NSG233/NSG 233 Exam 4 V2 | Medical-
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A nurse is caring for a client in the emergent phase of a major burn injury. Which of the
following laboratory results should the nurse expect to find during this stage?
A. Decreased hemoglobin and hematocrit
B. Increased serum sodium level
C. Decreased serum glucose level
D. Increased serum potassium level
Correct Answer: D
Rationale: During the emergent phase of a burn, massive cell destruction leads to the
release of potassium into the extracellular fluid, resulting in hyperkalemia. Fluid shifts out
of the vascular space also cause hemoconcentration, which increases hematocrit levels
rather than decreasing them. Additionally, sodium levels typically decrease because
sodium follows water into the interstitial spaces during the fluid shift.
2. A client is admitted to the ICU with a suspected diagnosis of septic shock. Which of the
following clinical manifestations is considered an early sign of this condition?
A. Hypotension and cool, clammy skin
B. Decreased respiratory rate and bradycardia
,C. Urine output of 10 mL per hour
D. Warm, flushed skin and tachycardia
Correct Answer: D
Rationale: In the early (hyperdynamic) phase of septic shock, the body attempts to
compensate for infection with a high cardiac output, leading to warm, flushed skin.
Tachycardia and an increased respiratory rate are also common compensatory
mechanisms as the body struggles to maintain perfusion. Cold, clammy skin and severe
hypotension are typically late signs seen in the hypodynamic or ‘cold’ phase of shock.
3. A nurse is calculating the fluid resuscitation requirements for a client using the Parkland
formula. The client weighs 80 kg and has sustained deep partial-thickness burns to 50% of
their total body surface area (TBSA). How much fluid should be administered in the first 8
hours?
A. 16,000 mL
B. 4,000 mL
C. 8,000 mL
D. 12,000 mL
Correct Answer: C
Rationale: The Parkland formula is calculated as 4 mL x weight (kg) x % TBSA burned. For
this client, the total 24-hour volume is 4 x 80 x 50 = 16,000 mL. According to the formula
,guidelines, half of the total volume (8,000 mL) must be administered within the first 8
hours following the injury.
4. Which hemodynamic parameter should the nurse monitor to specifically evaluate the
preload of the right side of the heart?
A. Pulmonary artery wedge pressure (PAWP)
B. Systemic vascular resistance (SVR)
C. Central venous pressure (CVP)
D. Mean arterial pressure (MAP)
Correct Answer: C
Rationale: Central venous pressure (CVP) is the clinical measurement used to assess the
pressure in the right atrium and the preload of the right ventricle. Normal CVP ranges from
2 to 8 mm Hg, and levels outside this range can indicate fluid volume status issues. In
contrast, PAWP measures left-sided heart preload, and SVR measures afterload.
5. A client in the ICU is being treated for Acute Respiratory Distress Syndrome (ARDS). The
nurse knows that the primary pathophysiological change in ARDS is:
A. Damage to the alveolar-capillary membrane
B. Increased compliance of the lung tissue
C. Excessive production of pulmonary surfactant
D. Obstruction of the main stem bronchus
, Correct Answer: A
Rationale: ARDS is characterized by a systemic inflammatory response that causes
significant damage to the alveolar-capillary membrane. This damage results in increased
permeability, leading to fluid accumulation in the alveoli and severe hypoxia that does not
respond to supplemental oxygen. The loss of surfactant and decreased lung compliance are
secondary consequences of this membrane destruction.
6. While assessing a client with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What does this finding indicate?
A. The system is functioning correctly.
B. There is an air leak in the system.
C. The client has a pneumothorax that is resolving.
D. The suction pressure is set too high.
Correct Answer: B
Rationale: Intermittent bubbling is expected in the water-seal chamber when a client has a
pneumothorax, especially during coughing or exhaling. However, continuous bubbling
signifies that there is a leak somewhere in the drainage system or at the insertion site. The
nurse must systematically check the tubing and connections to locate and secure the leak to
ensure proper lung re-expansion.
