NUR2755 Exam 4 Actual Exam Style V1 |
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is caring for a client in the compensatory stage of shock. Which of the following
clinical findings should the nurse expect?
A. Systolic blood pressure less than 80 mmHg
B. Narrowing pulse pressure and tachycardia
C. Absent bowel sounds and paralytic ileus
D. Profound metabolic acidosis and cold, mottled skin
Answer: B
Rationale: During the compensatory stage of shock, the body initiates the fight-or-flight
response to maintain cardiac output. Tachycardia and narrowing pulse pressure occur as
the sympathetic nervous system releases epinephrine and norepinephrine. Hypotension
and organ failure typically characterize the progressive and refractory stages rather than
the compensatory phase.
2. A patient arrives at the emergency department with deep partial-thickness burns to the
front of both legs and the entire abdomen. Using the Rule of Nines, what is the estimated
Total Body Surface Area (TBSA) burned?
A. 27%
,B. 18%
C. 36%
D. 45%
Answer: A
Rationale: According to the Rule of Nines, the entire abdomen accounts for 9% of the
TBSA. Each leg represents 18% total, so the front of both legs accounts for 18% (9% each).
Adding 9% for the abdomen and 18% for the legs results in a total of 27% TBSA.
3. A nurse is participating in a mass casualty triage exercise. Which patient should receive a
Red Tag?
A. A client with a sucking chest wound and difficulty breathing.
B. A client with an open humerus fracture and controlled bleeding.
C. A client with massive head trauma and no spontaneous respirations.
D. A client with multiple abrasions who is walking around the scene.
Answer: A
Rationale: A Red Tag is assigned to patients with immediate life-threatening injuries that
are treatable, such as airway or breathing emergencies. A sucking chest wound indicates a
tension pneumothorax risk, requiring immediate intervention to survive. Patients with no
respirations are tagged black, while stable fractures are tagged yellow or green.
, 4. A client with septic shock has been prescribed a large volume of crystalloids. Which
assessment finding indicates the treatment is effective?
A. Central Venous Pressure (CVP) of 2 mmHg
B. Blood glucose level of 180 mg/dL
C. Mean Arterial Pressure (MAP) of 70 mmHg
D. Lactate level of 5 mmol/L
Answer: C
Rationale: The goal of fluid resuscitation in septic shock is to maintain adequate organ
perfusion, typically indicated by a MAP of at least 65 mmHg. A CVP of 2 is too low and
suggests continued hypovolemia, while an elevated lactate level indicates ongoing tissue
hypoxia. Achieving a MAP of 70 suggests that the fluid boluses are successfully improving
systemic circulation.
5. The nurse is caring for a patient with a T4 spinal cord injury. The patient’s heart rate is 48
bpm and blood pressure is 88/50 mmHg. Which type of shock is likely occurring?
A. Hypovolemic shock
B. Cardiogenic shock
C. Septic shock
D. Neurogenic shock
Answer: D
NUR 2755 Multidimensional Care IV / MDC
4 | Rasmussen
1. A nurse is caring for a client in the compensatory stage of shock. Which of the following
clinical findings should the nurse expect?
A. Systolic blood pressure less than 80 mmHg
B. Narrowing pulse pressure and tachycardia
C. Absent bowel sounds and paralytic ileus
D. Profound metabolic acidosis and cold, mottled skin
Answer: B
Rationale: During the compensatory stage of shock, the body initiates the fight-or-flight
response to maintain cardiac output. Tachycardia and narrowing pulse pressure occur as
the sympathetic nervous system releases epinephrine and norepinephrine. Hypotension
and organ failure typically characterize the progressive and refractory stages rather than
the compensatory phase.
2. A patient arrives at the emergency department with deep partial-thickness burns to the
front of both legs and the entire abdomen. Using the Rule of Nines, what is the estimated
Total Body Surface Area (TBSA) burned?
A. 27%
,B. 18%
C. 36%
D. 45%
Answer: A
Rationale: According to the Rule of Nines, the entire abdomen accounts for 9% of the
TBSA. Each leg represents 18% total, so the front of both legs accounts for 18% (9% each).
Adding 9% for the abdomen and 18% for the legs results in a total of 27% TBSA.
3. A nurse is participating in a mass casualty triage exercise. Which patient should receive a
Red Tag?
A. A client with a sucking chest wound and difficulty breathing.
B. A client with an open humerus fracture and controlled bleeding.
C. A client with massive head trauma and no spontaneous respirations.
D. A client with multiple abrasions who is walking around the scene.
Answer: A
Rationale: A Red Tag is assigned to patients with immediate life-threatening injuries that
are treatable, such as airway or breathing emergencies. A sucking chest wound indicates a
tension pneumothorax risk, requiring immediate intervention to survive. Patients with no
respirations are tagged black, while stable fractures are tagged yellow or green.
, 4. A client with septic shock has been prescribed a large volume of crystalloids. Which
assessment finding indicates the treatment is effective?
A. Central Venous Pressure (CVP) of 2 mmHg
B. Blood glucose level of 180 mg/dL
C. Mean Arterial Pressure (MAP) of 70 mmHg
D. Lactate level of 5 mmol/L
Answer: C
Rationale: The goal of fluid resuscitation in septic shock is to maintain adequate organ
perfusion, typically indicated by a MAP of at least 65 mmHg. A CVP of 2 is too low and
suggests continued hypovolemia, while an elevated lactate level indicates ongoing tissue
hypoxia. Achieving a MAP of 70 suggests that the fluid boluses are successfully improving
systemic circulation.
5. The nurse is caring for a patient with a T4 spinal cord injury. The patient’s heart rate is 48
bpm and blood pressure is 88/50 mmHg. Which type of shock is likely occurring?
A. Hypovolemic shock
B. Cardiogenic shock
C. Septic shock
D. Neurogenic shock
Answer: D
