NR341/NR 341 Exam 4 V1 | Complex Adult Health
Q&A with Rationale | Chamberlain University
1. A patient arrives at the emergency department with a suspected myocardial infarction,
reporting crushing chest pain and a BP of 90/60 mmHg. Using the Emergency Severity Index
(ESI), which level should the nurse assign?
A. ESI 2
B. ESI 1
C. ESI 3
D. ESI 4
Correct Answer: A
Explanation: ESI level 2 is assigned to patients in high-risk situations where the condition
could deteriorate rapidly. This patient has unstable vital signs and symptoms suggestive of
a cardiac event, requiring immediate assessment. ESI 1 is reserved for patients requiring
immediate life-saving interventions such as intubation or CPR.
2. During the primary survey of a trauma patient, the nurse notes the absence of breath
sounds on the left side and tracheal deviation to the right. What is the priority intervention?
A. Obtain a portable chest X-ray
B. Administer high-flow oxygen via non-rebreather
C. Insert a large-bore orogastric tube
,D. Perform needle decompression
Correct Answer: D
Explanation: Tracheal deviation and absent breath sounds are hallmark signs of a tension
pneumothorax. This is a life-threatening condition that must be addressed during the
‘Breathing’ portion of the primary survey. Needle decompression followed by chest tube
insertion is the standard emergency treatment to relieve pleural pressure.
3. A patient is in the emergent phase of a 40% total body surface area (TBSA) burn. Which
laboratory value should the nurse anticipate?
A. Hypernatremia
B. Hypokalemia
C. Decreased hematocrit
D. Hyperkalemia
Correct Answer: D
Explanation: Hyperkalemia occurs in the emergent phase of burns due to massive cell
destruction and the release of potassium into the extracellular fluid. Hemoconcentration
also typically results in an increased hematocrit level due to fluid loss. Sodium levels often
decrease as sodium moves into the interstitial spaces with fluid shifts.
4. Which clinical manifestation is a hallmark sign of neurogenic shock following a spinal cord
injury at T3?
A. Tachycardia and hypertension
, B. Bradycardia and hyperthermia
C. Tachycardia and cool, clammy skin
D. Bradycardia and hypotension
Correct Answer: D
Explanation: Neurogenic shock is characterized by the loss of sympathetic tone, leading to
massive vasodilation and bradycardia. This differs from other forms of shock where the
body typically compensates with tachycardia. The hypotension results from the increased
vascular capacity and reduced venous return to the heart.
5. The nurse is caring for a patient in septic shock. Which hemodynamic parameter would the
nurse expect to find?
A. High Systemic Vascular Resistance (SVR)
B. Decreased Cardiac Output
C. Low Central Venous Pressure (CVP)
D. High Pulmonary Artery Wedge Pressure (PAWP)
Correct Answer: C
Explanation: In septic shock, massive vasodilation and capillary leak lead to a relative and
absolute hypovolemia, resulting in a low CVP. Systemic Vascular Resistance (SVR) is
typically low due to the vasodilation caused by inflammatory mediators. Early septic shock
Q&A with Rationale | Chamberlain University
1. A patient arrives at the emergency department with a suspected myocardial infarction,
reporting crushing chest pain and a BP of 90/60 mmHg. Using the Emergency Severity Index
(ESI), which level should the nurse assign?
A. ESI 2
B. ESI 1
C. ESI 3
D. ESI 4
Correct Answer: A
Explanation: ESI level 2 is assigned to patients in high-risk situations where the condition
could deteriorate rapidly. This patient has unstable vital signs and symptoms suggestive of
a cardiac event, requiring immediate assessment. ESI 1 is reserved for patients requiring
immediate life-saving interventions such as intubation or CPR.
2. During the primary survey of a trauma patient, the nurse notes the absence of breath
sounds on the left side and tracheal deviation to the right. What is the priority intervention?
A. Obtain a portable chest X-ray
B. Administer high-flow oxygen via non-rebreather
C. Insert a large-bore orogastric tube
,D. Perform needle decompression
Correct Answer: D
Explanation: Tracheal deviation and absent breath sounds are hallmark signs of a tension
pneumothorax. This is a life-threatening condition that must be addressed during the
‘Breathing’ portion of the primary survey. Needle decompression followed by chest tube
insertion is the standard emergency treatment to relieve pleural pressure.
3. A patient is in the emergent phase of a 40% total body surface area (TBSA) burn. Which
laboratory value should the nurse anticipate?
A. Hypernatremia
B. Hypokalemia
C. Decreased hematocrit
D. Hyperkalemia
Correct Answer: D
Explanation: Hyperkalemia occurs in the emergent phase of burns due to massive cell
destruction and the release of potassium into the extracellular fluid. Hemoconcentration
also typically results in an increased hematocrit level due to fluid loss. Sodium levels often
decrease as sodium moves into the interstitial spaces with fluid shifts.
4. Which clinical manifestation is a hallmark sign of neurogenic shock following a spinal cord
injury at T3?
A. Tachycardia and hypertension
, B. Bradycardia and hyperthermia
C. Tachycardia and cool, clammy skin
D. Bradycardia and hypotension
Correct Answer: D
Explanation: Neurogenic shock is characterized by the loss of sympathetic tone, leading to
massive vasodilation and bradycardia. This differs from other forms of shock where the
body typically compensates with tachycardia. The hypotension results from the increased
vascular capacity and reduced venous return to the heart.
5. The nurse is caring for a patient in septic shock. Which hemodynamic parameter would the
nurse expect to find?
A. High Systemic Vascular Resistance (SVR)
B. Decreased Cardiac Output
C. Low Central Venous Pressure (CVP)
D. High Pulmonary Artery Wedge Pressure (PAWP)
Correct Answer: C
Explanation: In septic shock, massive vasodilation and capillary leak lead to a relative and
absolute hypovolemia, resulting in a low CVP. Systemic Vascular Resistance (SVR) is
typically low due to the vasodilation caused by inflammatory mediators. Early septic shock
