NUR2755 Exam 2 Actual Exam Style V2 |
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is triaging victims at the scene of a multi-car accident. A patient has a large open
leg wound but is conscious, breathing at 24 breaths per minute, and has a radial pulse. Which
triage tag should the nurse apply?
A. Green
B. Yellow
C. Red
D. Black
Answer: B
Rationale: Yellow tags are for victims whose injuries are significant but not yet life-
threatening. This patient is stable regarding airway, breathing, and circulation (ABC) but
requires medical attention for the open wound. Red tags are reserved for immediate life
threats, while Green is for the ‘walking wounded’.
2. A patient with 40% total body surface area (TBSA) burns is in the emergent phase of injury.
Which of the following electrolyte imbalances should the nurse expect?
A. Hypernatremia and Hypokalemia
B. Hypokalemia and Hypophosphatemia
,C. Hypocalcemia and Hypernatremia
D. Hyponatremia and Hyperkalemia
Answer: D
Rationale: During the emergent phase of a burn, massive cellular destruction releases
potassium into the bloodstream, leading to hyperkalemia. Sodium follows the fluid shift out
of the vascular space into the interstitial space, resulting in hyponatremia. These
imbalances are critical to monitor to prevent cardiac arrhythmias and other complications.
3. The nurse is caring for a patient in septic shock. Which of the following findings indicates
that the patient has moved into the progressive stage of shock?
A. Mean arterial pressure (MAP) of 75 mmHg
B. Cool, clammy skin and metabolic acidosis
C. Increased urine output to 50 mL/hr
D. Serum lactate level of 1.2 mmol/L
Answer: B
Rationale: The progressive stage of shock is characterized by the failure of compensatory
mechanisms, leading to organ dysfunction. Symptoms include cool/clammy skin, decreased
tissue perfusion, and the buildup of lactic acid resulting in metabolic acidosis. A MAP below
65 mmHg and significantly decreased urine output are also hallmark signs of this stage.
, 4. Using the Parkland formula, calculate the total fluid volume needed in the first 24 hours for
a patient weighing 70 kg with 50% TBSA burns. (Formula: 4mL x kg x %TBSA)
A. 14,000 mL
B. 7,000 mL
C. 28,000 mL
D. 3,500 mL
Answer: A
Rationale: The calculation is 4 mL multiplied by 70 kg multiplied by 50, which equals
14,000 mL. According to the Parkland formula, half of this total (7,000 mL) must be
administered in the first 8 hours. The remaining half is administered over the subsequent
16 hours.
5. A nurse is assessing a client who has sustained a high-voltage electrical burn. What is the
priority assessment for this client?
A. Pain level
B. Cardiac rhythm
C. Peripheral pulses
D. Urine specific gravity
Answer: B
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is triaging victims at the scene of a multi-car accident. A patient has a large open
leg wound but is conscious, breathing at 24 breaths per minute, and has a radial pulse. Which
triage tag should the nurse apply?
A. Green
B. Yellow
C. Red
D. Black
Answer: B
Rationale: Yellow tags are for victims whose injuries are significant but not yet life-
threatening. This patient is stable regarding airway, breathing, and circulation (ABC) but
requires medical attention for the open wound. Red tags are reserved for immediate life
threats, while Green is for the ‘walking wounded’.
2. A patient with 40% total body surface area (TBSA) burns is in the emergent phase of injury.
Which of the following electrolyte imbalances should the nurse expect?
A. Hypernatremia and Hypokalemia
B. Hypokalemia and Hypophosphatemia
,C. Hypocalcemia and Hypernatremia
D. Hyponatremia and Hyperkalemia
Answer: D
Rationale: During the emergent phase of a burn, massive cellular destruction releases
potassium into the bloodstream, leading to hyperkalemia. Sodium follows the fluid shift out
of the vascular space into the interstitial space, resulting in hyponatremia. These
imbalances are critical to monitor to prevent cardiac arrhythmias and other complications.
3. The nurse is caring for a patient in septic shock. Which of the following findings indicates
that the patient has moved into the progressive stage of shock?
A. Mean arterial pressure (MAP) of 75 mmHg
B. Cool, clammy skin and metabolic acidosis
C. Increased urine output to 50 mL/hr
D. Serum lactate level of 1.2 mmol/L
Answer: B
Rationale: The progressive stage of shock is characterized by the failure of compensatory
mechanisms, leading to organ dysfunction. Symptoms include cool/clammy skin, decreased
tissue perfusion, and the buildup of lactic acid resulting in metabolic acidosis. A MAP below
65 mmHg and significantly decreased urine output are also hallmark signs of this stage.
, 4. Using the Parkland formula, calculate the total fluid volume needed in the first 24 hours for
a patient weighing 70 kg with 50% TBSA burns. (Formula: 4mL x kg x %TBSA)
A. 14,000 mL
B. 7,000 mL
C. 28,000 mL
D. 3,500 mL
Answer: A
Rationale: The calculation is 4 mL multiplied by 70 kg multiplied by 50, which equals
14,000 mL. According to the Parkland formula, half of this total (7,000 mL) must be
administered in the first 8 hours. The remaining half is administered over the subsequent
16 hours.
5. A nurse is assessing a client who has sustained a high-voltage electrical burn. What is the
priority assessment for this client?
A. Pain level
B. Cardiac rhythm
C. Peripheral pulses
D. Urine specific gravity
Answer: B
