NUR2790/NUR 2790 Exam 4 V2 |
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is triaging victims at the scene of a multi-vehicle accident using the START method.
Which patient should receive a red tag?
A. A patient who is walking and has minor abrasions.
B. A patient with a respiratory rate of 35 breaths per minute.
C. A patient with no respirations even after repositioning the airway.
D. A patient who follows simple commands and has a broken arm.
Correct Answer: B
Expert Explanation: In the START triage system, a respiratory rate greater than 30
breaths per minute indicates an immediate (red tag) priority. Patients who are walking are
tagged green, while those not breathing after airway manipulation are tagged black. Red
tags are reserved for those with life-threatening injuries who are likely to survive if treated
immediately.
,2. A client arrives in the emergency department with partial-thickness burns to the entire left
arm and the anterior trunk. Using the Rule of Nines, what is the total body surface area
(TBSA) affected?
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Expert Explanation: According to the Rule of Nines, the entire arm accounts for 9% of the
TBSA. The anterior trunk accounts for 18% of the TBSA. Adding 9% and 18% results in a
total of 27% TBSA burned.
3. The high-pressure alarm on a patient’s mechanical ventilator is sounding. What is the most
appropriate initial action by the nurse?
A. Suction the patient’s airway for secretions.
B. Check the patient’s oxygen saturation level.
C. Assess the patient and the tubing for kinks or biting.
D. Increase the fraction of inspired oxygen (FiO2).
Correct Answer: C
, Expert Explanation: A high-pressure alarm indicates that the ventilator is meeting
resistance while trying to deliver a breath. Common causes include the patient biting the
tube, kinks in the circuit, or excessive secretions. The nurse must first assess the patient
and the equipment to identify the source of resistance.
4. A patient in the early stage of septic shock exhibits which of the following clinical
manifestations?
A. Warm, flushed skin and tachycardia.
B. Cool, clammy skin and bradycardia.
C. Decreased urine output and hypotension.
D. Lethargy and pale mucous membranes.
Correct Answer: A
Expert Explanation: In the hyperdynamic or warm phase of septic shock, cardiac output is
often high and systemic vascular resistance is low. This results in warm, flushed skin and a
rapid heart rate. As shock progresses to the cold phase, the skin becomes cool and clammy
due to hypoperfusion.
5. Which laboratory result is most indicative of Disseminated Intravascular Coagulation (DIC)?
A. Increased platelet count.
B. Elevated D-dimer levels.
C. Shortened Prothrombin Time (PT).
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is triaging victims at the scene of a multi-vehicle accident using the START method.
Which patient should receive a red tag?
A. A patient who is walking and has minor abrasions.
B. A patient with a respiratory rate of 35 breaths per minute.
C. A patient with no respirations even after repositioning the airway.
D. A patient who follows simple commands and has a broken arm.
Correct Answer: B
Expert Explanation: In the START triage system, a respiratory rate greater than 30
breaths per minute indicates an immediate (red tag) priority. Patients who are walking are
tagged green, while those not breathing after airway manipulation are tagged black. Red
tags are reserved for those with life-threatening injuries who are likely to survive if treated
immediately.
,2. A client arrives in the emergency department with partial-thickness burns to the entire left
arm and the anterior trunk. Using the Rule of Nines, what is the total body surface area
(TBSA) affected?
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Expert Explanation: According to the Rule of Nines, the entire arm accounts for 9% of the
TBSA. The anterior trunk accounts for 18% of the TBSA. Adding 9% and 18% results in a
total of 27% TBSA burned.
3. The high-pressure alarm on a patient’s mechanical ventilator is sounding. What is the most
appropriate initial action by the nurse?
A. Suction the patient’s airway for secretions.
B. Check the patient’s oxygen saturation level.
C. Assess the patient and the tubing for kinks or biting.
D. Increase the fraction of inspired oxygen (FiO2).
Correct Answer: C
, Expert Explanation: A high-pressure alarm indicates that the ventilator is meeting
resistance while trying to deliver a breath. Common causes include the patient biting the
tube, kinks in the circuit, or excessive secretions. The nurse must first assess the patient
and the equipment to identify the source of resistance.
4. A patient in the early stage of septic shock exhibits which of the following clinical
manifestations?
A. Warm, flushed skin and tachycardia.
B. Cool, clammy skin and bradycardia.
C. Decreased urine output and hypotension.
D. Lethargy and pale mucous membranes.
Correct Answer: A
Expert Explanation: In the hyperdynamic or warm phase of septic shock, cardiac output is
often high and systemic vascular resistance is low. This results in warm, flushed skin and a
rapid heart rate. As shock progresses to the cold phase, the skin becomes cool and clammy
due to hypoperfusion.
5. Which laboratory result is most indicative of Disseminated Intravascular Coagulation (DIC)?
A. Increased platelet count.
B. Elevated D-dimer levels.
C. Shortened Prothrombin Time (PT).
