Nightingale College BSN 366 Final Exam (pdf) | 2026/2027 |
Concepts of Nursing IV | Nursing
1. During a mass casualty incident, which color tag is assigned to a client
who has a sucking chest wound and is in respiratory distress?
A) Red
B) Yellow
C) Green
D) Black
Correct Answer: Red
Rationale: Red tags are for immediate life-threatening injuries that require
rapid medical attention, such as airway or breathing issues like a sucking
chest wound. Yellow tags are for serious but non-life-threatening injuries,
green for minor injuries, and black for deceased or expectant.
2. Which clinical manifestation is the hallmark of Acute Respiratory Distress
Syndrome (ARDS)?
A) Bradypnea
B) Refractory hypoxemia
C) Respiratory alkalosis
D) Clear breath sounds
Correct Answer: Refractory hypoxemia
Rationale: Refractory hypoxemia is characterized by low arterial oxygen
levels that do not improve with high concentrations of supplemental oxygen.
This is the hallmark of ARDS and distinguishes it from other respiratory
conditions.
,3. Using the Rule of Nines, calculate the total body surface area (TBSA)
burned for a client with burns on the entire left arm and the anterior trunk.
A) 18%
B) 45%
C) 36%
D) 27%
Correct Answer: 27%
Rationale: The entire left arm is 9% and the anterior trunk is 18%, totaling
27%. The Rule of Nines assigns 9% to each arm, 18% to the anterior trunk,
18% to the posterior trunk, 18% to each leg, and 1% to the perineum.
4. A client in the progressive stage of shock shows which of the following
physiological changes?
A) Increased urine output
B) Metabolic alkalosis
C) Interstitial edema (Anasarca)
D) Decreased capillary permeability
Correct Answer: Interstitial edema (Anasarca)
Rationale: In the progressive stage of shock, increased capillary permeability
leads to fluid leaking into the interstitial space, causing generalized edema
(anasarca). This results from the failure of compensatory mechanisms and
ongoing tissue hypoxia.
5. Which medication is the primary treatment for a client experiencing
anaphylactic shock?
,A) Dopamine
B) Hydrocortisone
C) Diphenhydramine
D) Epinephrine
Correct Answer: Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis to cause
bronchodilation and vasoconstriction. It rapidly reverses the life-threatening
effects of anaphylactic shock. Antihistamines and corticosteroids are
adjunctive therapies.
6. A client with type 1 diabetes presents to the emergency department with
confusion, fruity breath odor, and deep, rapid respirations. Which diagnosis is
most likely?
A) Hyperglycemic hyperosmolar state (HHS)
B) Diabetic ketoacidosis (DKA)
C) Hypoglycemia
D) Lactic acidosis
Correct Answer: Diabetic ketoacidosis (DKA)
Rationale: DKA is characterized by hyperglycemia, ketosis, and metabolic
acidosis. Fruity breath odor (acetone) and Kussmaul respirations (deep, rapid
breathing) are classic signs. HHS typically presents with extreme
hyperglycemia without significant ketosis.
7. A client with acute pancreatitis has a serum amylase of 800 U/L and lipase
of 900 U/L. Which intervention is the priority?
A) Administer oral fluids
, B) Maintain NPO status
C) Encourage ambulation
D) Apply heat to the abdomen
Correct Answer: Maintain NPO status
Rationale: In acute pancreatitis, the pancreas must be rested to reduce
inflammation and enzyme secretion. Maintaining NPO status and providing IV
fluids is a priority to prevent further stimulation of the pancreas. Oral fluids
would stimulate pancreatic secretions and worsen the condition.
8. The earliest sign of heart failure exacerbation is:
A) Dyspnea
B) Peripheral edema
C) Weight gain
D) Crackles on auscultation
Correct Answer: Weight gain
Rationale: Fluid retention is often the first sign of worsening heart failure
before edema or dyspnea occurs. Daily weight monitoring is essential for
early detection of fluid overload. A weight gain of 2-3 pounds in 24 hours
should be reported.
