NURS 480 Exam 1 V2 | NURS 480
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 1) | West Coast University
1. A patient in the emergent phase of a major burn injury is receiving fluid resuscitation.
Which clinical finding is the most reliable indicator that the fluid volume replacement is
adequate?
A. A urinary output of 30 to 50 mL/hour
B. A heart rate of less than 110 beats per minute
C. A systolic blood pressure greater than 100 mmHg
D. A central venous pressure of 12 mmHg
Answer: A
Rationale: Urine output is the most sensitive and reliable indicator of vital organ perfusion
and the adequacy of fluid resuscitation in a burn patient. For adult patients without
electrical injury, the goal is typically 0.5 mL/kg/hr or roughly 30 to 50 mL/hr. Other
parameters such as blood pressure and heart rate can be influenced by the massive
catecholamine release associated with burn trauma, making them less specific.
2. The nurse is caring for a patient with septic shock. Which hemodynamic profile is most
consistent with the early (hyperdynamic) phase of this condition?
A. Decreased central venous pressure and increased systemic vascular resistance
,B. Decreased cardiac output and increased systemic vascular resistance
C. Increased pulmonary artery wedge pressure and decreased heart rate
D. Increased cardiac output and decreased systemic vascular resistance
Answer: D
Rationale: During the early or warm phase of septic shock, the body experiences massive
vasodilation due to inflammatory mediators, which drastically lowers systemic vascular
resistance (SVR). To compensate for this drop in resistance and maintain perfusion, the
heart increases its rate and stroke volume, leading to an elevated cardiac output. This
phase is unique compared to other forms of shock where cardiac output is typically low
from the start.
3. A patient with Acute Respiratory Distress Syndrome (ARDS) is placed on mechanical
ventilation with high levels of Positive End-Expiratory Pressure (PEEP). What is the primary
purpose of PEEP in this patient?
A. To prevent alveolar collapse and improve oxygenation
B. To increase the fraction of inspired oxygen (FiO2)
C. To decrease the risk of barotrauma to the lung tissue
D. To facilitate the removal of secretions from the lower airways
Answer: A
,Rationale: ARDS is characterized by the collapse of alveoli and the filling of air sacs with
fluid, leading to severe hypoxemia. PEEP provides constant pressure during the expiratory
phase to keep the alveoli open, thereby increasing the surface area available for gas
exchange. This recruitment of alveoli helps improve arterial oxygen saturation and may
allow for a reduction in the required FiO2, which prevents oxygen toxicity.
4. A victim of a house fire is brought to the emergency department with soot around the nose
and mouth, a hoarse voice, and singed nasal hairs. What is the priority nursing intervention?
A. Insert a large-bore intravenous line for fluid resuscitation
B. Prepare for immediate endotracheal intubation
C. Assess the total body surface area burned
D. Administer high-flow oxygen via a non-rebreather mask
Answer: B
Rationale: The presence of soot, hoarseness, and singed nasal hairs strongly suggests an
upper airway inhalation injury, which can lead to rapid and catastrophic airway edema. In
such cases, the priority is to secure the airway before swelling makes intubation
impossible. While oxygen and fluids are important, maintaining a patent airway takes
precedence in the primary survey of a burn victim.
, 5. An 80 kg patient has sustained partial-thickness burns over 50% of their body. Using the
Parkland formula (4 mL/kg/%TBSA), how much Lactated Ringer’s solution should the nurse
administer during the first 8 hours after the injury occurred?
A. 8,000 mL
B. 16,000 mL
C. 4,000 mL
D. 10,000 mL
Answer: A
Rationale: The Parkland formula calculates the total 24-hour fluid requirement as 4 mL x
weight in kg x % TBSA (4 x 80 x 50 = 16,000 mL). According to the protocol, half of this
total volume (8,000 mL) must be administered within the first 8 hours following the time of
the injury. The remaining half is then distributed over the subsequent 16 hours.
6. During a mass casualty incident, the nurse triage officer assesses a patient who is
unconscious, has an open head injury with exposed brain matter, and has agonal respirations.
Which color tag should be assigned to this patient?
