Multidimensional Care IV – NUR 2755 –
Exam 2 Questions and Correct Answers
(A+ graded, Brand New) – Rasmussen
Section 1: Burns and Burn Care
This section covers the emergency and acute management of burn
injuries, including fluid resuscitation, wound care, and identifying
complications.
Question 1
A nurse is caring for a client with a 25% total body surface area (TBSA)
partial-thickness burn. Which intervention is the priority during the
emergent phase?
A) Administer antibiotics prophylactically
B) Initiate fluid resuscitation
C) Apply silver sulfadiazine immediately
D) Perform wound debridement
Correct ,,,,answer,,,,: B) Initiate fluid resuscitation
Rationale: During the emergent phase, the priority is to prevent
hypovolemic shock. Fluid loss from damaged skin can lead to a
dangerous drop in blood volume, so restoring circulating volume with
IV fluids is the immediate concern. The Parkland formula is used to
guide this fluid resuscitation in the first 24 hours .
,Question 2
A client with a major burn injury develops tachycardia and hypotension.
Which type of shock is most likely?
A) Cardiogenic shock
B) Hypovolemic shock
C) Septic shock
D) Neurogenic shock
Correct ,,,,answer,,,,: B) Hypovolemic shock
Rationale: Burn injuries cause significant fluid loss through damaged
capillaries and evaporative water loss from the wound surface. This fluid
shift from the intravascular space to the interstitial space leads to
hypovolemia, which manifests as tachycardia and hypotension .
Question 3
A nurse is applying silver sulfadiazine (Silvadene) to a client’s burn
wounds. What is the primary purpose of this medication?
A) Pain relief
B) Prevent infection
C) Promote skin regeneration
D) Reduce edema
Correct ,,,,answer,,,,: B) Prevent infection
Rationale: Silver sulfadiazine is a topical antimicrobial cream. Its
primary purpose is to prevent and treat burn wound infections by
inhibiting bacterial growth. It is not an analgesic and does not directly
promote skin growth or reduce edema .
Question 4
A nurse is monitoring a client with burns during the acute phase. Which
metabolic change is expected?
,A) Decreased metabolic rate
B) Hypermetabolism
C) Hypoglycemia
D) Reduced protein catabolism
Correct ,,,,answer,,,,: B) Hypermetabolism
Rationale: Major burns trigger a profound hypermetabolic stress
response. The body's metabolic rate can increase significantly to support
healing and fight inflammation. This leads to increased calorie and
protein needs, making nutritional support a critical part of care .
Question 5
A client is admitted with burns to the face, neck, and hands. Which
finding requires the most immediate action by the nurse?
A) The client reports a pain level of 7 on a 0-10 scale.
B) The client's voice becomes hoarse and they develop a brassy cough.
C) The client's family member requests to see them.
D) The client's blood pressure is 148/90 mm Hg.
Correct ,,,,answer,,,,: B) The client's voice becomes hoarse and they
develop a brassy cough.
Rationale: A hoarse voice and brassy cough are late signs of respiratory
distress from an inhalation injury. This indicates that the airway may be
swelling, putting the client at immediate risk for complete airway
obstruction. This is a higher priority than pain management, family
visitation, or non-critical vital signs .
Section 2: Shock States
, This section focuses on identifying, differentiating, and managing
various types of shock (e.g., hypovolemic, cardiogenic, septic,
neurogenic).
Question 6
A nurse is assessing a client with septic shock. Which finding is most
critical to report immediately?
A) Heart rate 88 bpm
B) Mean arterial pressure (MAP) 55 mm Hg
C) Temperature 99°F
D) Urine output 40 mL/hr
Correct ,,,,answer,,,,: B) Mean arterial pressure (MAP) 55 mm Hg
Rationale: An MAP of less than 65 mm Hg indicates inadequate tissue
perfusion. MAP is a key measure of perfusion to vital organs. A value of
55 mm Hg requires immediate intervention, such as administering
vasopressors or increasing fluid resuscitation, to prevent organ damage .
Question 7
A client with hypovolemic shock is receiving fluid resuscitation. Which
intervention is included in the initial stage?
A) Administer vasopressors
B) Establish IV access and infuse isotonic fluids
C) Initiate mechanical ventilation
D) Administer corticosteroids
Correct ,,,,answer,,,,: B) Establish IV access and infuse isotonic
fluids
Rationale: The cornerstone of initial hypovolemic shock management is
to restore circulating volume. Large-bore IV access is established, and
isotonic crystalloids (like Lactated Ringer's or normal saline) are rapidly
Exam 2 Questions and Correct Answers
(A+ graded, Brand New) – Rasmussen
Section 1: Burns and Burn Care
This section covers the emergency and acute management of burn
injuries, including fluid resuscitation, wound care, and identifying
complications.
