NUR104 | NUR104 Medsurg 2 Exam 4 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a patient in the emergent phase of a major burn injury. Which
nursing intervention is the highest priority?
A. Administering prescribed analgesic medication for pain relief.
B. Inserting a large-bore intravenous catheter for fluid resuscitation.
C. Calculating the total body surface area burned using the Rule of Nines.
D. Assessing airway patency and maintaining cervical spine stability.
Correct Answer: D
Expert Explanation: The emergent phase of burn management focuses on the
immediate life-saving measures categorized by the ABCs. Airway maintenance is the
absolute priority because inhalation injuries can cause rapid edema and obstruction.
The nurse must ensure the patient has a patent airway and adequate oxygenation
before addressing other needs. While fluid resuscitation and pain management are
critical, they follow the establishment of a secure airway. Continuous monitoring of
respiratory effort and breath sounds is essential during this initial period of care.
,2. A nurse assesses a pressure injury and observes full-thickness skin loss with visible
subcutaneous fat, but no exposed bone, tendon, or muscle. How should the nurse
stage this injury?
A. Stage 3
B. Stage 2
C. Stage 4
D. Unstageable
Correct Answer: A
Expert Explanation: A Stage 3 pressure injury involves full-thickness tissue loss
where subcutaneous fat may be visible in the wound bed. At this stage, the depth of
the wound does not yet expose underlying structures like bone or muscle. Slough or
eschar may be present but do not obscure the depth of tissue loss. The nurse must
assess for undermining or tunneling, which are common features of Stage 3 injuries.
Proper documentation and pressure relief strategies are vital to prevent the wound
from progressing to a Stage 4 injury.
3. A patient is admitted with suspected carbon monoxide poisoning following a house
fire. Which clinical finding should the nurse expect to observe?
A. Pulse oximetry reading of 85% on room air.
B. Cherry-red skin color and headache.
,C. Severe expiratory wheezing and stridor.
D. Copious amounts of black, carbonaceous sputum.
Correct Answer: B
Expert Explanation: Carbon monoxide has a much higher affinity for hemoglobin
than oxygen, leading to tissue hypoxia despite normal pulse oximetry readings. The
classic clinical sign of carbon monoxide poisoning is a cherry-red appearance of the
skin and mucous membranes. Patients often report neurological symptoms such as
headache, dizziness, and confusion due to cerebral hypoxia. Pulse oximetry is
unreliable because the device cannot distinguish between carboxyhemoglobin and
oxyhemoglobin. Immediate treatment with 100% humidified oxygen is necessary to
displace the carbon monoxide from the hemoglobin molecules.
4. The nurse is using the Parkland formula to calculate fluid resuscitation for a patient
with burns. Which intravenous fluid is most commonly used in the first 24 hours?
A. 0.45% Normal Saline
B. 5% Dextrose in Water
C. Lactated Ringer’s solution
D. Albumin 5% solution
Correct Answer: C
, Expert Explanation: Lactated Ringer’s (LR) is the fluid of choice for burn
resuscitation because its composition closely matches extracellular fluid. LR helps to
correct the metabolic acidosis that often occurs during the emergent phase of a burn
injury. It provides necessary electrolytes and buffers without causing the
hyperchloremic acidosis associated with large volumes of normal saline. The
Parkland formula dictates that half of the calculated volume is administered within
the first eight hours post-burn. Consistent monitoring of urine output is the best
indicator of the adequacy of this fluid resuscitation strategy.
5. A nurse is caring for a patient with herpes zoster (shingles). Which isolation
precaution should the nurse implement for a patient with disseminated lesions?
A. Standard precautions only
B. Contact precautions only
C. Airborne and Contact precautions
D. Droplet precautions
Correct Answer: C
Expert Explanation: Herpes zoster is caused by the reactivation of the varicella-
zoster virus and can be transmitted via direct contact or air. For patients with
disseminated disease or who are immunocompromised, both airborne and contact
precautions are required. This involves placing the patient in a negative-pressure
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a patient in the emergent phase of a major burn injury. Which
nursing intervention is the highest priority?
