NUR 417 Exam 4 V3 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 4) | Concordia
1. A patient arrives in the emergency department with deep partial-thickness burns to the
chest and abdomen. Which physiological change should the nurse expect to see during the
first 24 hours (emergent phase) of the burn injury?
A. Increased renal perfusion resulting in diuresis.
B. Decreased peripheral resistance due to massive vasodilation.
C. Increased capillary permeability leading to fluid shift from the intravascular to the
interstitial space.
D. Decreased hemoglobin and hematocrit due to blood loss.
Correct Answer: C
Explanation: During the emergent phase of a burn, the massive release of inflammatory
mediators causes increased capillary permeability. This results in the leakage of plasma
and proteins into the interstitial space, commonly referred to as third spacing.
Consequently, the nurse must monitor for signs of hypovolemic shock and electrolyte
imbalances such as hyperkalemia.
,2. The nurse is caring for a patient who has just been admitted with a 40% Total Body Surface
Area (TBSA) burn. Following the Parkland (Baxter) Formula, the patient is to receive 12,000
mL of fluid in the first 24 hours. How much fluid should be administered in the first 8 hours?
A. 3,000 mL
B. 4,000 mL
C. 8,000 mL
D. 6,000 mL
Correct Answer: D
Explanation: The Parkland Formula dictates that half of the total calculated 24-hour fluid
volume must be administered within the first 8 hours post-burn. In this scenario, 12,000
mL divided by 2 is 6,000 mL. The remaining half is then distributed over the subsequent 16
hours to maintain adequate tissue perfusion.
3. A patient in the Intensive Care Unit (ICU) is exhibiting signs of Septic Shock. The nurse
notes a Blood Pressure of 82/40 mmHg, Heart Rate of 122 bpm, and a Lactate level of 5
mmol/L. Which intervention is the highest priority?
A. Obtain blood cultures from two different sites.
B. Start broad-spectrum antibiotics within 3 hours.
C. Administer a 30 mL/kg isotonic crystalloid bolus.
D. Administer Norepinephrine to maintain a MAP > 65 mmHg.
,Correct Answer: C
Explanation: According to the Surviving Sepsis Campaign guidelines, the initial treatment
for sepsis-induced hypotension or a lactate level of 4 mmol/L or higher is a rapid fluid
bolus of 30 mL/kg. While cultures and antibiotics are essential, restoring intravascular
volume is the immediate priority to improve organ perfusion. If the patient remains
hypotensive after fluid resuscitation, vasopressors like Norepinephrine would then be
initiated.
4. A patient with a history of heart failure is admitted with Cardiogenic Shock. Which
hemodynamic finding would the nurse most likely observe?
A. Increased Systemic Vascular Resistance (SVR)
B. Increased Cardiac Index (CI)
C. Decreased Pulmonary Artery Wedge Pressure (PAWP)
D. Decreased Central Venous Pressure (CVP)
Correct Answer: A
Explanation: In cardiogenic shock, the heart fails to pump effectively, leading to a decrease
in cardiac output and cardiac index. To compensate for the low output, the body increases
systemic vascular resistance (SVR) through vasoconstriction. Additionally, PAWP and CVP
are typically elevated due to fluid backup and pump failure.
, 5. A patient is being treated for Acute Respiratory Distress Syndrome (ARDS). The nurse
understands that the primary pathophysiological change in ARDS is:
A. Bronchoconstriction caused by histamine release.
B. Pulmonary hypertension resulting from chronic hypoxia.
C. Alveolar collapse due to excess surfactant production.
D. Increased alveolar-capillary membrane permeability.
Correct Answer: D
Explanation: ARDS is characterized by damage to the alveolar-capillary membrane, which
leads to increased permeability and the flooding of the alveoli with protein-rich fluid. This
impairs gas exchange and leads to refractory hypoxemia, a hallmark of the condition.
Surfactant production is actually decreased in ARDS, contributing to further alveolar
collapse (atelectasis).
6. The nurse is assessing a patient following a motor vehicle accident. The patient has a
sucking chest wound. What is the immediate nursing action?
