement
B. Crepitus around the injury site
C. Dullness upon percussion of the affected side
D. Tracheal deviation to the unaffected side
Answer: D
Rationale: Tension pneumothorax causes air to be trapped in the pleural space, increasing
pressure and shifting the mediastinum and trachea toward the unaffected side.
8. What is the primary goal of the emergent phase of burn care?
A. Infection prevention
B. Fluid resuscitation
C. Wound grafting
D. Physical therapy
Answer: B
