NUR 2755 Exam 2 Updated: Multidimensional Care IV /
MDC 4 - Rasmussen
1. When caring for a patient who has septic shock, which assessment finding is most
important for the nurse to report to the care provider?
A. BP 92/56
B. Skin cool and clammy
C. Apical pulse 118 beats/min
D. Arterial oxygen saturation 91%
Answer: B
Rationale: Cool, clammy skin in a septic shock patient indicates progression
from the early "warm" (hyperdynamic) phase to the late "cold" (hypodynamic)
phase of shock. This signals worsening tissue perfusion, peripheral
vasoconstriction, and potential cardiovascular decompensation requiring
immediate intervention .
2. A nurse is caring for a client in hypovolemic shock related to hemorrhage. Which IV
solution should the nurse prepare to infuse with a blood transfusion?
A. 3% Sodium chloride solution
B. Total parenteral nutrition
C. Normal saline solution
D. Lactated Ringer's solution
Answer: C
Rationale: Only normal saline (0.9% NaCl) is compatible with blood products.
Lactated Ringer's contains calcium, which can bind with citrate in stored blood
,and cause clotting. Hypertonic saline and TPN are not compatible with blood
transfusions .
3. Calculate the mean arterial pressure (MAP) for a patient with a blood pressure of
84/46 mmHg. (Record answer to the nearest whole number)
A. 54 mmHg
B. 59 mmHg
C. 64 mmHg
D. 69 mmHg
Answer: B
*Rationale: MAP = SBP + 2(DBP) ÷ 3. Calculation: 84 + 2(46) = 84 + 92 = 176 ÷ 3 =
58.6 mmHg, rounded to 59 mmHg. A MAP of at least 65 mmHg is needed to perfuse
vital organs .*
4. A client is admitted with burns to 35% of total body surface area (TBSA). Using the
Parkland Formula (4 mL/kg/%TBSA), calculate the fluid requirement for the first 8
hours for a patient weighing 70 kg.
A. 2,450 mL
B. 4,900 mL
C. 7,350 mL
D. 9,800 mL
Answer: B
*Rationale: Parkland Formula: 4 mL × 70 kg × 35% TBSA = 9,800 mL total over 24
hours. Half of this volume (4,900 mL) is given in the first 8 hours post-burn. The
remaining half is given over the next 16 hours .*
5. During the compensatory stage of shock, which physiological response occurs?
A. Decreased heart rate
B. Increased urinary output
C. Peripheral vasodilation
,D. Increased systemic vascular resistance (SVR)
Answer: D
Rationale: During compensatory shock, the sympathetic nervous system
activates baroreceptors, causing release of catecholamines (epinephrine,
norepinephrine). This leads to vasoconstriction (increased SVR), increased heart
rate, and increased contractility to maintain perfusion to vital organs .
6. Which type of shock is caused by a severe allergic reaction?
A. Septic shock
B. Neurogenic shock
C. Anaphylactic shock
D. Cardiogenic shock
Answer: C
Rationale: Anaphylactic shock results from a severe allergic reaction causing
massive histamine release, leading to vasodilation, increased capillary
permeability, and bronchoconstriction. It is a distributive shock subtype .
7. A patient with neurogenic shock would most likely present with which finding?
A. Tachycardia and hypertension
B. Bradycardia and hypotension
C. Fever and bounding pulses
D. Tachypnea and jugular venous distension
Answer: B
Rationale: Neurogenic shock results from loss of sympathetic nervous system
tone (often from spinal cord injury). This causes unopposed vagal tone leading
to bradycardia, as well as vasodilation leading to hypotension. Warm, dry skin
is also typical .
8. A patient with a traumatic brain injury begins showing signs of shock. How should
the patient be positioned?
, A. Head lower than body (Trendelenburg)
B. Flat with legs elevated (Modified Trendelenburg)
C. Flat on the back (Supine)
D. High Fowler's position
Answer: C
Rationale: In a patient with head injury, elevating the legs may increase
intracranial pressure (ICP). The patient should be kept flat (supine) to maintain
cerebral perfusion while avoiding increased ICP. Modified Trendelenburg is used
for hypovolemic shock without head injury .
9. Which finding is the best indicator that fluid resuscitation for a patient with
hypovolemic shock has been successful?
A. Hemoglobin is within normal limits
B. Urine output is 60 mL over the last hour
C. Pulmonary artery wedge pressure (PAWP) is 12 mmHg
D. Heart rate is 110 beats/min
Answer: B
*Rationale: Urine output of at least 0.5 mL/kg/hour (approximately 30-60 mL/hour)
indicates adequate renal perfusion and is one of the most reliable clinical indicators of
successful fluid resuscitation in shock .*
10. Which medication places a client with shock at risk for a hypertensive reaction,
requiring the nurse to assess blood pressure at least every 15 minutes?
