NUR 2755 MDC 4 | Exam 3
NUR 2755 – Multidimensional Care IV (MDC 4) Exam 3
Questions with Answers| Rasmussen University|
Updated| Pass Guaranteed
1. A nurse is assessing a trauma patient who has been bleeding. Which
finding is the EARLIEST indicator of compensated shock?
A. Systolic blood pressure of 78 mmHg
B. Restlessness, anxiety, and tachycardia
C. Urine output of 5 mL/hr
D. Cyanosis of the lips
Answer: B
Rationale: In the compensatory stage the sympathetic nervous system is
activated, causing anxiety/restlessness, tachycardia, and cool skin while BP
is still maintained. Hypotension, oliguria, and cyanosis are late findings of
progressive shock.
2. Which stage of shock is characterized by anaerobic metabolism,
lactic acid accumulation, and cellular ischemia as compensatory
mechanisms begin to fail?
A. Initial stage
B. Compensatory stage
C. Progressive stage
D. Refractory stage
Answer: C
Rationale: In the progressive stage, decreased perfusion forces cells into
anaerobic metabolism. Lactic acidosis, capillary leak, and organ dysfunction
develop. The refractory stage follows, when MODS is established and the
patient no longer responds to therapy.
Page 1
, NUR 2755 MDC 4 | Exam 3
3. Which physiologic response is a COMPENSATORY mechanism
during early shock?
A. Decreased release of antidiuretic hormone
B. Activation of the renin-angiotensin-aldosterone system
C. Peripheral vasodilation
D. Decreased heart rate
Answer: B
Rationale: Falling perfusion activates the RAAS (angiotensin II
vasoconstriction, aldosterone sodium/water retention) and ADH release to
restore volume and pressure. The SNS also raises heart rate and causes
vasoconstriction of skin, gut, and kidneys to shunt blood to the heart and
brain.
4. A patient has lost approximately 35% of blood volume (about 1,750
mL). Which findings does the nurse expect with this Class III
hemorrhage?
A. Normal BP, HR less than 100, anxious mood
B. Normal BP, HR 100-110, slight anxiety
C. HR greater than 120, decreased BP, confusion, RR 30-40
D. No pulse, unresponsive
Answer: C
Rationale: Class III hemorrhage (30-40% loss) produces marked tachycardia
(>120), hypotension, tachypnea (30-40), decreased urine output, and
confusion/anxiety. Class I-II losses (up to 30%) may show normal BP.
Page 2
, NUR 2755 MDC 4 | Exam 3
5. A patient's blood pressure is 88/46 mmHg. What is the mean arterial
pressure (MAP), and what is the appropriate nursing action?
A. 60 mmHg; adequate, continue to monitor
B. 60 mmHg; below 65, notify the provider and prepare for interventions
C. 76 mmHg; adequate
D. 76 mmHg; below 80, reassess in 1 hour
Answer: B
Rationale: MAP = (SBP + 2 x DBP) / 3 = (88 + 92) / 3 = 60 mmHg. A MAP of
65 mmHg or higher is generally required to perfuse vital organs, so the
provider must be notified and fluids/vasoactive support anticipated.
6. Which is the PRIORITY nursing intervention for a patient in
hemorrhagic shock from a femoral wound?
A. Obtain a 12-lead ECG
B. Apply direct pressure, and establish two large-bore IV lines
C. Insert a urinary catheter
D. Administer an oral fluid challenge
Answer: B
Rationale: Stopping the source of volume loss and restoring circulating
volume come first (Circulation in ABC/MARCH). Two large-bore IVs (14-16
gauge) allow rapid crystalloid and blood administration. Other actions follow.
7. The provider activates the massive transfusion protocol. What ratio of
blood products is generally targeted?
A. PRBC : FFP : platelets = 4:1:1
B. PRBC : FFP : platelets = 1:1:1
C. PRBC only until Hgb above 12
D. Platelets first, followed by cryoprecipitate only
Page 3
, NUR 2755 MDC 4 | Exam 3
Answer: B
Rationale: Balanced resuscitation (approximately 1:1:1) replaces clotting
factors and platelets along with red cells, reducing dilutional coagulopathy.
Excess crystalloid worsens the lethal triad of hypothermia, acidosis, and
coagulopathy.
8. A nurse performs a passive leg raise on a hypotensive patient. What
is the purpose of this test?
A. To treat hypotension long-term
B. To predict fluid responsiveness by transiently shifting about 300 mL of
venous blood to the heart
C. To assess for deep vein thrombosis
D. To lower intracranial pressure
Answer: B
Rationale: With the trunk semi-recumbent and legs raised to 45 degrees,
venous return increases. A rise in stroke volume/cardiac output (about 10-
15%) predicts the patient will respond to a fluid bolus. It is a reversible, self-
contained "fluid challenge."
9. The minimum acceptable urine output for an 80-kg adult in shock is:
A. 10 mL/hr
B. 20 mL/hr
C. 40 mL/hr
D. 80 mL/hr
Answer: C
Rationale: The goal is at least 0.5 mL/kg/hr: 0.5 x 80 = 40 mL/hr. Urine
output is a sensitive indicator of renal, and therefore overall, organ perfusion.
