NSG4100 Nursing Practice - Adult Health III Exam
3 Version 3 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient in the emergent phase of a major burn injury has a blood pressure of
88/50 mmHg and a heart rate of 120 bpm. Which intravenous fluid is the priority for
the nurse to administer?
A. Lactated Ringer’s
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. 3% Hypertonic Saline
Correct Answer: A
Expert Explanation: Lactated Ringer’s is the preferred crystalloid for fluid
resuscitation in burn patients because its composition most closely resembles
plasma. It helps to expand the intravascular volume and replace lost electrolytes
without causing the hyperchloremic acidosis often seen with high volumes of 0.9%
Normal Saline. This intervention is critical during the first 24 hours to prevent
hypovolemic shock and maintain organ perfusion.
,2. The nurse is caring for a patient with septic shock. Which clinical finding should the
nurse prioritize as indicative of worsening multi-organ dysfunction syndrome (MODS)?
A. Heart rate of 95 bpm
B. Serum creatinine level of 2.8 mg/dL
C. Urine output of 45 mL/hr
D. Oxygen saturation of 94% on 2L NC
Correct Answer: B
Expert Explanation: An elevated creatinine level of 2.8 mg/dL indicates significant
renal impairment, which is a hallmark sign of MODS in a septic patient. Normal
creatinine is generally below 1.2 mg/dL, and a doubling suggests a decrease in the
glomerular filtration rate. Monitoring renal function is vital as the kidneys are
among the first organs to fail due to hypoperfusion and systemic inflammation.
3. A client with full-thickness burns to the chest and neck is at high risk for which
immediate complication?
A. Airway obstruction
B. Hypothermia
C. Infection
D. Fluid volume excess
,Correct Answer: A
Expert Explanation: Burns to the chest and neck often involve inhalation injury or
cause significant edema that can compress the trachea. Airway management is the
top priority in the emergent phase of burn care to ensure the patient remains
ventilated. Nurses must monitor for stridor, hoarseness, and soot in the sputum as
indicators of potential airway collapse.
4. Which laboratory value is most indicative of disseminated intravascular coagulation
(DIC) in a patient with sepsis?
A. Prolonged Prothrombin Time (PT)
B. Decreased D-dimer level
C. Increased Platelet count
D. Increased Fibrinogen level
Correct Answer: A
Expert Explanation: DIC is characterized by the consumption of clotting factors,
which leads to prolonged PT and PTT values. Additionally, you would expect to see a
decrease in platelets and an increase in D-dimer, reflecting the simultaneous
formation and breakdown of clots. This coagulopathy puts the patient at extreme
risk for both thrombosis and hemorrhage.
, 5. A patient with a CD4+ T-cell count of 150 cells/mm3 and oral candidiasis is
admitted. How should the nurse categorize this patient’s HIV status?
A. HIV Stage 1
B. HIV Stage 2
C. HIV Stage 0
D. HIV Stage 3 (AIDS)
Correct Answer: D
Expert Explanation: A CD4+ count below 200 cells/mm3 is a clinical definition of
AIDS (Stage 3 HIV), regardless of whether an opportunistic infection is present. Oral
candidiasis is an opportunistic infection commonly seen in immunocompromised
individuals. At this stage, the patient’s immune system is severely depleted, making
them highly susceptible to life-threatening conditions.
6. When using the Parkland Formula (4mL x kg x %TBSA), how much fluid should a
70kg patient with 40% burns receive in the first 8 hours?
A. 11,200 mL
B. 5,600 mL
C. 2,800 mL
D. 1,400 mL
3 Version 3 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient in the emergent phase of a major burn injury has a blood pressure of
88/50 mmHg and a heart rate of 120 bpm. Which intravenous fluid is the priority for
the nurse to administer?
A. Lactated Ringer’s
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. 3% Hypertonic Saline
Correct Answer: A
Expert Explanation: Lactated Ringer’s is the preferred crystalloid for fluid
resuscitation in burn patients because its composition most closely resembles
plasma. It helps to expand the intravascular volume and replace lost electrolytes
without causing the hyperchloremic acidosis often seen with high volumes of 0.9%
Normal Saline. This intervention is critical during the first 24 hours to prevent
hypovolemic shock and maintain organ perfusion.
,2. The nurse is caring for a patient with septic shock. Which clinical finding should the
nurse prioritize as indicative of worsening multi-organ dysfunction syndrome (MODS)?
A. Heart rate of 95 bpm
B. Serum creatinine level of 2.8 mg/dL
C. Urine output of 45 mL/hr
D. Oxygen saturation of 94% on 2L NC
Correct Answer: B
Expert Explanation: An elevated creatinine level of 2.8 mg/dL indicates significant
renal impairment, which is a hallmark sign of MODS in a septic patient. Normal
creatinine is generally below 1.2 mg/dL, and a doubling suggests a decrease in the
glomerular filtration rate. Monitoring renal function is vital as the kidneys are
among the first organs to fail due to hypoperfusion and systemic inflammation.
3. A client with full-thickness burns to the chest and neck is at high risk for which
immediate complication?
A. Airway obstruction
B. Hypothermia
C. Infection
D. Fluid volume excess
,Correct Answer: A
Expert Explanation: Burns to the chest and neck often involve inhalation injury or
cause significant edema that can compress the trachea. Airway management is the
top priority in the emergent phase of burn care to ensure the patient remains
ventilated. Nurses must monitor for stridor, hoarseness, and soot in the sputum as
indicators of potential airway collapse.
4. Which laboratory value is most indicative of disseminated intravascular coagulation
(DIC) in a patient with sepsis?
A. Prolonged Prothrombin Time (PT)
B. Decreased D-dimer level
C. Increased Platelet count
D. Increased Fibrinogen level
Correct Answer: A
Expert Explanation: DIC is characterized by the consumption of clotting factors,
which leads to prolonged PT and PTT values. Additionally, you would expect to see a
decrease in platelets and an increase in D-dimer, reflecting the simultaneous
formation and breakdown of clots. This coagulopathy puts the patient at extreme
risk for both thrombosis and hemorrhage.
, 5. A patient with a CD4+ T-cell count of 150 cells/mm3 and oral candidiasis is
admitted. How should the nurse categorize this patient’s HIV status?
A. HIV Stage 1
B. HIV Stage 2
C. HIV Stage 0
D. HIV Stage 3 (AIDS)
Correct Answer: D
Expert Explanation: A CD4+ count below 200 cells/mm3 is a clinical definition of
AIDS (Stage 3 HIV), regardless of whether an opportunistic infection is present. Oral
candidiasis is an opportunistic infection commonly seen in immunocompromised
individuals. At this stage, the patient’s immune system is severely depleted, making
them highly susceptible to life-threatening conditions.
6. When using the Parkland Formula (4mL x kg x %TBSA), how much fluid should a
70kg patient with 40% burns receive in the first 8 hours?
A. 11,200 mL
B. 5,600 mL
C. 2,800 mL
D. 1,400 mL
