NUR 417 Exam 4 V1 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 4) | Concordia
1. A nurse is caring for a patient in the early stages of septic shock. Which clinical finding
should the nurse anticipate first?
A. Tachycardia and warm, flushed skin
B. Decreased cardiac output and cool skin
C. Hypotension and bradycardia
D. Anuria and metabolic acidosis
Correct Answer: A
Explanation: In the early or hyperdynamic phase of septic shock, the body exhibits a high
cardiac output and systemic vasodilation. This results in tachycardia and warm, flushed
skin due to the inflammatory response. Early recognition at this stage is critical to
preventing progression to the hypodynamic stage where organ failure occurs.
2. A patient with 40% total body surface area (TBSA) burns is in the emergent phase. Using
the Parkland formula (4mL/kg/%TBSA), how much fluid should a 70kg patient receive in the
first 8 hours?
A. 2,800 mL
B. 11,200 mL
,C. 5,600 mL
D. 7,400 mL
Correct Answer: C
Explanation: The total fluid for 24 hours is calculated as 4mL x 70kg x 40% = 11,200 mL.
According to the Parkland formula, half of the total volume must be administered within
the first 8 hours post-injury. Therefore, 11,200 mL / 2 = 5,600 mL is the correct volume for
the first 8 hours.
3. Which hemodynamic parameter is the most sensitive indicator of right-sided heart function
and fluid volume status?
A. Mean Arterial Pressure (MAP)
B. Pulmonary Artery Wedge Pressure (PAWP)
C. Central Venous Pressure (CVP)
D. Cardiac Index (CI)
Correct Answer: C
Explanation: Central Venous Pressure (CVP) measures the pressure in the right atrium
and reflects right ventricular end-diastolic pressure. It is used clinically to assess fluid
volume status and right heart preload. A low CVP typically indicates hypovolemia, while a
high CVP suggests fluid overload or right heart failure.
, 4. A patient on mechanical ventilation triggers the high-pressure alarm. Which action should
the nurse take first?
A. Check for kinks in the ventilator tubing
B. Suction the patient for possible secretions
C. Assess the patient’s respiratory status and breath sounds
D. Increase the oxygen concentration to 100%
Correct Answer: C
Explanation: The nurse’s first priority is always to assess the patient to ensure safety and
adequate ventilation. Once the patient’s immediate status is confirmed, the nurse can then
investigate mechanical causes such as secretions or tubing kinks. If the cause is not quickly
found, the patient should be manually ventilated with a bag-valve-mask.
5. In the event of a mass casualty incident, which color tag is assigned to a patient who has a
sucking chest wound and is in respiratory distress?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
Adult II | Actual Q&A with Rationale (NUR417
Exam 4) | Concordia
1. A nurse is caring for a patient in the early stages of septic shock. Which clinical finding
should the nurse anticipate first?
A. Tachycardia and warm, flushed skin
B. Decreased cardiac output and cool skin
C. Hypotension and bradycardia
D. Anuria and metabolic acidosis
Correct Answer: A
Explanation: In the early or hyperdynamic phase of septic shock, the body exhibits a high
cardiac output and systemic vasodilation. This results in tachycardia and warm, flushed
skin due to the inflammatory response. Early recognition at this stage is critical to
preventing progression to the hypodynamic stage where organ failure occurs.
2. A patient with 40% total body surface area (TBSA) burns is in the emergent phase. Using
the Parkland formula (4mL/kg/%TBSA), how much fluid should a 70kg patient receive in the
first 8 hours?
A. 2,800 mL
B. 11,200 mL
,C. 5,600 mL
D. 7,400 mL
Correct Answer: C
Explanation: The total fluid for 24 hours is calculated as 4mL x 70kg x 40% = 11,200 mL.
According to the Parkland formula, half of the total volume must be administered within
the first 8 hours post-injury. Therefore, 11,200 mL / 2 = 5,600 mL is the correct volume for
the first 8 hours.
3. Which hemodynamic parameter is the most sensitive indicator of right-sided heart function
and fluid volume status?
A. Mean Arterial Pressure (MAP)
B. Pulmonary Artery Wedge Pressure (PAWP)
C. Central Venous Pressure (CVP)
D. Cardiac Index (CI)
Correct Answer: C
Explanation: Central Venous Pressure (CVP) measures the pressure in the right atrium
and reflects right ventricular end-diastolic pressure. It is used clinically to assess fluid
volume status and right heart preload. A low CVP typically indicates hypovolemia, while a
high CVP suggests fluid overload or right heart failure.
, 4. A patient on mechanical ventilation triggers the high-pressure alarm. Which action should
the nurse take first?
A. Check for kinks in the ventilator tubing
B. Suction the patient for possible secretions
C. Assess the patient’s respiratory status and breath sounds
D. Increase the oxygen concentration to 100%
Correct Answer: C
Explanation: The nurse’s first priority is always to assess the patient to ensure safety and
adequate ventilation. Once the patient’s immediate status is confirmed, the nurse can then
investigate mechanical causes such as secretions or tubing kinks. If the cause is not quickly
found, the patient should be manually ventilated with a bag-valve-mask.
5. In the event of a mass casualty incident, which color tag is assigned to a patient who has a
sucking chest wound and is in respiratory distress?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