Page 4
NUR 2755 – Multidimensional Care IV (MDC 4) Exam 3
Questions with Answers| Rasmussen University|
Updated| Pass Guaranteed
1. A nurse is assessing a trauma patient who has been bleeding. Which
finding is the EARLIEST indicator of compensated shock?
A. Systolic blood pressure of 78 mmHg
B. Restlessness, anxiety, and tachycardia
C. Urine output of 5 mL/hr
D. Cyanosis of the lips
Answer: B
Rationale: In the compensatory stage the sympathetic nervous system is
activated, causing anxiety/restlessness, tachycardia, and cool skin while BP
is still maintained. Hypotension, oliguria, and cyanosis are late findings of
progressive shock.
2. Which stage of shock is characterized by anaerobic metabolism,
lactic acid accumulation, and cellular ischemia as compensatory
mechanisms begin to fail?
A. Initial stage
B. Compensatory stage
C. Progressive stage
D. Refractory stage
Answer: C
Rationale: In the progressive stage, decreased perfusion forces cells into
anaerobic metabolism. Lactic acidosis, capillary leak, and organ dysfunction
develop. The refractory stage follows, when MODS is established and the
patient no longer responds to therapy.
Page 1
, NUR 2755 MDC 4 | Exam 3
3. Which physiologic response is a COMPENSATORY mechanism
during early shock?
A. Decreased release of antidiuretic hormone
B. Activation of the renin-angiotensin-aldosterone system
C. Peripheral vasodilation
D. Decreased heart rate
Answer: B
Rationale: Falling perfusion activates the RAAS (angiotensin II
vasoconstriction, aldosterone sodium/water retention) and ADH release to
restore volume and pressure. The SNS also raises heart rate and causes
vasoconstriction of skin, gut, and kidneys to shunt blood to the heart and
brain.
4. A patient has lost approximately 35% of blood volume (about 1,750
mL). Which findings does the nurse expect with this Class III
hemorrhage?
A. Normal BP, HR less than 100, anxious mood
B. Normal BP, HR 100-110, slight anxiety
C. HR greater than 120, decreased BP, confusion, RR 30-40
D. No pulse, unresponsive
Answer: C
Rationale: Class III hemorrhage (30-40% loss) produces marked tachycardia
(>120), hypotension, tachypnea (30-40), decreased urine output, and
confusion/anxiety. Class I-II losses (up to 30%) may show normal BP.
Page 2
, NUR 2755 MDC 4 | Exam 3
5. A patient's blood pressure is 88/46 mmHg. What is the mean arterial
pressure (MAP), and what is the appropriate nursing action?
A. 60 mmHg; adequate, continue to monitor
B. 60 mmHg; below 65, notify the provider and prepare for interventions
C. 76 mmHg; adequate
D. 76 mmHg; below 80, reassess in 1 hour
Answer: B
Rationale: MAP = (SBP + 2 x DBP) / 3 = (88 + 92) / 3 = 60 mmHg. A MAP of
65 mmHg or higher is generally required to perfuse vital organs, so the
provider must be notified and fluids/vasoactive support anticipated.
6. Which is the PRIORITY nursing intervention for a patient in
hemorrhagic shock from a femoral wound?
A. Obtain a 12-lead ECG
B. Apply direct pressure, and establish two large-bore IV lines
C. Insert a urinary catheter
D. Administer an oral fluid challenge
Answer: B
Rationale: Stopping the source of volume loss and restoring circulating
volume come first (Circulation in ABC/MARCH). Two large-bore IVs (14-16
gauge) allow rapid crystalloid and blood administration. Other actions follow.
7. The provider activates the massive transfusion protocol. What ratio of
blood products is generally targeted?
A. PRBC : FFP : platelets = 4:1:1
B. PRBC : FFP : platelets = 1:1:1
C. PRBC only until Hgb above 12
D. Platelets first, followed by cryoprecipitate only
Page 3
, NUR 2755 MDC 4 | Exam 3
Answer: B
Rationale: Balanced resuscitation (approximately 1:1:1) replaces clotting
factors and platelets along with red cells, reducing dilutional coagulopathy.
Excess crystalloid worsens the lethal triad of hypothermia, acidosis, and
coagulopathy.
8. A nurse performs a passive leg raise on a hypotensive patient. What
is the purpose of this test?
A. To treat hypotension long-term
B. To predict fluid responsiveness by transiently shifting about 300 mL of
venous blood to the heart
C. To assess for deep vein thrombosis
D. To lower intracranial pressure
Answer: B
Rationale: With the trunk semi-recumbent and legs raised to 45 degrees,
venous return increases. A rise in stroke volume/cardiac output (about 10-
15%) predicts the patient will respond to a fluid bolus. It is a reversible, self-
contained "fluid challenge."
9. The minimum acceptable urine output for an 80-kg adult in shock is:
A. 10 mL/hr
B. 20 mL/hr
C. 40 mL/hr
D. 80 mL/hr
Answer: C
Rationale: The goal is at least 0.5 mL/kg/hr: 0.5 x 80 = 40 mL/hr. Urine
output is a sensitive indicator of renal, and therefore overall, organ perfusion.
Page 4
