NSG4100 | NSG4100 Nursing Practice - Adult
Health III Exam 4 Version 2 | Questions with
Correct Answers and Expert Explanation for Each
Question | Galen
1. A nurse is caring for a patient in the ICU who is being treated for septic shock.
Which of the following assessment findings would indicate that the patient is
progressing to Multiple Organ Dysfunction Syndrome (MODS)?
A. A decrease in serum creatinine levels and increased urine output.
B. Mean arterial pressure (MAP) of 70 mmHg after fluid resuscitation.
C. Respiratory rate of 22 breaths per minute with an SpO2 of 95%.
D. Development of jaundice, elevated liver enzymes, and decreased platelet count.
Correct Answer: D
Expert Explanation: Multiple Organ Dysfunction Syndrome is characterized by the
failure of two or more organ systems in an acutely ill patient. The presence of
jaundice and elevated liver enzymes indicates hepatic dysfunction, while a
decreased platelet count suggests hematologic failure or disseminated intravascular
coagulation. These multisystem findings are hallmark indicators that the
inflammatory response is leading to organ failure beyond the initial insult.
,2. An emergency room nurse is triaging patients using the Emergency Severity Index
(ESI). Which patient should be assigned an ESI level 1?
A. A 45-year-old female with a simple radius fracture and a pain level of 6/10.
B. A 60-year-old male with chest pain that is relieved by nitroglycerin.
C. A 22-year-old male who is unresponsive with agonal respirations.
D. An 18-year-old female with a 2-cm laceration on her forearm.
Correct Answer: C
Expert Explanation: ESI level 1 is reserved for patients who require immediate life-
saving interventions. An unresponsive patient with agonal respirations is in
respiratory or cardiac arrest and needs immediate resuscitation to survive. Other
levels such as ESI 2 or 3 are used for patients who are stable but need urgent care,
which does not apply to this life-threatening scenario.
3. A patient who suffered partial and full-thickness burns to 40% of their body is in the
emergent phase. Which electrolyte abnormality should the nurse monitor for most
closely during this first 24 hours?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
,D. Hypomagnesemia
Correct Answer: A
Expert Explanation: During the emergent phase of a burn injury, massive cell
destruction occurs, which releases intracellular potassium into the extracellular
fluid. This leads to hyperkalemia, which can cause dangerous cardiac dysrhythmias.
The nurse must monitor the ECG and serum potassium levels frequently during this
period to ensure patient safety.
4. Using the Parkland Formula, calculate the total fluid resuscitation required in the
first 24 hours for a 75 kg patient with 30% Total Body Surface Area (TBSA) burns.
(Formula: 4mL x kg x %TBSA)
A. 4,500 mL
B. 9,000 mL
C. 6,000 mL
D. 12,000 mL
Correct Answer: B
Expert Explanation: The Parkland Formula calculates fluid requirements as 4 mL
multiplied by the weight in kilograms multiplied by the percentage of TBSA burned.
In this case, 4 mL x 75 kg x 30 = 9,000 mL. Half of this total volume is administered
over the first 8 hours, and the remaining half is given over the next 16 hours.
, 5. A nurse is caring for a patient on mechanical ventilation. The high-pressure alarm
sounds. Which action should the nurse take first?
A. Check the patient for signs of biting the endotracheal tube or coughing.
B. Manually bag the patient with 100% oxygen using a BVM.
C. Silence the alarm and increase the tidal volume setting.
D. Auscultate the patient’s lung sounds for a pneumothorax.
Correct Answer: A
Expert Explanation: A high-pressure alarm is triggered when the ventilator
encounters resistance, often caused by the patient biting the tube, coughing, or
secretions. The nurse should first assess the patient to identify the cause of the
resistance before moving to more invasive or complex interventions. If the cause
cannot be identified or corrected quickly, then manual ventilation with a BVM would
be the next step.
6. A patient with a T4 spinal cord injury reports a sudden, throbbing headache and is
found to have a blood pressure of 190/110 mmHg. What is the priority nursing action?
