NURS 480 Exam 4 V2 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 4) | West Coast University
1. A patient in the emergent phase of a major burn injury has a blood pressure of 88/50
mmHg and a heart rate of 124 bpm. Which intravenous fluid should the nurse anticipate
administering as the first priority?
A. Lactated Ringer’s solution
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. Albumin 5%
Answer: A
Rationale: Lactated Ringer’s is the fluid of choice for burn resuscitation because it closely
matches extracellular fluid composition. In the emergent phase, large volumes are required
to compensate for fluid shifts and prevent hypovolemic shock. Normal saline is avoided in
large volumes to prevent hyperchloremic acidosis.
2. When assessing a patient for Systemic Inflammatory Response Syndrome (SIRS), which
clinical finding would the nurse recognize as meeting the criteria?
A. White blood cell count of 9,000 cells/mm3
,B. Heart rate of 88 beats per minute
C. Temperature of 101.2°F (38.4°C)
D. Partial pressure of arterial CO2 (PaCO2) of 42 mmHg
Answer: C
Rationale: The criteria for SIRS include a temperature greater than 38°C or less than 36°C.
Other criteria include a heart rate over 90, respiratory rate over 20, or WBC count over
12,000 or under 4,000. Identifying SIRS early is critical to prevent progression to sepsis
and organ dysfunction.
3. A patient weighs 70 kg and has sustained second- and third-degree burns over 40% of the
total body surface area (TBSA). Using the Parkland formula, calculate the total fluid volume
required in the first 24 hours.
A. 11,200 mL
B. 5,600 mL
C. 8,400 mL
D. 14,000 mL
Answer: A
Rationale: The Parkland formula calculates fluid requirements as 4 mL x kg x % TBSA. For
this patient, the calculation is 4 x 70 x 40, which equals 11,200 mL. Half of this volume must
be administered within the first 8 hours post-injury.
, 4. The nurse is caring for a patient in septic shock. Which vasoactive medication is typically
considered the first-line agent to maintain a Mean Arterial Pressure (MAP) of at least 65
mmHg?
A. Dopamine
B. Epinephrine
C. Norepinephrine
D. Vasopressin
Answer: C
Rationale: Norepinephrine is the primary vasopressor recommended for septic shock
refractory to fluid resuscitation. It works primarily via alpha-adrenergic stimulation to
cause vasoconstriction. Maintaining a MAP above 65 mmHg ensures adequate tissue
perfusion to vital organs.
5. A patient arrives in the Emergency Department after a motor vehicle accident. According to
the primary survey, which action should the nurse perform first?
A. Check blood pressure and heart rate
B. Assess airway patency while maintaining cervical spine stabilization
C. Assess level of consciousness using GCS
D. Expose the patient to check for hidden injuries
Answer: B
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 4) | West Coast University
1. A patient in the emergent phase of a major burn injury has a blood pressure of 88/50
mmHg and a heart rate of 124 bpm. Which intravenous fluid should the nurse anticipate
administering as the first priority?
A. Lactated Ringer’s solution
B. 5% Dextrose in Water
C. 0.45% Normal Saline
D. Albumin 5%
Answer: A
Rationale: Lactated Ringer’s is the fluid of choice for burn resuscitation because it closely
matches extracellular fluid composition. In the emergent phase, large volumes are required
to compensate for fluid shifts and prevent hypovolemic shock. Normal saline is avoided in
large volumes to prevent hyperchloremic acidosis.
2. When assessing a patient for Systemic Inflammatory Response Syndrome (SIRS), which
clinical finding would the nurse recognize as meeting the criteria?
A. White blood cell count of 9,000 cells/mm3
,B. Heart rate of 88 beats per minute
C. Temperature of 101.2°F (38.4°C)
D. Partial pressure of arterial CO2 (PaCO2) of 42 mmHg
Answer: C
Rationale: The criteria for SIRS include a temperature greater than 38°C or less than 36°C.
Other criteria include a heart rate over 90, respiratory rate over 20, or WBC count over
12,000 or under 4,000. Identifying SIRS early is critical to prevent progression to sepsis
and organ dysfunction.
3. A patient weighs 70 kg and has sustained second- and third-degree burns over 40% of the
total body surface area (TBSA). Using the Parkland formula, calculate the total fluid volume
required in the first 24 hours.
A. 11,200 mL
B. 5,600 mL
C. 8,400 mL
D. 14,000 mL
Answer: A
Rationale: The Parkland formula calculates fluid requirements as 4 mL x kg x % TBSA. For
this patient, the calculation is 4 x 70 x 40, which equals 11,200 mL. Half of this volume must
be administered within the first 8 hours post-injury.
, 4. The nurse is caring for a patient in septic shock. Which vasoactive medication is typically
considered the first-line agent to maintain a Mean Arterial Pressure (MAP) of at least 65
mmHg?
A. Dopamine
B. Epinephrine
C. Norepinephrine
D. Vasopressin
Answer: C
Rationale: Norepinephrine is the primary vasopressor recommended for septic shock
refractory to fluid resuscitation. It works primarily via alpha-adrenergic stimulation to
cause vasoconstriction. Maintaining a MAP above 65 mmHg ensures adequate tissue
perfusion to vital organs.
5. A patient arrives in the Emergency Department after a motor vehicle accident. According to
the primary survey, which action should the nurse perform first?
A. Check blood pressure and heart rate
B. Assess airway patency while maintaining cervical spine stabilization
C. Assess level of consciousness using GCS
D. Expose the patient to check for hidden injuries
Answer: B
