NR341/NR 341 Exam 4 V2 | Complex Adult
Health Q&A with Rationale | Chamberlain
University
1. A patient arrives in the emergency department with deep partial-thickness burns to the
entire left arm and the anterior trunk. Using the Rule of Nines, what is the estimated total
body surface area (TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Correct Answer: B
Expert Explanation: The Rule of Nines assigns 9% to the entire left arm and 18% to the
anterior trunk. Adding these two percentages together results in a total of 27% TBSA.
Accurate calculation of burn surface area is critical for determining fluid resuscitation
requirements in the emergent phase.
2. A client is in the emergent phase of burn care. Which of the following electrolyte
imbalances should the nurse expect to find?
A. Hypokalemia and hypernatremia
B. Hyperkalemia and hyponatremia
,C. Hypocalcemia and hyperkalemia
D. Hypermagnesemia and hyponatremia
Correct Answer: B
Expert Explanation: During the emergent phase, potassium is released from damaged
cells into the extracellular space, leading to hyperkalemia. Sodium follows water into the
interstitial space due to increased capillary permeability, resulting in hyponatremia.
Monitoring these levels is vital to prevent cardiac arrhythmias and neurological
complications.
3. The nurse is caring for a patient weighing 70 kg with a 50% TBSA burn. According to the
Parkland formula (4 mL/kg/TBSA), how many milliliters of fluid should be administered in the
first 8 hours?
A. 3,500 mL
B. 14,000 mL
C. 7,000 mL
D. 10,500 mL
Correct Answer: C
Expert Explanation: The total 24-hour fluid requirement is calculated as 4 mL x 70 kg x 50
= 14,000 mL. The Parkland formula dictates that half of this total volume, which is 7,000
mL, must be infused within the first 8 hours from the time of injury. Consistent monitoring
of urine output is the best indicator that this resuscitation is effective.
, 4. A patient with a high-level spinal cord injury (T2) is experiencing a sudden, throbbing
headache and a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication.
B. Lower the head of the bed to the flat position.
C. Check the patient’s bladder for distension.
D. Notify the healthcare provider immediately.
Correct Answer: C
Expert Explanation: These symptoms are classic signs of autonomic dysreflexia, a life-
threatening emergency in spinal cord injury patients. The most common cause is a full
bladder or impacted bowel, which triggers a massive sympathetic response. The nurse
must first eliminate the stimulus by checking the catheter or bladder before proceeding
with other interventions.
5. Which of the following assessments is most indicative of the ‘Compensatory Stage’ of
shock?
A. Narrowing pulse pressure and cold, clammy skin.
B. Lethargy and decreased responsiveness.
C. Mean arterial pressure (MAP) less than 60 mmHg.
D. Anuria and metabolic acidosis.
Correct Answer: A
Health Q&A with Rationale | Chamberlain
University
1. A patient arrives in the emergency department with deep partial-thickness burns to the
entire left arm and the anterior trunk. Using the Rule of Nines, what is the estimated total
body surface area (TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Correct Answer: B
Expert Explanation: The Rule of Nines assigns 9% to the entire left arm and 18% to the
anterior trunk. Adding these two percentages together results in a total of 27% TBSA.
Accurate calculation of burn surface area is critical for determining fluid resuscitation
requirements in the emergent phase.
2. A client is in the emergent phase of burn care. Which of the following electrolyte
imbalances should the nurse expect to find?
A. Hypokalemia and hypernatremia
B. Hyperkalemia and hyponatremia
,C. Hypocalcemia and hyperkalemia
D. Hypermagnesemia and hyponatremia
Correct Answer: B
Expert Explanation: During the emergent phase, potassium is released from damaged
cells into the extracellular space, leading to hyperkalemia. Sodium follows water into the
interstitial space due to increased capillary permeability, resulting in hyponatremia.
Monitoring these levels is vital to prevent cardiac arrhythmias and neurological
complications.
3. The nurse is caring for a patient weighing 70 kg with a 50% TBSA burn. According to the
Parkland formula (4 mL/kg/TBSA), how many milliliters of fluid should be administered in the
first 8 hours?
A. 3,500 mL
B. 14,000 mL
C. 7,000 mL
D. 10,500 mL
Correct Answer: C
Expert Explanation: The total 24-hour fluid requirement is calculated as 4 mL x 70 kg x 50
= 14,000 mL. The Parkland formula dictates that half of this total volume, which is 7,000
mL, must be infused within the first 8 hours from the time of injury. Consistent monitoring
of urine output is the best indicator that this resuscitation is effective.
, 4. A patient with a high-level spinal cord injury (T2) is experiencing a sudden, throbbing
headache and a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication.
B. Lower the head of the bed to the flat position.
C. Check the patient’s bladder for distension.
D. Notify the healthcare provider immediately.
Correct Answer: C
Expert Explanation: These symptoms are classic signs of autonomic dysreflexia, a life-
threatening emergency in spinal cord injury patients. The most common cause is a full
bladder or impacted bowel, which triggers a massive sympathetic response. The nurse
must first eliminate the stimulus by checking the catheter or bladder before proceeding
with other interventions.
5. Which of the following assessments is most indicative of the ‘Compensatory Stage’ of
shock?
A. Narrowing pulse pressure and cold, clammy skin.
B. Lethargy and decreased responsiveness.
C. Mean arterial pressure (MAP) less than 60 mmHg.
D. Anuria and metabolic acidosis.
Correct Answer: A