A. Administering prescribed analgesic medication for pain relief.
B. Inserting a large-bore intravenous catheter for fluid resuscitation.
C. Calculating the total body surface area burned using the Rule of Nines.
D. Assessing airway patency and maintaining cervical spine stability.
Correct Answer: D
Expert Explanation: The emergent phase of burn management focuses on the
immediate life-saving measures categorized by the ABCs. Airway maintenance is the
absolute priority because inhalation injuries can cause rapid edema and obstruction.
The nurse must ensure the patient has a patent airway and adequate oxygenation
before addressing other needs. While fluid resuscitation and pain management are
critical, they follow the establishment of a secure airway. Continuous monitoring of
respiratory effort and breath sounds is essential during this initial period of care.
,2. A nurse assesses a pressure injury and observes full-thickness skin loss with visible
subcutaneous fat, but no exposed bone, tendon, or muscle. How should the nurse
stage this injury?
A. Stage 3
B. Stage 2
C. Stage 4
D. Unstageable
Correct Answer: A
Expert Explanation: A Stage 3 pressure injury involves full-thickness tissue loss
where subcutaneous fat may be visible in the wound bed. At this stage, the depth of
the wound does not yet expose underlying structures like bone or muscle. Slough or
eschar may be present but do not obscure the depth of tissue loss. The nurse must
assess for undermining or tunneling, which are common features of Stage 3 injuries.
Proper documentation and pressure relief strategies are vital to prevent the wound
from progressing to a Stage 4 injury.
3. A patient is admitted with suspected carbon monoxide poisoning following a house
fire. Which clinical finding should the nurse expect to observe?
A. Pulse oximetry reading of 85% on room air.
B. Cherry-red skin color and headache.
,C. Severe expiratory wheezing and stridor.
D. Copious amounts of black, carbonaceous sputum.
Correct Answer: B
Expert Explanation: Carbon monoxide has a much higher affinity for hemoglobin
than oxygen, leading to tissue hypoxia despite normal pulse oximetry readings. The
classic clinical sign of carbon monoxide poisoning is a cherry-red appearance of the
skin and mucous membranes. Patients often report neurological symptoms such as
headache, dizziness, and confusion due to cerebral hypoxia. Pulse oximetry is
unreliable because the device cannot distinguish between carboxyhemoglobin and
oxyhemoglobin. Immediate treatment with 100% humidified oxygen is necessary to
displace the carbon monoxide from the hemoglobin molecules.
4. The nurse is using the Parkland formula to calculate fluid resuscitation for a patient
with burns. Which intravenous fluid is most commonly used in the first 24 hours?
A. 0.45% Normal Saline
B. 5% Dextrose in Water
C. Lactated Ringer’s solution
D. Albumin 5% solution
Correct Answer: C
, Expert Explanation: Lactated Ringer’s (LR) is the fluid of choice for burn
resuscitation because its composition closely matches extracellular fluid. LR helps to
correct the metabolic acidosis that often occurs during the emergent phase of a burn
injury. It provides necessary electrolytes and buffers without causing the
hyperchloremic acidosis associated with large volumes of normal saline. The
Parkland formula dictates that half of the calculated volume is administered within
the first eight hours post-burn. Consistent monitoring of urine output is the best
indicator of the adequacy of this fluid resuscitation strategy.
5. A nurse is caring for a patient with herpes zoster (shingles). Which isolation
precaution should the nurse implement for a patient with disseminated lesions?
A. Standard precautions only
B. Contact precautions only
C. Airborne and Contact precautions
D. Droplet precautions
Correct Answer: C
Expert Explanation: Herpes zoster is caused by the reactivation of the varicella-
zoster virus and can be transmitted via direct contact or air. For patients with
disseminated disease or who are immunocompromised, both airborne and contact
precautions are required. This involves placing the patient in a negative-pressure
