NSG233/NSG 233 Exam 4 V3 | Medical-
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient is admitted to the emergency department with a deep partial-thickness burn to
the chest and abdomen. Which assessment finding should the nurse prioritize during the
emergent phase?
A. Blood pressure of 100/60 mmHg
B. Severe pain reported by the patient
C. Urine output of 30 mL/hour
D. Presence of singed nasal hairs
Correct Answer: D
Rationale: The presence of singed nasal hairs is a significant indicator of potential
inhalation injury, which can lead to rapid airway obstruction. Airway management is the
highest priority in the emergent phase of burn care according to the ABC protocol. Early
identification allows for prophylactic intubation before edema makes the procedure
impossible.
2. When managing a patient in the progressive stage of shock, which physiological change
should the nurse expect to observe?
A. Increased cardiac output due to catecholamine release
,B. Respiratory alkalosis from hyperventilation
C. Metabolic acidosis and increased serum lactate levels
D. Warm, flushed skin due to vasodilation
Correct Answer: C
Rationale: In the progressive stage of shock, compensatory mechanisms begin to fail,
leading to anaerobic metabolism. This shift results in the production of lactic acid, causing
metabolic acidosis and elevated serum lactate levels. The nurse must monitor these values
closely to evaluate the severity of tissue hypoxia and the effectiveness of resuscitation.
3. A patient with septic shock has been receiving large volumes of crystalloids. Which clinical
finding indicates the need for the addition of vasopressors?
A. Heart rate is 110 beats per minute
B. Central Venous Pressure (CVP) is 10 mmHg
C. Mean Arterial Pressure (MAP) remains below 65 mmHg
D. Serum potassium level is 5.2 mEq/L
Correct Answer: C
Rationale: Vasopressors are indicated when fluid resuscitation fails to maintain adequate
tissue perfusion, typically defined as a MAP of at least 65 mmHg. Norepinephrine is usually
the first-line agent for septic shock to increase systemic vascular resistance. Maintaining an
, adequate MAP is essential for ensuring oxygen delivery to vital organs like the kidneys and
brain.
4. An adult patient weighs 70 kg and has sustained full-thickness burns to 40% of their body
surface area. Using the Parkland formula, calculate the total fluid volume needed for the first
24 hours.
A. 5,600 mL
B. 8,400 mL
C. 11,200 mL
D. 14,000 mL
Correct Answer: C
Rationale: The Parkland formula is calculated as 4 mL × kg × % TBSA. For this patient, the
calculation is 4 mL × 70 kg × 40 = 11,200 mL. Half of this total volume must be
administered within the first 8 hours following the time of the burn injury.
5. Which electrolyte imbalance is the nurse most likely to observe in a patient during the
emergent phase of a major burn injury?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Surgical Nursing III Q&A with Rationale |
Herzing University
1. A patient is admitted to the emergency department with a deep partial-thickness burn to
the chest and abdomen. Which assessment finding should the nurse prioritize during the
emergent phase?
A. Blood pressure of 100/60 mmHg
B. Severe pain reported by the patient
C. Urine output of 30 mL/hour
D. Presence of singed nasal hairs
Correct Answer: D
Rationale: The presence of singed nasal hairs is a significant indicator of potential
inhalation injury, which can lead to rapid airway obstruction. Airway management is the
highest priority in the emergent phase of burn care according to the ABC protocol. Early
identification allows for prophylactic intubation before edema makes the procedure
impossible.
2. When managing a patient in the progressive stage of shock, which physiological change
should the nurse expect to observe?
A. Increased cardiac output due to catecholamine release
,B. Respiratory alkalosis from hyperventilation
C. Metabolic acidosis and increased serum lactate levels
D. Warm, flushed skin due to vasodilation
Correct Answer: C
Rationale: In the progressive stage of shock, compensatory mechanisms begin to fail,
leading to anaerobic metabolism. This shift results in the production of lactic acid, causing
metabolic acidosis and elevated serum lactate levels. The nurse must monitor these values
closely to evaluate the severity of tissue hypoxia and the effectiveness of resuscitation.
3. A patient with septic shock has been receiving large volumes of crystalloids. Which clinical
finding indicates the need for the addition of vasopressors?
A. Heart rate is 110 beats per minute
B. Central Venous Pressure (CVP) is 10 mmHg
C. Mean Arterial Pressure (MAP) remains below 65 mmHg
D. Serum potassium level is 5.2 mEq/L
Correct Answer: C
Rationale: Vasopressors are indicated when fluid resuscitation fails to maintain adequate
tissue perfusion, typically defined as a MAP of at least 65 mmHg. Norepinephrine is usually
the first-line agent for septic shock to increase systemic vascular resistance. Maintaining an
, adequate MAP is essential for ensuring oxygen delivery to vital organs like the kidneys and
brain.
4. An adult patient weighs 70 kg and has sustained full-thickness burns to 40% of their body
surface area. Using the Parkland formula, calculate the total fluid volume needed for the first
24 hours.
A. 5,600 mL
B. 8,400 mL
C. 11,200 mL
D. 14,000 mL
Correct Answer: C
Rationale: The Parkland formula is calculated as 4 mL × kg × % TBSA. For this patient, the
calculation is 4 mL × 70 kg × 40 = 11,200 mL. Half of this total volume must be
administered within the first 8 hours following the time of the burn injury.
5. Which electrolyte imbalance is the nurse most likely to observe in a patient during the
emergent phase of a major burn injury?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
