NUR2755 Exam 2 Actual Exam Style V1 |
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A patient is admitted with suspected sepsis. Which of the following findings is the most
sensitive indicator of early tissue hypoperfusion?
A. Blood pressure of 110/70 mmHg
B. Serum lactate level of 4.5 mmol/L
C. Urine output of 35 mL/hr
D. Heart rate of 95 beats per minute
Answer: B
Rationale: Lactate levels increase when cells switch to anaerobic metabolism due to
inadequate oxygen delivery. A level above 2 mmol/L is highly suggestive of tissue
hypoperfusion even if the blood pressure is still within normal limits. This makes lactate a
more sensitive early marker than vital sign changes in the initial stages of sepsis.
2. A nurse is caring for a patient in the compensatory stage of shock. Which physiological
finding should the nurse expect?
A. Metabolic alkalosis
B. Narrowing pulse pressure
C. Decreased heart rate
,D. Increased urinary output
Answer: B
Rationale: In the compensatory stage, the body attempts to maintain cardiac output
through sympathetic nervous system activation. This results in vasoconstriction, which
causes the diastolic blood pressure to rise and narrows the pulse pressure. Monitoring for a
narrowing pulse pressure is a critical assessment for identifying early shock progression.
3. A patient with full-thickness burns to 40% of their body is in the resuscitation phase. Which
IV fluid is most appropriate for initial volume replacement?
A. Lactated Ringer’s solution
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. Albumin 5%
Answer: A
Rationale: Lactated Ringer’s (LR) is the fluid of choice for burn resuscitation because its
composition most closely resembles extracellular fluid. It helps maintain electrolyte
balance and prevents the metabolic acidosis often seen in burn patients. Using isotonic
crystalloids like LR is standard practice per the Parkland formula.
4. Using the Rule of Nines, what is the estimated Total Body Surface Area (TBSA) for a patient
with burns to the entire left arm and the anterior trunk?
A. 18%
, B. 27%
C. 36%
D. 45%
Answer: B
Rationale: According to the Rule of Nines, the entire arm (anterior and posterior) accounts
for 9% of the TBSA. The anterior trunk accounts for 18%. Adding 9% and 18% results in a
total of 27% TBSA burned.
5. A patient is experiencing anaphylactic shock. Which medication should the nurse prepare
to administer first?
A. Diphenhydramine IV
B. Epinephrine IM
C. Methylprednisolone IV
D. Albuterol nebulizer
Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis because it rapidly causes
vasoconstriction and bronchodilation. It acts quickly to reverse life-threatening airway
obstruction and hypotension. Other medications like antihistamines and steroids are
secondary treatments and do not replace the immediate need for epinephrine.
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A patient is admitted with suspected sepsis. Which of the following findings is the most
sensitive indicator of early tissue hypoperfusion?
A. Blood pressure of 110/70 mmHg
B. Serum lactate level of 4.5 mmol/L
C. Urine output of 35 mL/hr
D. Heart rate of 95 beats per minute
Answer: B
Rationale: Lactate levels increase when cells switch to anaerobic metabolism due to
inadequate oxygen delivery. A level above 2 mmol/L is highly suggestive of tissue
hypoperfusion even if the blood pressure is still within normal limits. This makes lactate a
more sensitive early marker than vital sign changes in the initial stages of sepsis.
2. A nurse is caring for a patient in the compensatory stage of shock. Which physiological
finding should the nurse expect?
A. Metabolic alkalosis
B. Narrowing pulse pressure
C. Decreased heart rate
,D. Increased urinary output
Answer: B
Rationale: In the compensatory stage, the body attempts to maintain cardiac output
through sympathetic nervous system activation. This results in vasoconstriction, which
causes the diastolic blood pressure to rise and narrows the pulse pressure. Monitoring for a
narrowing pulse pressure is a critical assessment for identifying early shock progression.
3. A patient with full-thickness burns to 40% of their body is in the resuscitation phase. Which
IV fluid is most appropriate for initial volume replacement?
A. Lactated Ringer’s solution
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. Albumin 5%
Answer: A
Rationale: Lactated Ringer’s (LR) is the fluid of choice for burn resuscitation because its
composition most closely resembles extracellular fluid. It helps maintain electrolyte
balance and prevents the metabolic acidosis often seen in burn patients. Using isotonic
crystalloids like LR is standard practice per the Parkland formula.
4. Using the Rule of Nines, what is the estimated Total Body Surface Area (TBSA) for a patient
with burns to the entire left arm and the anterior trunk?
A. 18%
, B. 27%
C. 36%
D. 45%
Answer: B
Rationale: According to the Rule of Nines, the entire arm (anterior and posterior) accounts
for 9% of the TBSA. The anterior trunk accounts for 18%. Adding 9% and 18% results in a
total of 27% TBSA burned.
5. A patient is experiencing anaphylactic shock. Which medication should the nurse prepare
to administer first?
A. Diphenhydramine IV
B. Epinephrine IM
C. Methylprednisolone IV
D. Albuterol nebulizer
Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis because it rapidly causes
vasoconstriction and bronchodilation. It acts quickly to reverse life-threatening airway
obstruction and hypotension. Other medications like antihistamines and steroids are
secondary treatments and do not replace the immediate need for epinephrine.
