NUR2790/NUR 2790 Exam 4 V1 |
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is triaging victims at the scene of a mass casualty incident. Which patient should be
assigned a ‘red’ tag?
A. A patient with a minor laceration on the forearm who is walking around.
B. A patient with no respirations even after airway repositioning.
C. A patient with a sucking chest wound and labored respirations.
D. A patient with a closed fracture of the tibia who is stable.
Correct Answer: C
Expert Explanation: The red tag is for immediate priority patients who have life-
threatening injuries but a high chance of survival if treated. A sucking chest wound
indicates a tension pneumothorax or major respiratory distress requiring immediate
intervention. This classification ensures that resources are directed first to those who need
urgent care to live.
2. A patient weighs 70 kg and has sustained partial-thickness burns to 40% of their body
surface area. Using the Parkland formula, how much fluid should be given in the first 8 hours?
A. 5,600 mL
,B. 2,800 mL
C. 11,200 mL
D. 4,200 mL
Correct Answer: A
Expert Explanation: The Parkland formula calculates total fluid for 24 hours as 4 mL x
weight (kg) x % TBSA. For this patient, the total is 4 x 70 x 40 = 11,200 mL. Since half of the
total volume is administered in the first 8 hours, the nurse should give 5,600 mL.
3. Which assessment finding is most indicative of the ‘compensatory’ stage of shock?
A. Decreased urinary output and cool, clammy skin.
B. Normal blood pressure with a slightly increased heart rate.
C. Profound hypotension and metabolic acidosis.
D. Multiple organ dysfunction syndrome (MODS).
Correct Answer: B
Expert Explanation: In the compensatory stage of shock, the body’s homeostatic
mechanisms attempt to maintain cardiac output and blood pressure. The patient typically
exhibits a normal blood pressure but may show signs of tachycardia and tachypnea.
Identifying shock at this early stage is crucial for successful resuscitation and prevention of
permanent organ damage.
,4. A patient is admitted with a suspected spinal cord injury at the T4 level. Which vital sign
change would most suggest neurogenic shock?
A. Hypertension and tachycardia.
B. Hypotension and tachycardia.
C. Hypotension and bradycardia.
D. Hypertension and bradycardia.
Correct Answer: C
Expert Explanation: Neurogenic shock is characterized by a loss of sympathetic tone,
leading to vasodilation and a lack of compensatory tachycardia. Unlike other forms of
shock, the patient will present with both hypotension and a slow heart rate. This condition
is a medical emergency that requires vasopressors and careful fluid management to
maintain perfusion.
5. Which cardiac rhythm requires immediate unsynchronized defibrillation?
A. Ventricular Fibrillation
B. Atrial Fibrillation
C. Stable Ventricular Tachycardia
D. Sinus Bradycardia
Correct Answer: A
, Expert Explanation: Ventricular fibrillation is a pulseless, chaotic rhythm that leads to
cardiac arrest and death within minutes. Defibrillation is the only effective treatment to
stop the disorganized electrical activity and allow the SA node to take over. Delaying
defibrillation significantly decreases the patient’s chances of survival and neurological
recovery.
6. A nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm sounds.
What is the most likely cause?
A. A leak in the ventilator circuit.
B. The patient has disconnected from the machine.
C. The patient is biting the endotracheal tube.
D. The cuff of the endotracheal tube is deflated.
Correct Answer: C
Expert Explanation: High-pressure alarms occur when the ventilator encounters
resistance to air delivery, such as secretions or the patient biting the tube. In contrast, low-
pressure alarms are triggered by a loss of pressure, often due to a leak or disconnection.
The nurse should quickly assess the patient, clear secretions, and ensure the tube is
secured properly.
7. What is the primary goal of applying Positive End-Expiratory Pressure (PEEP) in a patient
with ARDS?
A. To increase the patient’s respiratory rate.
Professional Nursing III / PN3 Q&A
with Rationale | Rasmussen
University
1. A nurse is triaging victims at the scene of a mass casualty incident. Which patient should be
assigned a ‘red’ tag?
A. A patient with a minor laceration on the forearm who is walking around.
B. A patient with no respirations even after airway repositioning.
C. A patient with a sucking chest wound and labored respirations.
D. A patient with a closed fracture of the tibia who is stable.
Correct Answer: C
Expert Explanation: The red tag is for immediate priority patients who have life-
threatening injuries but a high chance of survival if treated. A sucking chest wound
indicates a tension pneumothorax or major respiratory distress requiring immediate
intervention. This classification ensures that resources are directed first to those who need
urgent care to live.
2. A patient weighs 70 kg and has sustained partial-thickness burns to 40% of their body
surface area. Using the Parkland formula, how much fluid should be given in the first 8 hours?
A. 5,600 mL
,B. 2,800 mL
C. 11,200 mL
D. 4,200 mL
Correct Answer: A
Expert Explanation: The Parkland formula calculates total fluid for 24 hours as 4 mL x
weight (kg) x % TBSA. For this patient, the total is 4 x 70 x 40 = 11,200 mL. Since half of the
total volume is administered in the first 8 hours, the nurse should give 5,600 mL.
3. Which assessment finding is most indicative of the ‘compensatory’ stage of shock?
A. Decreased urinary output and cool, clammy skin.
B. Normal blood pressure with a slightly increased heart rate.
C. Profound hypotension and metabolic acidosis.
D. Multiple organ dysfunction syndrome (MODS).
Correct Answer: B
Expert Explanation: In the compensatory stage of shock, the body’s homeostatic
mechanisms attempt to maintain cardiac output and blood pressure. The patient typically
exhibits a normal blood pressure but may show signs of tachycardia and tachypnea.
Identifying shock at this early stage is crucial for successful resuscitation and prevention of
permanent organ damage.
,4. A patient is admitted with a suspected spinal cord injury at the T4 level. Which vital sign
change would most suggest neurogenic shock?
A. Hypertension and tachycardia.
B. Hypotension and tachycardia.
C. Hypotension and bradycardia.
D. Hypertension and bradycardia.
Correct Answer: C
Expert Explanation: Neurogenic shock is characterized by a loss of sympathetic tone,
leading to vasodilation and a lack of compensatory tachycardia. Unlike other forms of
shock, the patient will present with both hypotension and a slow heart rate. This condition
is a medical emergency that requires vasopressors and careful fluid management to
maintain perfusion.
5. Which cardiac rhythm requires immediate unsynchronized defibrillation?
A. Ventricular Fibrillation
B. Atrial Fibrillation
C. Stable Ventricular Tachycardia
D. Sinus Bradycardia
Correct Answer: A
, Expert Explanation: Ventricular fibrillation is a pulseless, chaotic rhythm that leads to
cardiac arrest and death within minutes. Defibrillation is the only effective treatment to
stop the disorganized electrical activity and allow the SA node to take over. Delaying
defibrillation significantly decreases the patient’s chances of survival and neurological
recovery.
6. A nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm sounds.
What is the most likely cause?
A. A leak in the ventilator circuit.
B. The patient has disconnected from the machine.
C. The patient is biting the endotracheal tube.
D. The cuff of the endotracheal tube is deflated.
Correct Answer: C
Expert Explanation: High-pressure alarms occur when the ventilator encounters
resistance to air delivery, such as secretions or the patient biting the tube. In contrast, low-
pressure alarms are triggered by a loss of pressure, often due to a leak or disconnection.
The nurse should quickly assess the patient, clear secretions, and ensure the tube is
secured properly.
7. What is the primary goal of applying Positive End-Expiratory Pressure (PEEP) in a patient
with ARDS?
A. To increase the patient’s respiratory rate.
