NSG233/NSG 233 Exam 4 V1 | Medical-
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient arrives in the emergency department with partial-thickness burns to the entire
left arm and the anterior trunk. Using the Rule of Nines, what is the estimated percentage of
Total Body Surface Area (TBSA) affected?
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Rationale: The Rule of Nines assigns 9% to the entire arm and 18% to the anterior trunk.
Adding 9% and 18% results in a total of 27% TBSA. Accurate estimation is critical for
calculating fluid resuscitation requirements in the emergent phase.
2. Which clinical manifestation is most characteristic of the progressive stage of shock?
A. Increased urine output
B. Metabolic alkalosis
C. Cold, clammy skin and mottled extremities
,D. Narrow pulse pressure with stable mentation
Correct Answer: C
Rationale: During the progressive stage of shock, compensatory mechanisms fail, leading
to decreased peripheral perfusion evidenced by mottled, cold skin. Tissue hypoxia shifts
metabolism from aerobic to anaerobic, resulting in metabolic acidosis. This stage requires
immediate intervention to prevent multiple organ dysfunction syndrome (MODS).
3. A nurse is caring for a patient in septic shock. Which laboratory value should the nurse
prioritize to evaluate the effectiveness of tissue perfusion?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell count
C. Serum Lactate level
D. Hemoglobin level
Correct Answer: C
Rationale: Elevated serum lactate levels indicate anaerobic metabolism and inadequate
tissue oxygenation, which are hallmarks of septic shock. Monitoring lactate trends helps
clinicians determine if resuscitation efforts are successfully restoring perfusion. A
decreasing lactate level generally suggests improved cellular oxygen delivery.
4. In the ‘Emergent Phase’ of burn care, which electrolyte imbalance is the nurse most likely
to observe?
A. Hypocalcemia
, B. Hypokalemia
C. Hypernatremia
D. Hyperkalemia
Correct Answer: D
Rationale: Hyperkalemia occurs because cellular destruction releases massive amounts of
potassium into the extracellular fluid. This occurs immediately after the burn injury during
the fluid shift phase. The nurse must monitor for cardiac dysrhythmias associated with
elevated potassium levels.
5. During a mass casualty incident, a patient with a sucking chest wound is categorized.
Which color tag should the triage nurse assign?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
Rationale: A red tag indicates an immediate life-threatening injury that is treatable with
rapid intervention. A sucking chest wound compromises ventilation and requires
immediate chest tube insertion or occlusive dressing. Proper triage ensures that resources
are allocated to those with the highest chance of survival through immediate care.
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient arrives in the emergency department with partial-thickness burns to the entire
left arm and the anterior trunk. Using the Rule of Nines, what is the estimated percentage of
Total Body Surface Area (TBSA) affected?
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Rationale: The Rule of Nines assigns 9% to the entire arm and 18% to the anterior trunk.
Adding 9% and 18% results in a total of 27% TBSA. Accurate estimation is critical for
calculating fluid resuscitation requirements in the emergent phase.
2. Which clinical manifestation is most characteristic of the progressive stage of shock?
A. Increased urine output
B. Metabolic alkalosis
C. Cold, clammy skin and mottled extremities
,D. Narrow pulse pressure with stable mentation
Correct Answer: C
Rationale: During the progressive stage of shock, compensatory mechanisms fail, leading
to decreased peripheral perfusion evidenced by mottled, cold skin. Tissue hypoxia shifts
metabolism from aerobic to anaerobic, resulting in metabolic acidosis. This stage requires
immediate intervention to prevent multiple organ dysfunction syndrome (MODS).
3. A nurse is caring for a patient in septic shock. Which laboratory value should the nurse
prioritize to evaluate the effectiveness of tissue perfusion?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell count
C. Serum Lactate level
D. Hemoglobin level
Correct Answer: C
Rationale: Elevated serum lactate levels indicate anaerobic metabolism and inadequate
tissue oxygenation, which are hallmarks of septic shock. Monitoring lactate trends helps
clinicians determine if resuscitation efforts are successfully restoring perfusion. A
decreasing lactate level generally suggests improved cellular oxygen delivery.
4. In the ‘Emergent Phase’ of burn care, which electrolyte imbalance is the nurse most likely
to observe?
A. Hypocalcemia
, B. Hypokalemia
C. Hypernatremia
D. Hyperkalemia
Correct Answer: D
Rationale: Hyperkalemia occurs because cellular destruction releases massive amounts of
potassium into the extracellular fluid. This occurs immediately after the burn injury during
the fluid shift phase. The nurse must monitor for cardiac dysrhythmias associated with
elevated potassium levels.
5. During a mass casualty incident, a patient with a sucking chest wound is categorized.
Which color tag should the triage nurse assign?
A. Green
B. Yellow
C. Black
D. Red
Correct Answer: D
Rationale: A red tag indicates an immediate life-threatening injury that is treatable with
rapid intervention. A sucking chest wound compromises ventilation and requires
immediate chest tube insertion or occlusive dressing. Proper triage ensures that resources
are allocated to those with the highest chance of survival through immediate care.