A. Apply a sterile occlusive dressing taped on four sides.
B. Apply a non-porous dressing taped on three sides.
C. Prepare for immediate endotracheal intubation.
D. Insert a large-bore needle into the second intercostal space.
Correct Answer: B
Adult II | Actual Q&A with Rationale (NUR417
Exam 4) | Concordia
1. A patient arrives in the emergency department with deep partial-thickness burns to the
chest and abdomen. Which physiological change should the nurse expect to see during the
first 24 hours (emergent phase) of the burn injury?
A. Increased renal perfusion resulting in diuresis.
B. Decreased peripheral resistance due to massive vasodilation.
C. Increased capillary permeability leading to fluid shift from the intravascular to the
interstitial space.
D. Decreased hemoglobin and hematocrit due to blood loss.
Correct Answer: C
Explanation: During the emergent phase of a burn, the massive release of inflammatory
mediators causes increased capillary permeability. This results in the leakage of plasma
and proteins into the interstitial space, commonly referred to as third spacing.
Consequently, the nurse must monitor for signs of hypovolemic shock and electrolyte
imbalances such as hyperkalemia.
,2. The nurse is caring for a patient who has just been admitted with a 40% Total Body Surface
Area (TBSA) burn. Following the Parkland (Baxter) Formula, the patient is to receive 12,000
mL of fluid in the first 24 hours. How much fluid should be administered in the first 8 hours?
A. 3,000 mL
B. 4,000 mL
C. 8,000 mL
D. 6,000 mL
Correct Answer: D
Explanation: The Parkland Formula dictates that half of the total calculated 24-hour fluid
volume must be administered within the first 8 hours post-burn. In this scenario, 12,000
mL divided by 2 is 6,000 mL. The remaining half is then distributed over the subsequent 16
hours to maintain adequate tissue perfusion.
3. A patient in the Intensive Care Unit (ICU) is exhibiting signs of Septic Shock. The nurse
notes a Blood Pressure of 82/40 mmHg, Heart Rate of 122 bpm, and a Lactate level of 5
mmol/L. Which intervention is the highest priority?
A. Obtain blood cultures from two different sites.
B. Start broad-spectrum antibiotics within 3 hours.
C. Administer a 30 mL/kg isotonic crystalloid bolus.
D. Administer Norepinephrine to maintain a MAP > 65 mmHg.
,Correct Answer: C
Explanation: According to the Surviving Sepsis Campaign guidelines, the initial treatment
for sepsis-induced hypotension or a lactate level of 4 mmol/L or higher is a rapid fluid
bolus of 30 mL/kg. While cultures and antibiotics are essential, restoring intravascular
volume is the immediate priority to improve organ perfusion. If the patient remains
hypotensive after fluid resuscitation, vasopressors like Norepinephrine would then be
initiated.
4. A patient with a history of heart failure is admitted with Cardiogenic Shock. Which
hemodynamic finding would the nurse most likely observe?
A. Increased Systemic Vascular Resistance (SVR)
B. Increased Cardiac Index (CI)
C. Decreased Pulmonary Artery Wedge Pressure (PAWP)
D. Decreased Central Venous Pressure (CVP)
Correct Answer: A
Explanation: In cardiogenic shock, the heart fails to pump effectively, leading to a decrease
in cardiac output and cardiac index. To compensate for the low output, the body increases
systemic vascular resistance (SVR) through vasoconstriction. Additionally, PAWP and CVP
are typically elevated due to fluid backup and pump failure.
, 5. A patient is being treated for Acute Respiratory Distress Syndrome (ARDS). The nurse
understands that the primary pathophysiological change in ARDS is:
A. Bronchoconstriction caused by histamine release.
B. Pulmonary hypertension resulting from chronic hypoxia.
C. Alveolar collapse due to excess surfactant production.
D. Increased alveolar-capillary membrane permeability.
Correct Answer: D
Explanation: ARDS is characterized by damage to the alveolar-capillary membrane, which
leads to increased permeability and the flooding of the alveoli with protein-rich fluid. This
impairs gas exchange and leads to refractory hypoxemia, a hallmark of the condition.
Surfactant production is actually decreased in ARDS, contributing to further alveolar
collapse (atelectasis).
6. The nurse is assessing a patient following a motor vehicle accident. The patient has a
sucking chest wound. What is the immediate nursing action?
A. Apply a sterile occlusive dressing taped on four sides.
B. Apply a non-porous dressing taped on three sides.
C. Prepare for immediate endotracheal intubation.
D. Insert a large-bore needle into the second intercostal space.
Correct Answer: B
