NUR2755 Exam 4 Actual Exam Style V3 |
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A patient is admitted with suspected septic shock. Which of the following clinical findings
most accurately reflects the early (hyperdynamic) phase of sepsis?
A. Cool, clammy skin with decreased heart rate
B. Severe hypotension with oliguria
C. Warm, flushed skin and increased cardiac output
D. Confusion and bradycardia
Answer: C
Rationale: In the early phase of septic shock, the body attempts to compensate for
systemic vasodilation. This results in a hyperdynamic state characterized by warm skin and
a high cardiac output due to decreased peripheral resistance. It is critical to recognize these
signs early to initiate fluid resuscitation and antibiotic therapy.
2. A nurse is calculating the fluid resuscitation requirements for a client with 40% Total Body
Surface Area (TBSA) burns. The client weighs 75 kg. Using the Parkland formula (4 mL/kg/%
TBSA), what is the total volume to be infused in the first 24 hours?
A. 12,000 mL
B. 10,000 mL
,C. 6,000 mL
D. 15,000 mL
Answer: A
Rationale: The Parkland formula calculates total fluid requirements as 4 mL multiplied by
the weight in kilograms and the percentage of TBSA burned. For this client, the calculation
is 4 mL x 75 kg x 40, which equals 12,000 mL. Half of this volume is typically administered
within the first 8 hours post-injury.
3. During a mass casualty incident, a nurse is triaging victims. A patient has a patent airway
but is breathing 34 times per minute and has a capillary refill of 3 seconds. Which triage tag
color should the nurse assign?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: A red tag indicates an immediate priority for patients with life-threatening but
treatable injuries. Respiratory rates over 30 and delayed capillary refill are indicators of
physiological instability. This patient requires urgent medical attention to prevent further
deterioration.
, 4. A patient on a mechanical ventilator is showing a ‘High Pressure’ alarm. Which of the
following actions should the nurse perform first?
A. Suction the patient immediately for 30 seconds
B. Increase the oxygen concentration on the ventilator
C. Assess the patient’s breath sounds and check for tube obstruction
D. Call the respiratory therapist to change the ventilator settings
Answer: C
Rationale: High-pressure alarms usually indicate an obstruction or resistance in the
airway such as secretions, biting the tube, or a pneumothorax. The nurse’s first action
should always be to assess the patient and the circuit for the source of the resistance.
Troubleshooting should begin with the most common and easily corrected issues like
tubing kinks or patient coughing.
5. A client with full-thickness burns is in the emergent phase of injury. What is the primary
electrolyte imbalance the nurse should monitor for during this phase?
A. Hypokalemia
B. Hypocalcemia
C. Hypernatremia
D. Hyperkalemia
Answer: D
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A patient is admitted with suspected septic shock. Which of the following clinical findings
most accurately reflects the early (hyperdynamic) phase of sepsis?
A. Cool, clammy skin with decreased heart rate
B. Severe hypotension with oliguria
C. Warm, flushed skin and increased cardiac output
D. Confusion and bradycardia
Answer: C
Rationale: In the early phase of septic shock, the body attempts to compensate for
systemic vasodilation. This results in a hyperdynamic state characterized by warm skin and
a high cardiac output due to decreased peripheral resistance. It is critical to recognize these
signs early to initiate fluid resuscitation and antibiotic therapy.
2. A nurse is calculating the fluid resuscitation requirements for a client with 40% Total Body
Surface Area (TBSA) burns. The client weighs 75 kg. Using the Parkland formula (4 mL/kg/%
TBSA), what is the total volume to be infused in the first 24 hours?
A. 12,000 mL
B. 10,000 mL
,C. 6,000 mL
D. 15,000 mL
Answer: A
Rationale: The Parkland formula calculates total fluid requirements as 4 mL multiplied by
the weight in kilograms and the percentage of TBSA burned. For this client, the calculation
is 4 mL x 75 kg x 40, which equals 12,000 mL. Half of this volume is typically administered
within the first 8 hours post-injury.
3. During a mass casualty incident, a nurse is triaging victims. A patient has a patent airway
but is breathing 34 times per minute and has a capillary refill of 3 seconds. Which triage tag
color should the nurse assign?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: A red tag indicates an immediate priority for patients with life-threatening but
treatable injuries. Respiratory rates over 30 and delayed capillary refill are indicators of
physiological instability. This patient requires urgent medical attention to prevent further
deterioration.
, 4. A patient on a mechanical ventilator is showing a ‘High Pressure’ alarm. Which of the
following actions should the nurse perform first?
A. Suction the patient immediately for 30 seconds
B. Increase the oxygen concentration on the ventilator
C. Assess the patient’s breath sounds and check for tube obstruction
D. Call the respiratory therapist to change the ventilator settings
Answer: C
Rationale: High-pressure alarms usually indicate an obstruction or resistance in the
airway such as secretions, biting the tube, or a pneumothorax. The nurse’s first action
should always be to assess the patient and the circuit for the source of the resistance.
Troubleshooting should begin with the most common and easily corrected issues like
tubing kinks or patient coughing.
5. A client with full-thickness burns is in the emergent phase of injury. What is the primary
electrolyte imbalance the nurse should monitor for during this phase?
A. Hypokalemia
B. Hypocalcemia
C. Hypernatremia
D. Hyperkalemia
Answer: D