Question 1
A nurse is caring for a client with a 25% total body surface area (TBSA)
partial-thickness burn. Which intervention is the priority during the
emergent phase?
A) Administer antibiotics prophylactically
B) Initiate fluid resuscitation
C) Apply silver sulfadiazine immediately
D) Perform wound debridement
Correct ,,,,answer,,,,: B) Initiate fluid resuscitation
Rationale: During the emergent phase, the priority is to prevent
hypovolemic shock. Fluid loss from damaged skin can lead to a
dangerous drop in blood volume, so restoring circulating volume with
IV fluids is the immediate concern. The Parkland formula is used to
guide this fluid resuscitation in the first 24 hours .
,Question 2
A client with a major burn injury develops tachycardia and hypotension.
Which type of shock is most likely?
A) Cardiogenic shock
B) Hypovolemic shock
C) Septic shock
D) Neurogenic shock
Correct ,,,,answer,,,,: B) Hypovolemic shock
Rationale: Burn injuries cause significant fluid loss through damaged
capillaries and evaporative water loss from the wound surface. This fluid
shift from the intravascular space to the interstitial space leads to
hypovolemia, which manifests as tachycardia and hypotension .
Question 3
A nurse is applying silver sulfadiazine (Silvadene) to a client’s burn
wounds. What is the primary purpose of this medication?
A) Pain relief
B) Prevent infection
C) Promote skin regeneration
D) Reduce edema
Correct ,,,,answer,,,,: B) Prevent infection
Rationale: Silver sulfadiazine is a topical antimicrobial cream. Its
primary purpose is to prevent and treat burn wound infections by
inhibiting bacterial growth. It is not an analgesic and does not directly
promote skin growth or reduce edema .
Question 4
A nurse is monitoring a client with burns during the acute phase. Which
metabolic change is expected?
,A) Decreased metabolic rate
B) Hypermetabolism
C) Hypoglycemia
D) Reduced protein catabolism
Correct ,,,,answer,,,,: B) Hypermetabolism
Rationale: Major burns trigger a profound hypermetabolic stress
response. The body's metabolic rate can increase significantly to support
healing and fight inflammation. This leads to increased calorie and
protein needs, making nutritional support a critical part of care .
Question 5
A client is admitted with burns to the face, neck, and hands. Which
finding requires the most immediate action by the nurse?
A) The client reports a pain level of 7 on a 0-10 scale.
B) The client's voice becomes hoarse and they develop a brassy cough.
C) The client's family member requests to see them.
D) The client's blood pressure is 148/90 mm Hg.
Correct ,,,,answer,,,,: B) The client's voice becomes hoarse and they
develop a brassy cough.
Rationale: A hoarse voice and brassy cough are late signs of respiratory
distress from an inhalation injury. This indicates that the airway may be
swelling, putting the client at immediate risk for complete airway
obstruction. This is a higher priority than pain management, family
visitation, or non-critical vital signs .
Section 2: Shock States
, This section focuses on identifying, differentiating, and managing
various types of shock (e.g., hypovolemic, cardiogenic, septic,
neurogenic).
Question 6
A nurse is assessing a client with septic shock. Which finding is most
critical to report immediately?
A) Heart rate 88 bpm
B) Mean arterial pressure (MAP) 55 mm Hg
C) Temperature 99°F
D) Urine output 40 mL/hr
Correct ,,,,answer,,,,: B) Mean arterial pressure (MAP) 55 mm Hg
Rationale: An MAP of less than 65 mm Hg indicates inadequate tissue
perfusion. MAP is a key measure of perfusion to vital organs. A value of
55 mm Hg requires immediate intervention, such as administering
vasopressors or increasing fluid resuscitation, to prevent organ damage .
Question 7
A client with hypovolemic shock is receiving fluid resuscitation. Which
intervention is included in the initial stage?
A) Administer vasopressors
B) Establish IV access and infuse isotonic fluids
C) Initiate mechanical ventilation
D) Administer corticosteroids
Correct ,,,,answer,,,,: B) Establish IV access and infuse isotonic
fluids
Rationale: The cornerstone of initial hypovolemic shock management is
to restore circulating volume. Large-bore IV access is established, and
isotonic crystalloids (like Lactated Ringer's or normal saline) are rapidly
