NR341/NR 341 Exam 4 V3 | Complex Adult
Health Q&A with Rationale | Chamberlain
University
1. A patient who suffered a 40% total body surface area (TBSA) burn arrives in the Emergency
Department. 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 70kg?
A. 2,800 mL
B. 11,200 mL
C. 5,600 mL
D. 14,000 mL
Correct Answer: C
Expert Explanation: The total fluid for 24 hours is calculated as 4mL x 70kg x 40, which
equals 11,200 mL. According to the Parkland formula, half of this total volume must be
administered within the first 8 hours after the burn injury occurs. Therefore, the nurse
should set the infusion to deliver 5,600 mL during that initial 8-hour window.
2. Which clinical manifestation should the nurse prioritize as an early sign of ARDS in a
patient who recently aspirated gastric contents?
A. Severe cyanosis and tracheal deviation
B. Decreased heart rate and hypotension
,C. Productive cough with thick green sputum
D. Rapid onset of dyspnea and tachypnea
Correct Answer: D
Expert Explanation: Acute Respiratory Distress Syndrome (ARDS) typically begins with a
rapid onset of respiratory distress including tachypnea and dyspnea. Initial physical
examinations may reveal normal lung sounds before crackles develop later in the disease
progression. Cyanosis and severe hypoxia are generally later signs indicating profound
respiratory failure.
3. The nurse is caring for a patient with a spinal cord injury at the T4 level. The patient reports
a sudden, throbbing headache and the nurse notes a blood pressure of 190/100 mmHg. What
is the priority nursing action?
A. Administer an ordered analgesic for the headache
B. Elevate the head of the bed to 45 degrees or higher
C. Perform a digital rectal exam to check for impaction
D. Check the patient’s temperature for signs of infection
Correct Answer: B
Expert Explanation: These symptoms are classic indicators of autonomic dysreflexia,
which is a medical emergency for patients with injuries at or above T6. The immediate
priority is to elevate the head of the bed to promote venous drainage and lower intracranial
,pressure. Following this, the nurse should assess for the triggering cause, such as a kinked
catheter or bowel impaction.
4. A patient in the ICU has an intracranial pressure (ICP) monitor. The nurse notes a reading of
22 mmHg. Which intervention should the nurse implement first?
A. Suction the patient vigorously to clear the airway
B. Increase the room temperature to prevent shivering
C. Ensure the patient’s neck is in a neutral, midline position
D. Administer a bolus of hypotonic saline solution
Correct Answer: C
Expert Explanation: A normal ICP range is 5 to 15 mmHg, making 22 mmHg an elevated
reading that requires intervention. Keeping the neck in a neutral position prevents venous
obstruction and facilitates the drainage of cerebrospinal fluid. Suctioning should be limited
as it can further increase intracranial pressure by triggering coughing or the Valsalva
maneuver.
5. During the emergent phase of a burn injury, which electrolyte abnormality is the nurse
most likely to observe?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
, D. Hypoglycemia
Correct Answer: C
Expert Explanation: During the emergent phase, massive cell destruction causes the
release of potassium into the extracellular fluid, leading to hyperkalemia. This shift occurs
because the sodium-potassium pump fails due to decreased cellular oxygenation and
energy. Management of these levels is critical to prevent lethal cardiac arrhythmias.
6. The nurse is monitoring a patient with a pulmonary artery catheter. The Pulmonary Artery
Occlusion Pressure (PAOP) is 4 mmHg. What does this value likely indicate?
A. Left ventricular fluid overload
B. Mitral valve regurgitation
C. Pulmonary hypertension
D. Hypovolemia or dehydration
Correct Answer: D
Expert Explanation: The PAOP, or wedge pressure, reflects left atrial and left ventricular
end-diastolic pressure, with a normal range of 6 to 12 mmHg. A low reading of 4 mmHg
suggests a lack of volume in the vascular space, necessitating fluid resuscitation.
Conversely, high readings would indicate fluid volume excess or cardiac failure.
