NUR 265 Exam 4: Advanced MedSurg - Galen College of
Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is performing triage at a mass casualty incident using the START method. A victim is found with a
respiratory rate of 34 breaths/min. Which color tag should the nurse assign?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
Rationale: According to the START triage protocol, any victim with a respiratory rate over 30 breaths
per minute is tagged red. This indicates an immediate need for medical intervention to prevent death.
Green tags are reserved for the walking wounded who can follow commands. Yellow tags are for those
who can wait, and black tags are for the deceased or non-salvageable. Rapid assessment of breathing is
the first step in the triage algorithm.
2. A patient weighs 80 kg and has sustained partial-thickness burns over 40% of their body. Using the
Parkland formula, how much fluid should the nurse administer in the first 8 hours?
A. 3,200 mL
B. 6,400 mL
C. 12,800 mL
D. 4,800 mL
Correct Answer: B
,Rationale: The Parkland formula is 4 mL x weight (kg) x % TBSA burned. For this patient, the total 24-
hour volume is 4 x 80 x 40, which equals 12,800 mL. One-half of this total volume, 6,400 mL, must be
given in the first 8 hours post-injury. The remaining half is administered over the subsequent 16 hours.
Calculating fluid needs accurately is vital to prevent hypovolemic shock in burn victims.
3. A patient arrives in the ED with cherry-red skin and soot around the nose following a house fire. Which
action should the nurse take first?
A. Insert a large-bore IV line
B. Check for peripheral pulses
C. Calculate the Rule of Nines
D. Administer 100% oxygen via non-rebreather mask
Correct Answer: D
Rationale: Cherry-red skin color and soot indicate carbon monoxide poisoning and potential inhalation
injury. The nurse must prioritize oxygenation by providing 100% humidified oxygen immediately.
Carbon monoxide has a higher affinity for hemoglobin than oxygen does. While IV access is important, it
follows airway and breathing stabilization. Monitoring for stridor or respiratory distress is a key nursing
responsibility in this scenario.
4. During the emergent phase of a burn injury, which electrolyte imbalance does the nurse expect to find?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B
, Rationale: Hyperkalemia occurs during the emergent phase due to massive cell destruction and the
release of intracellular potassium. As cells are damaged by heat, they spill their contents into the
extracellular space. Conversely, hyponatremia typically occurs as sodium follows fluid into the interstitial
space. The nurse must monitor for cardiac arrhythmias associated with high potassium levels. Fluid
resuscitation eventually helps normalize these levels as the diuretic phase begins.
5. A patient in the ICU has a blood pressure of 80/40 mmHg, heart rate of 124, and a CVP of 2 mmHg. Which
type of shock is most likely occurring?
A. Hypovolemic
B. Cardiogenic
C. Neurogenic
D. Anaphylactic
Correct Answer: A
Rationale: Low blood pressure combined with a low Central Venous Pressure (CVP) of 2 mmHg indicates
hypovolemia. CVP measures right atrial pressure and reflects fluid volume status within the venous
system. In cardiogenic shock, the CVP would typically be elevated due to pump failure. Neurogenic shock
usually presents with bradycardia rather than tachycardia. The nurse should anticipate fluid boluses to
increase the preload and blood pressure.
6. A patient with septic shock has a MAP of 55 mmHg despite fluid resuscitation. Which medication should
the nurse prepare to administer next?
A. Furosemide
B. Nitroglycerin
C. Norepinephrine
Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is performing triage at a mass casualty incident using the START method. A victim is found with a
respiratory rate of 34 breaths/min. Which color tag should the nurse assign?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
Rationale: According to the START triage protocol, any victim with a respiratory rate over 30 breaths
per minute is tagged red. This indicates an immediate need for medical intervention to prevent death.
Green tags are reserved for the walking wounded who can follow commands. Yellow tags are for those
who can wait, and black tags are for the deceased or non-salvageable. Rapid assessment of breathing is
the first step in the triage algorithm.
2. A patient weighs 80 kg and has sustained partial-thickness burns over 40% of their body. Using the
Parkland formula, how much fluid should the nurse administer in the first 8 hours?
A. 3,200 mL
B. 6,400 mL
C. 12,800 mL
D. 4,800 mL
Correct Answer: B
,Rationale: The Parkland formula is 4 mL x weight (kg) x % TBSA burned. For this patient, the total 24-
hour volume is 4 x 80 x 40, which equals 12,800 mL. One-half of this total volume, 6,400 mL, must be
given in the first 8 hours post-injury. The remaining half is administered over the subsequent 16 hours.
Calculating fluid needs accurately is vital to prevent hypovolemic shock in burn victims.
3. A patient arrives in the ED with cherry-red skin and soot around the nose following a house fire. Which
action should the nurse take first?
A. Insert a large-bore IV line
B. Check for peripheral pulses
C. Calculate the Rule of Nines
D. Administer 100% oxygen via non-rebreather mask
Correct Answer: D
Rationale: Cherry-red skin color and soot indicate carbon monoxide poisoning and potential inhalation
injury. The nurse must prioritize oxygenation by providing 100% humidified oxygen immediately.
Carbon monoxide has a higher affinity for hemoglobin than oxygen does. While IV access is important, it
follows airway and breathing stabilization. Monitoring for stridor or respiratory distress is a key nursing
responsibility in this scenario.
4. During the emergent phase of a burn injury, which electrolyte imbalance does the nurse expect to find?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B
, Rationale: Hyperkalemia occurs during the emergent phase due to massive cell destruction and the
release of intracellular potassium. As cells are damaged by heat, they spill their contents into the
extracellular space. Conversely, hyponatremia typically occurs as sodium follows fluid into the interstitial
space. The nurse must monitor for cardiac arrhythmias associated with high potassium levels. Fluid
resuscitation eventually helps normalize these levels as the diuretic phase begins.
5. A patient in the ICU has a blood pressure of 80/40 mmHg, heart rate of 124, and a CVP of 2 mmHg. Which
type of shock is most likely occurring?
A. Hypovolemic
B. Cardiogenic
C. Neurogenic
D. Anaphylactic
Correct Answer: A
Rationale: Low blood pressure combined with a low Central Venous Pressure (CVP) of 2 mmHg indicates
hypovolemia. CVP measures right atrial pressure and reflects fluid volume status within the venous
system. In cardiogenic shock, the CVP would typically be elevated due to pump failure. Neurogenic shock
usually presents with bradycardia rather than tachycardia. The nurse should anticipate fluid boluses to
increase the preload and blood pressure.
6. A patient with septic shock has a MAP of 55 mmHg despite fluid resuscitation. Which medication should
the nurse prepare to administer next?
A. Furosemide
B. Nitroglycerin
C. Norepinephrine