A. Norepinephrine
B. Dobutamine
C. Sodium nitroprusside
D. Amiodarone
Answer: A
*Rationale: Norepinephrine (Levophed) is a potent vasopressor that causes significant
MDC 4 - Rasmussen
1. When caring for a patient who has septic shock, which assessment finding is most
important for the nurse to report to the care provider?
A. BP 92/56
B. Skin cool and clammy
C. Apical pulse 118 beats/min
D. Arterial oxygen saturation 91%
Answer: B
Rationale: Cool, clammy skin in a septic shock patient indicates progression
from the early "warm" (hyperdynamic) phase to the late "cold" (hypodynamic)
phase of shock. This signals worsening tissue perfusion, peripheral
vasoconstriction, and potential cardiovascular decompensation requiring
immediate intervention .
2. A nurse is caring for a client in hypovolemic shock related to hemorrhage. Which IV
solution should the nurse prepare to infuse with a blood transfusion?
A. 3% Sodium chloride solution
B. Total parenteral nutrition
C. Normal saline solution
D. Lactated Ringer's solution
Answer: C
Rationale: Only normal saline (0.9% NaCl) is compatible with blood products.
Lactated Ringer's contains calcium, which can bind with citrate in stored blood
,and cause clotting. Hypertonic saline and TPN are not compatible with blood
transfusions .
3. Calculate the mean arterial pressure (MAP) for a patient with a blood pressure of
84/46 mmHg. (Record answer to the nearest whole number)
A. 54 mmHg
B. 59 mmHg
C. 64 mmHg
D. 69 mmHg
Answer: B
*Rationale: MAP = SBP + 2(DBP) ÷ 3. Calculation: 84 + 2(46) = 84 + 92 = 176 ÷ 3 =
58.6 mmHg, rounded to 59 mmHg. A MAP of at least 65 mmHg is needed to perfuse
vital organs .*
4. A client is admitted with burns to 35% of total body surface area (TBSA). Using the
Parkland Formula (4 mL/kg/%TBSA), calculate the fluid requirement for the first 8
hours for a patient weighing 70 kg.
A. 2,450 mL
B. 4,900 mL
C. 7,350 mL
D. 9,800 mL
Answer: B
*Rationale: Parkland Formula: 4 mL × 70 kg × 35% TBSA = 9,800 mL total over 24
hours. Half of this volume (4,900 mL) is given in the first 8 hours post-burn. The
remaining half is given over the next 16 hours .*
5. During the compensatory stage of shock, which physiological response occurs?
A. Decreased heart rate
B. Increased urinary output
C. Peripheral vasodilation
,D. Increased systemic vascular resistance (SVR)
Answer: D
Rationale: During compensatory shock, the sympathetic nervous system
activates baroreceptors, causing release of catecholamines (epinephrine,
norepinephrine). This leads to vasoconstriction (increased SVR), increased heart
rate, and increased contractility to maintain perfusion to vital organs .
6. Which type of shock is caused by a severe allergic reaction?
A. Septic shock
B. Neurogenic shock
C. Anaphylactic shock
D. Cardiogenic shock
Answer: C
Rationale: Anaphylactic shock results from a severe allergic reaction causing
massive histamine release, leading to vasodilation, increased capillary
permeability, and bronchoconstriction. It is a distributive shock subtype .
7. A patient with neurogenic shock would most likely present with which finding?
A. Tachycardia and hypertension
B. Bradycardia and hypotension
C. Fever and bounding pulses
D. Tachypnea and jugular venous distension
Answer: B
Rationale: Neurogenic shock results from loss of sympathetic nervous system
tone (often from spinal cord injury). This causes unopposed vagal tone leading
to bradycardia, as well as vasodilation leading to hypotension. Warm, dry skin
is also typical .
8. A patient with a traumatic brain injury begins showing signs of shock. How should
the patient be positioned?
, A. Head lower than body (Trendelenburg)
B. Flat with legs elevated (Modified Trendelenburg)
C. Flat on the back (Supine)
D. High Fowler's position
Answer: C
Rationale: In a patient with head injury, elevating the legs may increase
intracranial pressure (ICP). The patient should be kept flat (supine) to maintain
cerebral perfusion while avoiding increased ICP. Modified Trendelenburg is used
for hypovolemic shock without head injury .
9. Which finding is the best indicator that fluid resuscitation for a patient with
hypovolemic shock has been successful?
A. Hemoglobin is within normal limits
B. Urine output is 60 mL over the last hour
C. Pulmonary artery wedge pressure (PAWP) is 12 mmHg
D. Heart rate is 110 beats/min
Answer: B
*Rationale: Urine output of at least 0.5 mL/kg/hour (approximately 30-60 mL/hour)
indicates adequate renal perfusion and is one of the most reliable clinical indicators of
successful fluid resuscitation in shock .*
10. Which medication places a client with shock at risk for a hypertensive reaction,
requiring the nurse to assess blood pressure at least every 15 minutes?
A. Norepinephrine
B. Dobutamine
C. Sodium nitroprusside
D. Amiodarone
Answer: A
*Rationale: Norepinephrine (Levophed) is a potent vasopressor that causes significant