A. Black
B. Yellow
C. Green
D. Red
Advanced Medical Surgical Health Nursing
| Actual Q&A with Rationale (NURS480
Exam 1) | West Coast University
1. A patient in the emergent phase of a major burn injury is receiving fluid resuscitation.
Which clinical finding is the most reliable indicator that the fluid volume replacement is
adequate?
A. A urinary output of 30 to 50 mL/hour
B. A heart rate of less than 110 beats per minute
C. A systolic blood pressure greater than 100 mmHg
D. A central venous pressure of 12 mmHg
Answer: A
Rationale: Urine output is the most sensitive and reliable indicator of vital organ perfusion
and the adequacy of fluid resuscitation in a burn patient. For adult patients without
electrical injury, the goal is typically 0.5 mL/kg/hr or roughly 30 to 50 mL/hr. Other
parameters such as blood pressure and heart rate can be influenced by the massive
catecholamine release associated with burn trauma, making them less specific.
2. The nurse is caring for a patient with septic shock. Which hemodynamic profile is most
consistent with the early (hyperdynamic) phase of this condition?
A. Decreased central venous pressure and increased systemic vascular resistance
,B. Decreased cardiac output and increased systemic vascular resistance
C. Increased pulmonary artery wedge pressure and decreased heart rate
D. Increased cardiac output and decreased systemic vascular resistance
Answer: D
Rationale: During the early or warm phase of septic shock, the body experiences massive
vasodilation due to inflammatory mediators, which drastically lowers systemic vascular
resistance (SVR). To compensate for this drop in resistance and maintain perfusion, the
heart increases its rate and stroke volume, leading to an elevated cardiac output. This
phase is unique compared to other forms of shock where cardiac output is typically low
from the start.
3. A patient with Acute Respiratory Distress Syndrome (ARDS) is placed on mechanical
ventilation with high levels of Positive End-Expiratory Pressure (PEEP). What is the primary
purpose of PEEP in this patient?
A. To prevent alveolar collapse and improve oxygenation
B. To increase the fraction of inspired oxygen (FiO2)
C. To decrease the risk of barotrauma to the lung tissue
D. To facilitate the removal of secretions from the lower airways
Answer: A
,Rationale: ARDS is characterized by the collapse of alveoli and the filling of air sacs with
fluid, leading to severe hypoxemia. PEEP provides constant pressure during the expiratory
phase to keep the alveoli open, thereby increasing the surface area available for gas
exchange. This recruitment of alveoli helps improve arterial oxygen saturation and may
allow for a reduction in the required FiO2, which prevents oxygen toxicity.
4. A victim of a house fire is brought to the emergency department with soot around the nose
and mouth, a hoarse voice, and singed nasal hairs. What is the priority nursing intervention?
A. Insert a large-bore intravenous line for fluid resuscitation
B. Prepare for immediate endotracheal intubation
C. Assess the total body surface area burned
D. Administer high-flow oxygen via a non-rebreather mask
Answer: B
Rationale: The presence of soot, hoarseness, and singed nasal hairs strongly suggests an
upper airway inhalation injury, which can lead to rapid and catastrophic airway edema. In
such cases, the priority is to secure the airway before swelling makes intubation
impossible. While oxygen and fluids are important, maintaining a patent airway takes
precedence in the primary survey of a burn victim.
, 5. An 80 kg patient has sustained partial-thickness burns over 50% of their body. Using the
Parkland formula (4 mL/kg/%TBSA), how much Lactated Ringer’s solution should the nurse
administer during the first 8 hours after the injury occurred?
A. 8,000 mL
B. 16,000 mL
C. 4,000 mL
D. 10,000 mL
Answer: A
Rationale: The Parkland formula calculates the total 24-hour fluid requirement as 4 mL x
weight in kg x % TBSA (4 x 80 x 50 = 16,000 mL). According to the protocol, half of this
total volume (8,000 mL) must be administered within the first 8 hours following the time of
the injury. The remaining half is then distributed over the subsequent 16 hours.
6. During a mass casualty incident, the nurse triage officer assesses a patient who is
unconscious, has an open head injury with exposed brain matter, and has agonal respirations.
Which color tag should be assigned to this patient?
A. Black
B. Yellow
C. Green
D. Red
