NUR2571/NUR 2571 Exam 4 V2 |
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is triaging victims of a multi-car accident. A patient has a patent airway but is
breathing at 34 breaths/min and has a capillary refill of 4 seconds. Which triage tag color
should be assigned?
A. Green
B. Red
C. Yellow
D. Black
Correct Answer: B
Expert Explanation: A red tag is assigned to victims with life-threatening injuries who
require immediate intervention. Criteria for red tagging include respiratory rates over 30
per minute or capillary refill greater than 2 seconds. This patient meets both criteria and
must be treated immediately to ensure survival.
2. Which assessment finding in a patient with a 30% total body surface area (TBSA) burn
indicates the beginning of the fluid remobilization (acute) phase?
A. Increased hematocrit levels
,B. Reduced serum potassium
C. Increased urinary output
D. Decreased blood pressure
Correct Answer: C
Expert Explanation: Increased urinary output is a hallmark sign that fluid is shifting from
the interstitial space back into the intravascular space. This usually occurs 48 to 72 hours
after the initial burn injury. During this phase, the nurse must monitor for fluid volume
overload and electrolyte imbalances.
3. A patient arrives in the Emergency Department with suspected carbon monoxide
poisoning. What is the priority nursing intervention?
A. Obtain an arterial blood gas (ABG) sample
B. Administer 100% oxygen via non-rebreather mask
C. Check the patient’s pulse oximetry reading
D. Prepare for immediate intubation
Correct Answer: B
Expert Explanation: Carbon monoxide has a higher affinity for hemoglobin than oxygen,
leading to tissue hypoxia. Administering 100% oxygen is the gold standard treatment to
help displace the carbon monoxide from the hemoglobin. Standard pulse oximetry is
unreliable because it cannot distinguish between oxyhemoglobin and carboxyhemoglobin.
, 4. Using the Parkland formula, calculate the total fluid volume needed in the first 24 hours for
a 75 kg patient with 40% TBSA burns.
A. 6,000 mL
B. 9,000 mL
C. 12,000 mL
D. 15,000 mL
Correct Answer: C
Expert Explanation: The Parkland formula is 4 mL x weight (kg) x % TBSA. In this case, 4
mL x 75 kg x 40 = 12,000 mL. Half of this volume is given in the first 8 hours, and the
remaining half over the next 16 hours.
5. A patient in the Emergency Severity Index (ESI) triage system presents with stable vital
signs but reports severe sudden abdominal pain. Which ESI level is most appropriate?
A. Level 1
B. Level 2
C. Level 3
D. Level 4
Correct Answer: B
Expert Explanation: ESI Level 2 is assigned to patients who are in a high-risk situation or
have severe pain/distress but are physiologically stable. Sudden severe abdominal pain
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is triaging victims of a multi-car accident. A patient has a patent airway but is
breathing at 34 breaths/min and has a capillary refill of 4 seconds. Which triage tag color
should be assigned?
A. Green
B. Red
C. Yellow
D. Black
Correct Answer: B
Expert Explanation: A red tag is assigned to victims with life-threatening injuries who
require immediate intervention. Criteria for red tagging include respiratory rates over 30
per minute or capillary refill greater than 2 seconds. This patient meets both criteria and
must be treated immediately to ensure survival.
2. Which assessment finding in a patient with a 30% total body surface area (TBSA) burn
indicates the beginning of the fluid remobilization (acute) phase?
A. Increased hematocrit levels
,B. Reduced serum potassium
C. Increased urinary output
D. Decreased blood pressure
Correct Answer: C
Expert Explanation: Increased urinary output is a hallmark sign that fluid is shifting from
the interstitial space back into the intravascular space. This usually occurs 48 to 72 hours
after the initial burn injury. During this phase, the nurse must monitor for fluid volume
overload and electrolyte imbalances.
3. A patient arrives in the Emergency Department with suspected carbon monoxide
poisoning. What is the priority nursing intervention?
A. Obtain an arterial blood gas (ABG) sample
B. Administer 100% oxygen via non-rebreather mask
C. Check the patient’s pulse oximetry reading
D. Prepare for immediate intubation
Correct Answer: B
Expert Explanation: Carbon monoxide has a higher affinity for hemoglobin than oxygen,
leading to tissue hypoxia. Administering 100% oxygen is the gold standard treatment to
help displace the carbon monoxide from the hemoglobin. Standard pulse oximetry is
unreliable because it cannot distinguish between oxyhemoglobin and carboxyhemoglobin.
, 4. Using the Parkland formula, calculate the total fluid volume needed in the first 24 hours for
a 75 kg patient with 40% TBSA burns.
A. 6,000 mL
B. 9,000 mL
C. 12,000 mL
D. 15,000 mL
Correct Answer: C
Expert Explanation: The Parkland formula is 4 mL x weight (kg) x % TBSA. In this case, 4
mL x 75 kg x 40 = 12,000 mL. Half of this volume is given in the first 8 hours, and the
remaining half over the next 16 hours.
5. A patient in the Emergency Severity Index (ESI) triage system presents with stable vital
signs but reports severe sudden abdominal pain. Which ESI level is most appropriate?
A. Level 1
B. Level 2
C. Level 3
D. Level 4
Correct Answer: B
Expert Explanation: ESI Level 2 is assigned to patients who are in a high-risk situation or
have severe pain/distress but are physiologically stable. Sudden severe abdominal pain
