NUR2755 Exam 4 Actual Exam Style V2 |
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is performing the primary survey on a client brought to the emergency department
after a motor vehicle accident. Which action should the nurse perform first?
A. Check the client’s level of consciousness.
B. Remove the client’s clothing for a full exam.
C. Palpate for a carotid and radial pulse.
D. Assess the patency of the client’s airway.
Answer: D
Rationale: The primary survey follows the ABCDE mnemonic, with Airway being the first
priority. If the airway is not patent, the client cannot be oxygenated, leading to rapid
deterioration. Assessing the airway involves checking for obstructions and ensuring the
cervical spine is stabilized if trauma is suspected.
2. The nurse is caring for a client in the emergent phase of a 40% total body surface area
(TBSA) burn. Which laboratory result should the nurse expect to find?
A. Hematocrit 32%
B. Sodium 150 mEq/L
C. Potassium 6.2 mEq/L
,D. Albumin 4.5 g/dL
Answer: C
Rationale: In the emergent phase of a burn, cell destruction causes intracellular potassium
to leak into the extracellular fluid, resulting in hyperkalemia. Additionally,
hemoconcentration occurs as fluid shifts out of the vascular space, leading to an increased
hematocrit. Sodium levels typically decrease because sodium follows fluid into the
interstitial spaces.
3. A nurse is triaging victims of a mass casualty event. A client has a respiratory rate of 34
breaths/minute and a radial pulse is present, but they cannot follow simple commands.
Which color tag should the nurse assign?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: Using the START triage system, any individual with a respiratory rate over 30 is
classified as ‘Immediate’ or Red. Furthermore, the inability to follow simple commands
indicates a neurological deficit requiring urgent intervention. This client is prioritized over
those who are stable or those with non-survivable injuries.
, 4. A client is diagnosed with Septic Shock. The nurse notes the client’s Mean Arterial Pressure
(MAP) is 55 mmHg. Which medication does the nurse anticipate the provider will order first?
A. Dopamine
B. Nitroglycerin
C. Norepinephrine
D. Furosemide
Answer: C
Rationale: Norepinephrine is the first-line vasopressor for septic shock when fluid
resuscitation fails to maintain a MAP of at least 65 mmHg. It works by increasing systemic
vascular resistance through alpha-adrenergic stimulation. Maintaining adequate MAP is
critical to ensure vital organ perfusion and prevent multi-organ dysfunction syndrome.
5. A client with a high-level spinal cord injury (T2) suddenly reports a severe throbbing
headache and has a blood pressure of 210/110 mmHg. What is the nurse’s priority action?
A. Sit the client upright and check for bladder distension.
B. Lower the head of the bed to a flat position.
C. Administer PRN antihypertensives.
D. Request a stat CT scan of the head.
Answer: A
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is performing the primary survey on a client brought to the emergency department
after a motor vehicle accident. Which action should the nurse perform first?
A. Check the client’s level of consciousness.
B. Remove the client’s clothing for a full exam.
C. Palpate for a carotid and radial pulse.
D. Assess the patency of the client’s airway.
Answer: D
Rationale: The primary survey follows the ABCDE mnemonic, with Airway being the first
priority. If the airway is not patent, the client cannot be oxygenated, leading to rapid
deterioration. Assessing the airway involves checking for obstructions and ensuring the
cervical spine is stabilized if trauma is suspected.
2. The nurse is caring for a client in the emergent phase of a 40% total body surface area
(TBSA) burn. Which laboratory result should the nurse expect to find?
A. Hematocrit 32%
B. Sodium 150 mEq/L
C. Potassium 6.2 mEq/L
,D. Albumin 4.5 g/dL
Answer: C
Rationale: In the emergent phase of a burn, cell destruction causes intracellular potassium
to leak into the extracellular fluid, resulting in hyperkalemia. Additionally,
hemoconcentration occurs as fluid shifts out of the vascular space, leading to an increased
hematocrit. Sodium levels typically decrease because sodium follows fluid into the
interstitial spaces.
3. A nurse is triaging victims of a mass casualty event. A client has a respiratory rate of 34
breaths/minute and a radial pulse is present, but they cannot follow simple commands.
Which color tag should the nurse assign?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: Using the START triage system, any individual with a respiratory rate over 30 is
classified as ‘Immediate’ or Red. Furthermore, the inability to follow simple commands
indicates a neurological deficit requiring urgent intervention. This client is prioritized over
those who are stable or those with non-survivable injuries.
, 4. A client is diagnosed with Septic Shock. The nurse notes the client’s Mean Arterial Pressure
(MAP) is 55 mmHg. Which medication does the nurse anticipate the provider will order first?
A. Dopamine
B. Nitroglycerin
C. Norepinephrine
D. Furosemide
Answer: C
Rationale: Norepinephrine is the first-line vasopressor for septic shock when fluid
resuscitation fails to maintain a MAP of at least 65 mmHg. It works by increasing systemic
vascular resistance through alpha-adrenergic stimulation. Maintaining adequate MAP is
critical to ensure vital organ perfusion and prevent multi-organ dysfunction syndrome.
5. A client with a high-level spinal cord injury (T2) suddenly reports a severe throbbing
headache and has a blood pressure of 210/110 mmHg. What is the nurse’s priority action?
A. Sit the client upright and check for bladder distension.
B. Lower the head of the bed to a flat position.
C. Administer PRN antihypertensives.
D. Request a stat CT scan of the head.
Answer: A