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A nurse is caring for a client in the emergent phase of a major burn injury. Which of the
following laboratory results should the nurse expect to find during this stage?
A. Decreased hemoglobin and hematocrit
B. Increased serum sodium level
C. Decreased serum glucose level
D. Increased serum potassium level
Correct Answer: D
Rationale: During the emergent phase of a burn, massive cell destruction leads to the
release of potassium into the extracellular fluid, resulting in hyperkalemia. Fluid shifts out
of the vascular space also cause hemoconcentration, which increases hematocrit levels
rather than decreasing them. Additionally, sodium levels typically decrease because
sodium follows water into the interstitial spaces during the fluid shift.
2. A client is admitted to the ICU with a suspected diagnosis of septic shock. Which of the
following clinical manifestations is considered an early sign of this condition?
A. Hypotension and cool, clammy skin
B. Decreased respiratory rate and bradycardia
,C. Urine output of 10 mL per hour
D. Warm, flushed skin and tachycardia
Correct Answer: D
Rationale: In the early (hyperdynamic) phase of septic shock, the body attempts to
compensate for infection with a high cardiac output, leading to warm, flushed skin.
Tachycardia and an increased respiratory rate are also common compensatory
mechanisms as the body struggles to maintain perfusion. Cold, clammy skin and severe
hypotension are typically late signs seen in the hypodynamic or ‘cold’ phase of shock.
3. A nurse is calculating the fluid resuscitation requirements for a client using the Parkland
formula. The client weighs 80 kg and has sustained deep partial-thickness burns to 50% of
their total body surface area (TBSA). How much fluid should be administered in the first 8
hours?
A. 16,000 mL
B. 4,000 mL
C. 8,000 mL
D. 12,000 mL
Correct Answer: C
Rationale: The Parkland formula is calculated as 4 mL x weight (kg) x % TBSA burned. For
this client, the total 24-hour volume is 4 x 80 x 50 = 16,000 mL. According to the formula
,guidelines, half of the total volume (8,000 mL) must be administered within the first 8
hours following the injury.
4. Which hemodynamic parameter should the nurse monitor to specifically evaluate the
preload of the right side of the heart?
A. Pulmonary artery wedge pressure (PAWP)
B. Systemic vascular resistance (SVR)
C. Central venous pressure (CVP)
D. Mean arterial pressure (MAP)
Correct Answer: C
Rationale: Central venous pressure (CVP) is the clinical measurement used to assess the
pressure in the right atrium and the preload of the right ventricle. Normal CVP ranges from
2 to 8 mm Hg, and levels outside this range can indicate fluid volume status issues. In
contrast, PAWP measures left-sided heart preload, and SVR measures afterload.
5. A client in the ICU is being treated for Acute Respiratory Distress Syndrome (ARDS). The
nurse knows that the primary pathophysiological change in ARDS is:
A. Damage to the alveolar-capillary membrane
B. Increased compliance of the lung tissue
C. Excessive production of pulmonary surfactant
D. Obstruction of the main stem bronchus
, Correct Answer: A
Rationale: ARDS is characterized by a systemic inflammatory response that causes
significant damage to the alveolar-capillary membrane. This damage results in increased
permeability, leading to fluid accumulation in the alveoli and severe hypoxia that does not
respond to supplemental oxygen. The loss of surfactant and decreased lung compliance are
secondary consequences of this membrane destruction.
6. While assessing a client with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What does this finding indicate?
A. The system is functioning correctly.
B. There is an air leak in the system.
C. The client has a pneumothorax that is resolving.
D. The suction pressure is set too high.
Correct Answer: B
Rationale: Intermittent bubbling is expected in the water-seal chamber when a client has a
pneumothorax, especially during coughing or exhaling. However, continuous bubbling
signifies that there is a leak somewhere in the drainage system or at the insertion site. The
nurse must systematically check the tubing and connections to locate and secure the leak to
ensure proper lung re-expansion.
