NUR2755 Exam 3 Actual Exam Style V2 |
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A patient arrives at the Emergency Department after a chemical spill. According to disaster
triage, a patient with a tension pneumothorax should be assigned which color tag?
A. Red
B. Yellow
C. Green
D. Black
Answer: A
Rationale: Red tags are assigned to patients with life-threatening injuries that require
immediate intervention to survive. A tension pneumothorax is a critical condition that
compromises both respiratory and circulatory function. The triage nurse must prioritize
these patients to prevent imminent death in a mass casualty incident.
2. Which assessment finding is the most sensitive early indicator of hypovolemic shock in a
trauma patient?
A. Decreased systolic blood pressure
B. Increased heart rate
C. Reduced urine output
,D. Narrowing pulse pressure
Answer: B
Rationale: Tachycardia is often the earliest sign of compensatory shock as the body
attempts to maintain cardiac output. Blood pressure may remain normal in the initial
stages due to compensatory mechanisms. Monitoring heart rate trends allows the nurse to
identify deterioration before hypotension occurs.
3. A nurse is caring for a patient with full-thickness burns covering 40% of their body. Using
the Parkland formula (4mL/kg/%BSA), how much fluid should a 70kg patient receive in the
first 8 hours?
A. 11,200 mL
B. 1,400 mL
C. 2,800 mL
D. 5,600 mL
Answer: D
Rationale: The total volume is calculated as 4mL x 70kg x 40 = 11,200 mL for the first 24
hours. Half of this total volume, which is 5,600 mL, must be administered within the first 8
hours from the time of the burn injury. Accurate fluid resuscitation is vital to prevent
hypovolemic burn shock and preserve organ function.
, 4. Which of the following is the priority nursing intervention during the ‘Primary Survey’ of a
trauma patient?
A. Obtaining a full set of vital signs
B. Assessing the patient’s neurological status
C. Removing all clothing to perform a head-to-toe assessment
D. Establishing an airway while maintaining cervical spine stabilization
Answer: D
Rationale: The Primary Survey follows the ABCDE sequence, where ‘A’ stands for Airway
and Alertness with cervical spine protection. Failure to secure the airway can lead to rapid
hypoxia and death in trauma victims. This step must be completed and stabilized before
moving to breathing or circulation assessments.
5. A patient with septic shock has a MAP of 55 mmHg despite fluid resuscitation. Which
medication should the nurse anticipate administering next?
A. Nitroglycerin
B. Furosemide
C. Atropine
D. Norepinephrine
Answer: D
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A patient arrives at the Emergency Department after a chemical spill. According to disaster
triage, a patient with a tension pneumothorax should be assigned which color tag?
A. Red
B. Yellow
C. Green
D. Black
Answer: A
Rationale: Red tags are assigned to patients with life-threatening injuries that require
immediate intervention to survive. A tension pneumothorax is a critical condition that
compromises both respiratory and circulatory function. The triage nurse must prioritize
these patients to prevent imminent death in a mass casualty incident.
2. Which assessment finding is the most sensitive early indicator of hypovolemic shock in a
trauma patient?
A. Decreased systolic blood pressure
B. Increased heart rate
C. Reduced urine output
,D. Narrowing pulse pressure
Answer: B
Rationale: Tachycardia is often the earliest sign of compensatory shock as the body
attempts to maintain cardiac output. Blood pressure may remain normal in the initial
stages due to compensatory mechanisms. Monitoring heart rate trends allows the nurse to
identify deterioration before hypotension occurs.
3. A nurse is caring for a patient with full-thickness burns covering 40% of their body. Using
the Parkland formula (4mL/kg/%BSA), how much fluid should a 70kg patient receive in the
first 8 hours?
A. 11,200 mL
B. 1,400 mL
C. 2,800 mL
D. 5,600 mL
Answer: D
Rationale: The total volume is calculated as 4mL x 70kg x 40 = 11,200 mL for the first 24
hours. Half of this total volume, which is 5,600 mL, must be administered within the first 8
hours from the time of the burn injury. Accurate fluid resuscitation is vital to prevent
hypovolemic burn shock and preserve organ function.
, 4. Which of the following is the priority nursing intervention during the ‘Primary Survey’ of a
trauma patient?
A. Obtaining a full set of vital signs
B. Assessing the patient’s neurological status
C. Removing all clothing to perform a head-to-toe assessment
D. Establishing an airway while maintaining cervical spine stabilization
Answer: D
Rationale: The Primary Survey follows the ABCDE sequence, where ‘A’ stands for Airway
and Alertness with cervical spine protection. Failure to secure the airway can lead to rapid
hypoxia and death in trauma victims. This step must be completed and stabilized before
moving to breathing or circulation assessments.
5. A patient with septic shock has a MAP of 55 mmHg despite fluid resuscitation. Which
medication should the nurse anticipate administering next?
A. Nitroglycerin
B. Furosemide
C. Atropine
D. Norepinephrine
Answer: D
