NUR2755 Exam 2 Actual Exam Style V3 |
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is caring for a client in the emergent phase of a major burn. Which electrolyte
abnormality should the nurse anticipate during this stage?
A. Hypercalcemia and hypernatremia
B. Hypokalemia and hypernatremia
C. Hypocalcemia and hypomagnesemia
D. Hyperkalemia and hyponatremia
Answer: D
Rationale: During the emergent phase, cell destruction releases potassium into the
extracellular fluid, leading to hyperkalemia. Simultaneously, sodium shifts into the
interstitial space along with fluid, resulting in hyponatremia. Monitoring these levels is
critical to prevent cardiac arrhythmias and further complications.
2. In a mass casualty incident, a patient with a sucking chest wound and labored breathing
would be assigned which triage tag color?
A. Green
B. Yellow
C. Red
,D. Black
Answer: C
Rationale: A red tag is used for patients with immediate, life-threatening injuries that are
treatable with rapid intervention. A sucking chest wound compromises the airway and
breathing, making it a top priority. Without immediate care, these patients are unlikely to
survive the initial trauma phase.
3. A patient is admitted with suspected Septic Shock. Which of the following findings is the
most indicative of this condition?
A. Blood pressure of 110/70 mmHg
B. Serum lactate level of 5.2 mmol/L
C. Urine output of 50 mL/hr
D. White blood cell count of 8,000/mm3
Answer: B
Rationale: A serum lactate level greater than 2 mmol/L indicates tissue hypoxia and
anaerobic metabolism, which are hallmarks of septic shock. In septic shock, persistent
hypotension and elevated lactate signify a failure of the circulatory system. This finding
necessitates immediate aggressive fluid resuscitation and investigation into the source of
infection.
, 4. Using the Parkland Formula, calculate the first 8-hour fluid requirement for a 70kg patient
with 40% TBSA burns.
A. 2,800 mL
B. 11,200 mL
C. 5,600 mL
D. 4,200 mL
Answer: C
Rationale: The Parkland Formula is calculated as 4 mL x weight in kg x %TBSA (4 x 70 x 40
= 11,200 mL total for 24 hours). Half of this total volume must be administered in the first 8
hours following the injury. Therefore, 11,200 divided by 2 equals 5,600 mL for the initial 8-
hour period.
5. Which clinical manifestation is a hallmark sign of Neurogenic Shock that distinguishes it
from other forms of shock?
A. Bradycardia
B. Hypertension
C. Tachycardia
D. Cool, clammy skin
Answer: A
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is caring for a client in the emergent phase of a major burn. Which electrolyte
abnormality should the nurse anticipate during this stage?
A. Hypercalcemia and hypernatremia
B. Hypokalemia and hypernatremia
C. Hypocalcemia and hypomagnesemia
D. Hyperkalemia and hyponatremia
Answer: D
Rationale: During the emergent phase, cell destruction releases potassium into the
extracellular fluid, leading to hyperkalemia. Simultaneously, sodium shifts into the
interstitial space along with fluid, resulting in hyponatremia. Monitoring these levels is
critical to prevent cardiac arrhythmias and further complications.
2. In a mass casualty incident, a patient with a sucking chest wound and labored breathing
would be assigned which triage tag color?
A. Green
B. Yellow
C. Red
,D. Black
Answer: C
Rationale: A red tag is used for patients with immediate, life-threatening injuries that are
treatable with rapid intervention. A sucking chest wound compromises the airway and
breathing, making it a top priority. Without immediate care, these patients are unlikely to
survive the initial trauma phase.
3. A patient is admitted with suspected Septic Shock. Which of the following findings is the
most indicative of this condition?
A. Blood pressure of 110/70 mmHg
B. Serum lactate level of 5.2 mmol/L
C. Urine output of 50 mL/hr
D. White blood cell count of 8,000/mm3
Answer: B
Rationale: A serum lactate level greater than 2 mmol/L indicates tissue hypoxia and
anaerobic metabolism, which are hallmarks of septic shock. In septic shock, persistent
hypotension and elevated lactate signify a failure of the circulatory system. This finding
necessitates immediate aggressive fluid resuscitation and investigation into the source of
infection.
, 4. Using the Parkland Formula, calculate the first 8-hour fluid requirement for a 70kg patient
with 40% TBSA burns.
A. 2,800 mL
B. 11,200 mL
C. 5,600 mL
D. 4,200 mL
Answer: C
Rationale: The Parkland Formula is calculated as 4 mL x weight in kg x %TBSA (4 x 70 x 40
= 11,200 mL total for 24 hours). Half of this total volume must be administered in the first 8
hours following the injury. Therefore, 11,200 divided by 2 equals 5,600 mL for the initial 8-
hour period.
5. Which clinical manifestation is a hallmark sign of Neurogenic Shock that distinguishes it
from other forms of shock?
A. Bradycardia
B. Hypertension
C. Tachycardia
D. Cool, clammy skin
Answer: A
