NURS 480 Exam 4 V3 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 4) | West Coast University
1. A nurse is caring for a patient who has sustained 45% Total Body Surface Area (TBSA)
burns. Using the Parkland formula (4mL x kg x %TBSA), how much fluid should the nurse
administer in the first 8 hours for a patient weighing 70 kg?
A. 6,300 mL
B. 6,300 mL
C. 12,600 mL
D. 25,200 mL
Answer: B
Rationale: The total fluid requirement for 24 hours is calculated as 4mL x 70kg x 45 =
12,600 mL. According to the Parkland formula, half of the total volume must be
administered within the first 8 hours from the time of the injury. Therefore, 12,600 mL
divided by 2 is 6,300 mL, which is the amount given in the first 8-hour window.
2. When performing triage at a mass casualty incident, which patient should the nurse assign
a ‘Red’ tag?
A. A patient with a fractured radius and stable vitals
,B. A patient who is not breathing after airway repositioning
C. A patient with a sucking chest wound and respiratory rate of 34
D. A patient with a large scalp laceration who is walking and talking
Answer: C
Rationale: Red tags are assigned to patients with immediate life-threatening injuries who
have a chance of survival with rapid intervention. A sucking chest wound indicates a
tension pneumothorax risk and a respiratory rate over 30 meets the immediate priority
criteria. Green tags are for the ‘walking wounded,’ while black tags are for those who are
deceased or have non-survivable injuries.
3. A patient in the emergent phase of burn care has a potassium level of 6.2 mEq/L. What is
the physiological cause of this finding?
A. Massive cell destruction and release of intracellular potassium
B. Excessive fluid resuscitation with potassium-enriched fluids
C. Renal failure due to hypovolemia
D. Metabolic alkalosis causing a potassium shift
Answer: A
Rationale: In the emergent phase of a burn injury, massive cell destruction occurs, which
releases intracellular potassium into the extracellular space. This leads to hyperkalemia,
, which must be monitored closely for cardiac dysrhythmias. Once the diuretic phase begins,
potassium levels typically drop as the mineral is excreted in the urine.
4. Which assessment finding is most indicative of neurogenic shock in a patient with a T4
spinal cord injury?
A. Tachycardia and hypertension
B. Cool, clammy skin and rapid respirations
C. Bradycardia and hypotension
D. Increased systemic vascular resistance
Answer: C
Rationale: Neurogenic shock is characterized by a loss of sympathetic tone, leading to
massive vasodilation and a lack of compensatory tachycardia. Unlike other forms of shock,
the patient will present with hypotension accompanied by bradycardia. The skin is
typically warm and dry due to vasodilation rather than cool and clammy.
5. A nurse is caring for a patient suspected of having septic shock. Which lab value is the most
sensitive indicator of tissue hypoperfusion?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell Count
C. Serum Lactate
D. Hemoglobin
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 4) | West Coast University
1. A nurse is caring for a patient who has sustained 45% Total Body Surface Area (TBSA)
burns. Using the Parkland formula (4mL x kg x %TBSA), how much fluid should the nurse
administer in the first 8 hours for a patient weighing 70 kg?
A. 6,300 mL
B. 6,300 mL
C. 12,600 mL
D. 25,200 mL
Answer: B
Rationale: The total fluid requirement for 24 hours is calculated as 4mL x 70kg x 45 =
12,600 mL. According to the Parkland formula, half of the total volume must be
administered within the first 8 hours from the time of the injury. Therefore, 12,600 mL
divided by 2 is 6,300 mL, which is the amount given in the first 8-hour window.
2. When performing triage at a mass casualty incident, which patient should the nurse assign
a ‘Red’ tag?
A. A patient with a fractured radius and stable vitals
,B. A patient who is not breathing after airway repositioning
C. A patient with a sucking chest wound and respiratory rate of 34
D. A patient with a large scalp laceration who is walking and talking
Answer: C
Rationale: Red tags are assigned to patients with immediate life-threatening injuries who
have a chance of survival with rapid intervention. A sucking chest wound indicates a
tension pneumothorax risk and a respiratory rate over 30 meets the immediate priority
criteria. Green tags are for the ‘walking wounded,’ while black tags are for those who are
deceased or have non-survivable injuries.
3. A patient in the emergent phase of burn care has a potassium level of 6.2 mEq/L. What is
the physiological cause of this finding?
A. Massive cell destruction and release of intracellular potassium
B. Excessive fluid resuscitation with potassium-enriched fluids
C. Renal failure due to hypovolemia
D. Metabolic alkalosis causing a potassium shift
Answer: A
Rationale: In the emergent phase of a burn injury, massive cell destruction occurs, which
releases intracellular potassium into the extracellular space. This leads to hyperkalemia,
, which must be monitored closely for cardiac dysrhythmias. Once the diuretic phase begins,
potassium levels typically drop as the mineral is excreted in the urine.
4. Which assessment finding is most indicative of neurogenic shock in a patient with a T4
spinal cord injury?
A. Tachycardia and hypertension
B. Cool, clammy skin and rapid respirations
C. Bradycardia and hypotension
D. Increased systemic vascular resistance
Answer: C
Rationale: Neurogenic shock is characterized by a loss of sympathetic tone, leading to
massive vasodilation and a lack of compensatory tachycardia. Unlike other forms of shock,
the patient will present with hypotension accompanied by bradycardia. The skin is
typically warm and dry due to vasodilation rather than cool and clammy.
5. A nurse is caring for a patient suspected of having septic shock. Which lab value is the most
sensitive indicator of tissue hypoperfusion?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell Count
C. Serum Lactate
D. Hemoglobin
