NUR 205 | NUR 205 Med Surg Exam 4 Version 3 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient presents with a pressure injury that has full-thickness skin loss where
subcutaneous fat is visible, but bone and muscle are not exposed. Which stage should
the nurse document?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Correct Answer: C
Expert Explanation: A Stage III pressure injury involves full-thickness skin loss
involving damage to or necrosis of subcutaneous tissue. In this stage, subcutaneous
fat may be visible, but bone, tendon, and muscle are not yet exposed. It may also
include undermining or tunneling of the wound. The nurse must carefully assess for
these signs to differentiate it from Stage IV. Proper staging ensures that the correct
wound management protocols are followed for healing.
,2. Using the Parkland Formula, calculate the total fluid resuscitation needed in the
first 24 hours for a patient weighing 70 kg with a 40% total body surface area (TBSA)
burn.
A. 5,600 mL
B. 2,800 mL
C. 8,400 mL
D. 11,200 mL
Correct Answer: D
Expert Explanation: The Parkland Formula is calculated as 4 mL multiplied by the
patient’s weight in kilograms multiplied by the TBSA percentage. For this patient,
the calculation is 4 mL x 70 kg x 40, which equals 11,200 mL. One half of this total
volume must be infused within the first 8 hours post-injury. The remaining half is
administered over the subsequent 16 hours. Accurate fluid resuscitation is vital to
prevent hypovolemic shock in burn victims.
3. A patient receiving chemotherapy has a neutrophil count of 450/mm³. Which
nursing intervention is the highest priority?
A. Administering prescribed antiemetics
B. Placing the patient in a private room and initiating protective precautions
,C. Encouraging a high-protein diet with fresh salads
D. Assessing for signs of bleeding in the gums
Correct Answer: B
Expert Explanation: A neutrophil count below 500/mm³ indicates severe
neutropenia and puts the patient at high risk for life-threatening infections. The
nurse must implement protective environment precautions, often called
neutropenic precautions. This includes placing the patient in a private room and
limiting exposure to potential pathogens. Visitors and staff must follow strict hand
hygiene protocols. Patients should also avoid fresh fruits, flowers, and stagnant
water which may harbor bacteria.
4. Which assessment finding is characteristic of a full-thickness (third-degree) burn?
A. Extreme pain and weeping blisters
B. Pink to red skin that is very painful
C. Blanching with pressure and mild edema
D. Leathery, waxy white or charred appearance
Correct Answer: D
Expert Explanation: Full-thickness burns involve the destruction of the entire
epidermis and dermis, and sometimes underlying tissue. The skin often appears
, leathery, waxy white, or even charred and black. Because the nerve endings are
destroyed, these areas are typically insensitive to touch or pain. Surrounding areas
of partial-thickness burns may still be very painful. Surgical intervention such as
skin grafting is usually required for healing.
5. During the emergent phase of burn care, which electrolyte imbalance is most
commonly expected?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypernatremia
Correct Answer: A
Expert Explanation: Hyperkalemia occurs during the emergent phase due to
massive cell destruction caused by the burn. When cells are damaged, they release
intracellular potassium into the extracellular fluid. This elevation in serum
potassium can lead to dangerous cardiac arrhythmias. The nurse must monitor the
patient’s ECG for signs like peaked T waves. Management focuses on stabilizing the
patient and promoting potassium excretion as the fluid shift stabilizes.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient presents with a pressure injury that has full-thickness skin loss where
subcutaneous fat is visible, but bone and muscle are not exposed. Which stage should
the nurse document?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Correct Answer: C
Expert Explanation: A Stage III pressure injury involves full-thickness skin loss
involving damage to or necrosis of subcutaneous tissue. In this stage, subcutaneous
fat may be visible, but bone, tendon, and muscle are not yet exposed. It may also
include undermining or tunneling of the wound. The nurse must carefully assess for
these signs to differentiate it from Stage IV. Proper staging ensures that the correct
wound management protocols are followed for healing.
,2. Using the Parkland Formula, calculate the total fluid resuscitation needed in the
first 24 hours for a patient weighing 70 kg with a 40% total body surface area (TBSA)
burn.
A. 5,600 mL
B. 2,800 mL
C. 8,400 mL
D. 11,200 mL
Correct Answer: D
Expert Explanation: The Parkland Formula is calculated as 4 mL multiplied by the
patient’s weight in kilograms multiplied by the TBSA percentage. For this patient,
the calculation is 4 mL x 70 kg x 40, which equals 11,200 mL. One half of this total
volume must be infused within the first 8 hours post-injury. The remaining half is
administered over the subsequent 16 hours. Accurate fluid resuscitation is vital to
prevent hypovolemic shock in burn victims.
3. A patient receiving chemotherapy has a neutrophil count of 450/mm³. Which
nursing intervention is the highest priority?
A. Administering prescribed antiemetics
B. Placing the patient in a private room and initiating protective precautions
,C. Encouraging a high-protein diet with fresh salads
D. Assessing for signs of bleeding in the gums
Correct Answer: B
Expert Explanation: A neutrophil count below 500/mm³ indicates severe
neutropenia and puts the patient at high risk for life-threatening infections. The
nurse must implement protective environment precautions, often called
neutropenic precautions. This includes placing the patient in a private room and
limiting exposure to potential pathogens. Visitors and staff must follow strict hand
hygiene protocols. Patients should also avoid fresh fruits, flowers, and stagnant
water which may harbor bacteria.
4. Which assessment finding is characteristic of a full-thickness (third-degree) burn?
A. Extreme pain and weeping blisters
B. Pink to red skin that is very painful
C. Blanching with pressure and mild edema
D. Leathery, waxy white or charred appearance
Correct Answer: D
Expert Explanation: Full-thickness burns involve the destruction of the entire
epidermis and dermis, and sometimes underlying tissue. The skin often appears
, leathery, waxy white, or even charred and black. Because the nerve endings are
destroyed, these areas are typically insensitive to touch or pain. Surrounding areas
of partial-thickness burns may still be very painful. Surgical intervention such as
skin grafting is usually required for healing.
5. During the emergent phase of burn care, which electrolyte imbalance is most
commonly expected?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypernatremia
Correct Answer: A
Expert Explanation: Hyperkalemia occurs during the emergent phase due to
massive cell destruction caused by the burn. When cells are damaged, they release
intracellular potassium into the extracellular fluid. This elevation in serum
potassium can lead to dangerous cardiac arrhythmias. The nurse must monitor the
patient’s ECG for signs like peaked T waves. Management focuses on stabilizing the
patient and promoting potassium excretion as the fluid shift stabilizes.