7. Which assessment finding is a hallmark of the progressive stage of shock?
A. Mean arterial pressure (MAP) within normal limits
Health Q&A with Rationale | Chamberlain
University
1. A patient who suffered a 40% total body surface area (TBSA) burn arrives in the Emergency
Department. 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 70kg?
A. 2,800 mL
B. 11,200 mL
C. 5,600 mL
D. 14,000 mL
Correct Answer: C
Expert Explanation: The total fluid for 24 hours is calculated as 4mL x 70kg x 40, which
equals 11,200 mL. According to the Parkland formula, half of this total volume must be
administered within the first 8 hours after the burn injury occurs. Therefore, the nurse
should set the infusion to deliver 5,600 mL during that initial 8-hour window.
2. Which clinical manifestation should the nurse prioritize as an early sign of ARDS in a
patient who recently aspirated gastric contents?
A. Severe cyanosis and tracheal deviation
B. Decreased heart rate and hypotension
,C. Productive cough with thick green sputum
D. Rapid onset of dyspnea and tachypnea
Correct Answer: D
Expert Explanation: Acute Respiratory Distress Syndrome (ARDS) typically begins with a
rapid onset of respiratory distress including tachypnea and dyspnea. Initial physical
examinations may reveal normal lung sounds before crackles develop later in the disease
progression. Cyanosis and severe hypoxia are generally later signs indicating profound
respiratory failure.
3. The nurse is caring for a patient with a spinal cord injury at the T4 level. The patient reports
a sudden, throbbing headache and the nurse notes a blood pressure of 190/100 mmHg. What
is the priority nursing action?
A. Administer an ordered analgesic for the headache
B. Elevate the head of the bed to 45 degrees or higher
C. Perform a digital rectal exam to check for impaction
D. Check the patient’s temperature for signs of infection
Correct Answer: B
Expert Explanation: These symptoms are classic indicators of autonomic dysreflexia,
which is a medical emergency for patients with injuries at or above T6. The immediate
priority is to elevate the head of the bed to promote venous drainage and lower intracranial
,pressure. Following this, the nurse should assess for the triggering cause, such as a kinked
catheter or bowel impaction.
4. A patient in the ICU has an intracranial pressure (ICP) monitor. The nurse notes a reading of
22 mmHg. Which intervention should the nurse implement first?
A. Suction the patient vigorously to clear the airway
B. Increase the room temperature to prevent shivering
C. Ensure the patient’s neck is in a neutral, midline position
D. Administer a bolus of hypotonic saline solution
Correct Answer: C
Expert Explanation: A normal ICP range is 5 to 15 mmHg, making 22 mmHg an elevated
reading that requires intervention. Keeping the neck in a neutral position prevents venous
obstruction and facilitates the drainage of cerebrospinal fluid. Suctioning should be limited
as it can further increase intracranial pressure by triggering coughing or the Valsalva
maneuver.
5. During the emergent phase of a burn injury, which electrolyte abnormality is the nurse
most likely to observe?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
, D. Hypoglycemia
Correct Answer: C
Expert Explanation: During the emergent phase, massive cell destruction causes the
release of potassium into the extracellular fluid, leading to hyperkalemia. This shift occurs
because the sodium-potassium pump fails due to decreased cellular oxygenation and
energy. Management of these levels is critical to prevent lethal cardiac arrhythmias.
6. The nurse is monitoring a patient with a pulmonary artery catheter. The Pulmonary Artery
Occlusion Pressure (PAOP) is 4 mmHg. What does this value likely indicate?
A. Left ventricular fluid overload
B. Mitral valve regurgitation
C. Pulmonary hypertension
D. Hypovolemia or dehydration
Correct Answer: D
Expert Explanation: The PAOP, or wedge pressure, reflects left atrial and left ventricular
end-diastolic pressure, with a normal range of 6 to 12 mmHg. A low reading of 4 mmHg
suggests a lack of volume in the vascular space, necessitating fluid resuscitation.
Conversely, high readings would indicate fluid volume excess or cardiac failure.
7. Which assessment finding is a hallmark of the progressive stage of shock?
A. Mean arterial pressure (MAP) within normal limits
