NURS 480 Exam 4 V1 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 4) | West Coast University
1. A patient arrives in the emergency department with deep partial-thickness burns to the
entire left arm and the entire anterior trunk. Using the Rule of Nines, what is the estimated
percentage of Total Body Surface Area (TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Answer: B
Rationale: According to the Rule of Nines, the entire arm accounts for 9% and the anterior
trunk accounts for 18%. Adding these two percentages together results in a total of 27%
TBSA. Accurate calculation is essential for determining the appropriate fluid resuscitation
volume using the Parkland formula.
2. A nurse is caring for a 70 kg patient with a 40% TBSA burn. Using the Parkland Formula (4
mL/kg/%TBSA), calculate the total fluid volume to be administered in the first 24 hours.
A. 11,200 mL
,B. 8,400 mL
C. 5,600 mL
D. 14,000 mL
Answer: A
Rationale: The Parkland formula is calculated as 4 mL x weight in kg x % TBSA burned,
which is 4 x 70 x 40 = 11,200 mL. This total volume is required to maintain organ perfusion
and prevent hypovolemic shock. The nurse must plan to deliver half of this volume in the
first 8 hours from the time of the burn injury.
3. Which clinical finding is most indicative of the ‘warm’ or hyperdynamic phase of septic
shock?
A. Severe metabolic acidosis and oliguria
B. Decreased cardiac output and cool, clammy skin
C. Increased cardiac output and decreased systemic vascular resistance
D. Bradycardia and hypertension
Answer: C
Rationale: In early septic shock, the body compensates for vasodilation by increasing
cardiac output, which leads to the characteristic warm skin. Systemic vascular resistance
(SVR) decreases due to the widespread inflammatory response and massive vasodilation.
,Recognizing this early stage is critical for initiating timely antibiotic and fluid therapy to
improve patient outcomes.
4. A patient with a traumatic brain injury presents with a blood pressure of 190/60 mmHg, a
heart rate of 45 bpm, and irregular respirations. The nurse recognizes this as:
A. Beck’s Triad
B. Virchow’s Triad
C. Cushing’s Triad
D. Horner’s Syndrome
Answer: C
Rationale: Cushing’s Triad consists of widening pulse pressure (systolic hypertension),
bradycardia, and irregular respirations, indicating late-stage increased intracranial
pressure. This clinical manifestation suggests that brain herniation may be imminent
unless intervention is provided immediately. The nurse must prioritize neurosurgical
consultation and measures to reduce ICP.
5. During the resuscitative phase of burn care, which electrolyte abnormality is the nurse
most likely to observe?
A. Hypokalemia
B. Hypocalcemia
C. Hypernatremia
, D. Hyperkalemia
Answer: D
Rationale: Hyperkalemia occurs in the initial phase of a major burn due to massive cell
destruction and the release of potassium into the extracellular space. Conversely,
hyponatremia is often seen because sodium follows water into the interstitial space as
capillary permeability increases. Monitoring serum electrolyte levels is vital during fluid
resuscitation to prevent cardiac arrhythmias.
6. A patient is admitted with neurogenic shock following a spinal cord injury at T3. Which
hemodynamic profile should the nurse anticipate?
A. Tachycardia and hypertension
B. Bradycardia and hypotension
C. Tachycardia and hypotension
D. Bradycardia and hypertension
Answer: B
Rationale: Neurogenic shock is characterized by the loss of sympathetic nervous system
tone, resulting in massive vasodilation and a lack of compensatory tachycardia. The
absence of sympathetic input to the heart leads to bradycardia despite a low blood
pressure. Treatment often includes vasopressors and atropine to maintain adequate
perfusion.
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 4) | West Coast University
1. A patient arrives in the emergency department with deep partial-thickness burns to the
entire left arm and the entire anterior trunk. Using the Rule of Nines, what is the estimated
percentage of Total Body Surface Area (TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Answer: B
Rationale: According to the Rule of Nines, the entire arm accounts for 9% and the anterior
trunk accounts for 18%. Adding these two percentages together results in a total of 27%
TBSA. Accurate calculation is essential for determining the appropriate fluid resuscitation
volume using the Parkland formula.
2. A nurse is caring for a 70 kg patient with a 40% TBSA burn. Using the Parkland Formula (4
mL/kg/%TBSA), calculate the total fluid volume to be administered in the first 24 hours.
A. 11,200 mL
,B. 8,400 mL
C. 5,600 mL
D. 14,000 mL
Answer: A
Rationale: The Parkland formula is calculated as 4 mL x weight in kg x % TBSA burned,
which is 4 x 70 x 40 = 11,200 mL. This total volume is required to maintain organ perfusion
and prevent hypovolemic shock. The nurse must plan to deliver half of this volume in the
first 8 hours from the time of the burn injury.
3. Which clinical finding is most indicative of the ‘warm’ or hyperdynamic phase of septic
shock?
A. Severe metabolic acidosis and oliguria
B. Decreased cardiac output and cool, clammy skin
C. Increased cardiac output and decreased systemic vascular resistance
D. Bradycardia and hypertension
Answer: C
Rationale: In early septic shock, the body compensates for vasodilation by increasing
cardiac output, which leads to the characteristic warm skin. Systemic vascular resistance
(SVR) decreases due to the widespread inflammatory response and massive vasodilation.
,Recognizing this early stage is critical for initiating timely antibiotic and fluid therapy to
improve patient outcomes.
4. A patient with a traumatic brain injury presents with a blood pressure of 190/60 mmHg, a
heart rate of 45 bpm, and irregular respirations. The nurse recognizes this as:
A. Beck’s Triad
B. Virchow’s Triad
C. Cushing’s Triad
D. Horner’s Syndrome
Answer: C
Rationale: Cushing’s Triad consists of widening pulse pressure (systolic hypertension),
bradycardia, and irregular respirations, indicating late-stage increased intracranial
pressure. This clinical manifestation suggests that brain herniation may be imminent
unless intervention is provided immediately. The nurse must prioritize neurosurgical
consultation and measures to reduce ICP.
5. During the resuscitative phase of burn care, which electrolyte abnormality is the nurse
most likely to observe?
A. Hypokalemia
B. Hypocalcemia
C. Hypernatremia
, D. Hyperkalemia
Answer: D
Rationale: Hyperkalemia occurs in the initial phase of a major burn due to massive cell
destruction and the release of potassium into the extracellular space. Conversely,
hyponatremia is often seen because sodium follows water into the interstitial space as
capillary permeability increases. Monitoring serum electrolyte levels is vital during fluid
resuscitation to prevent cardiac arrhythmias.
6. A patient is admitted with neurogenic shock following a spinal cord injury at T3. Which
hemodynamic profile should the nurse anticipate?
A. Tachycardia and hypertension
B. Bradycardia and hypotension
C. Tachycardia and hypotension
D. Bradycardia and hypertension
Answer: B
Rationale: Neurogenic shock is characterized by the loss of sympathetic nervous system
tone, resulting in massive vasodilation and a lack of compensatory tachycardia. The
absence of sympathetic input to the heart leads to bradycardia despite a low blood
pressure. Treatment often includes vasopressors and atropine to maintain adequate
perfusion.