9. Which acid-base imbalance is most commonly associated with severe
diarrhea?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
Concepts of Nursing IV | Nursing
1. During a mass casualty incident, which color tag is assigned to a client
who has a sucking chest wound and is in respiratory distress?
A) Red
B) Yellow
C) Green
D) Black
Correct Answer: Red
Rationale: Red tags are for immediate life-threatening injuries that require
rapid medical attention, such as airway or breathing issues like a sucking
chest wound. Yellow tags are for serious but non-life-threatening injuries,
green for minor injuries, and black for deceased or expectant.
2. Which clinical manifestation is the hallmark of Acute Respiratory Distress
Syndrome (ARDS)?
A) Bradypnea
B) Refractory hypoxemia
C) Respiratory alkalosis
D) Clear breath sounds
Correct Answer: Refractory hypoxemia
Rationale: Refractory hypoxemia is characterized by low arterial oxygen
levels that do not improve with high concentrations of supplemental oxygen.
This is the hallmark of ARDS and distinguishes it from other respiratory
conditions.
,3. Using the Rule of Nines, calculate the total body surface area (TBSA)
burned for a client with burns on the entire left arm and the anterior trunk.
A) 18%
B) 45%
C) 36%
D) 27%
Correct Answer: 27%
Rationale: The entire left arm is 9% and the anterior trunk is 18%, totaling
27%. The Rule of Nines assigns 9% to each arm, 18% to the anterior trunk,
18% to the posterior trunk, 18% to each leg, and 1% to the perineum.
4. A client in the progressive stage of shock shows which of the following
physiological changes?
A) Increased urine output
B) Metabolic alkalosis
C) Interstitial edema (Anasarca)
D) Decreased capillary permeability
Correct Answer: Interstitial edema (Anasarca)
Rationale: In the progressive stage of shock, increased capillary permeability
leads to fluid leaking into the interstitial space, causing generalized edema
(anasarca). This results from the failure of compensatory mechanisms and
ongoing tissue hypoxia.
5. Which medication is the primary treatment for a client experiencing
anaphylactic shock?
,A) Dopamine
B) Hydrocortisone
C) Diphenhydramine
D) Epinephrine
Correct Answer: Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis to cause
bronchodilation and vasoconstriction. It rapidly reverses the life-threatening
effects of anaphylactic shock. Antihistamines and corticosteroids are
adjunctive therapies.
6. A client with type 1 diabetes presents to the emergency department with
confusion, fruity breath odor, and deep, rapid respirations. Which diagnosis is
most likely?
A) Hyperglycemic hyperosmolar state (HHS)
B) Diabetic ketoacidosis (DKA)
C) Hypoglycemia
D) Lactic acidosis
Correct Answer: Diabetic ketoacidosis (DKA)
Rationale: DKA is characterized by hyperglycemia, ketosis, and metabolic
acidosis. Fruity breath odor (acetone) and Kussmaul respirations (deep, rapid
breathing) are classic signs. HHS typically presents with extreme
hyperglycemia without significant ketosis.
7. A client with acute pancreatitis has a serum amylase of 800 U/L and lipase
of 900 U/L. Which intervention is the priority?
A) Administer oral fluids
, B) Maintain NPO status
C) Encourage ambulation
D) Apply heat to the abdomen
Correct Answer: Maintain NPO status
Rationale: In acute pancreatitis, the pancreas must be rested to reduce
inflammation and enzyme secretion. Maintaining NPO status and providing IV
fluids is a priority to prevent further stimulation of the pancreas. Oral fluids
would stimulate pancreatic secretions and worsen the condition.
8. The earliest sign of heart failure exacerbation is:
A) Dyspnea
B) Peripheral edema
C) Weight gain
D) Crackles on auscultation
Correct Answer: Weight gain
Rationale: Fluid retention is often the first sign of worsening heart failure
before edema or dyspnea occurs. Daily weight monitoring is essential for
early detection of fluid overload. A weight gain of 2-3 pounds in 24 hours
should be reported.
9. Which acid-base imbalance is most commonly associated with severe
diarrhea?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