A. Assess the patient’s bladder for distension or a clogged catheter.
B. Administer an ordered dose of IV hydralazine.
C. Lower the head of the bed to a flat position.
Health III Exam 4 Version 2 | Questions with
Correct Answers and Expert Explanation for Each
Question | Galen
1. A nurse is caring for a patient in the ICU who is being treated for septic shock.
Which of the following assessment findings would indicate that the patient is
progressing to Multiple Organ Dysfunction Syndrome (MODS)?
A. A decrease in serum creatinine levels and increased urine output.
B. Mean arterial pressure (MAP) of 70 mmHg after fluid resuscitation.
C. Respiratory rate of 22 breaths per minute with an SpO2 of 95%.
D. Development of jaundice, elevated liver enzymes, and decreased platelet count.
Correct Answer: D
Expert Explanation: Multiple Organ Dysfunction Syndrome is characterized by the
failure of two or more organ systems in an acutely ill patient. The presence of
jaundice and elevated liver enzymes indicates hepatic dysfunction, while a
decreased platelet count suggests hematologic failure or disseminated intravascular
coagulation. These multisystem findings are hallmark indicators that the
inflammatory response is leading to organ failure beyond the initial insult.
,2. An emergency room nurse is triaging patients using the Emergency Severity Index
(ESI). Which patient should be assigned an ESI level 1?
A. A 45-year-old female with a simple radius fracture and a pain level of 6/10.
B. A 60-year-old male with chest pain that is relieved by nitroglycerin.
C. A 22-year-old male who is unresponsive with agonal respirations.
D. An 18-year-old female with a 2-cm laceration on her forearm.
Correct Answer: C
Expert Explanation: ESI level 1 is reserved for patients who require immediate life-
saving interventions. An unresponsive patient with agonal respirations is in
respiratory or cardiac arrest and needs immediate resuscitation to survive. Other
levels such as ESI 2 or 3 are used for patients who are stable but need urgent care,
which does not apply to this life-threatening scenario.
3. A patient who suffered partial and full-thickness burns to 40% of their body is in the
emergent phase. Which electrolyte abnormality should the nurse monitor for most
closely during this first 24 hours?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
,D. Hypomagnesemia
Correct Answer: A
Expert Explanation: During the emergent phase of a burn injury, massive cell
destruction occurs, which releases intracellular potassium into the extracellular
fluid. This leads to hyperkalemia, which can cause dangerous cardiac dysrhythmias.
The nurse must monitor the ECG and serum potassium levels frequently during this
period to ensure patient safety.
4. Using the Parkland Formula, calculate the total fluid resuscitation required in the
first 24 hours for a 75 kg patient with 30% Total Body Surface Area (TBSA) burns.
(Formula: 4mL x kg x %TBSA)
A. 4,500 mL
B. 9,000 mL
C. 6,000 mL
D. 12,000 mL
Correct Answer: B
Expert Explanation: The Parkland Formula calculates fluid requirements as 4 mL
multiplied by the weight in kilograms multiplied by the percentage of TBSA burned.
In this case, 4 mL x 75 kg x 30 = 9,000 mL. Half of this total volume is administered
over the first 8 hours, and the remaining half is given over the next 16 hours.
, 5. A nurse is caring for a patient on mechanical ventilation. The high-pressure alarm
sounds. Which action should the nurse take first?
A. Check the patient for signs of biting the endotracheal tube or coughing.
B. Manually bag the patient with 100% oxygen using a BVM.
C. Silence the alarm and increase the tidal volume setting.
D. Auscultate the patient’s lung sounds for a pneumothorax.
Correct Answer: A
Expert Explanation: A high-pressure alarm is triggered when the ventilator
encounters resistance, often caused by the patient biting the tube, coughing, or
secretions. The nurse should first assess the patient to identify the cause of the
resistance before moving to more invasive or complex interventions. If the cause
cannot be identified or corrected quickly, then manual ventilation with a BVM would
be the next step.
6. A patient with a T4 spinal cord injury reports a sudden, throbbing headache and is
found to have a blood pressure of 190/110 mmHg. What is the priority nursing action?
A. Assess the patient’s bladder for distension or a clogged catheter.
B. Administer an ordered dose of IV hydralazine.
C. Lower the head of the bed to a flat position.
