NUR 445 Exam 4: Acute & Chronic Health Disruptions In
Adults III V1 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient arrives in the emergency department with severe burns. Using the Rule of Nines, what
percentage is assigned to an adult with burns on both entire legs?
A. 36%
B. 18%
C. 9%
D. 27%
Ans: A
Explanation: The Rule of Nines is a standardized method used to quickly estimate the total body surface
area affected by burns. In an adult, each leg represents 18 percent of the total body surface area.
Therefore, burns covering both entire legs would equal 36 percent. This calculation is vital for
determining the volume of fluid resuscitation needed in the early stages of treatment. Proper estimation
helps prevent complications associated with under-resuscitation or over-resuscitation.
2. Which clinical finding is most indicative of the early stage of septic shock?
A. Bradycardia
B. Warm, flushed skin
C. Hypertension
D. Low cardiac output
Ans: B
,Explanation: In the early or hyperdynamic phase of septic shock, the patient often exhibits warm and
flushed skin due to vasodilation. This phase is characterized by a high cardiac output and a decrease in
systemic vascular resistance. Tachycardia is also typically present as a compensatory mechanism to
maintain tissue perfusion. Recognizing these early signs is essential for implementing the sepsis bundle
and improving patient outcomes. Later stages typically present with cold, clammy skin as the patient
enters a hypodynamic state.
3. What is the primary goal of administering a vasopressor like norepinephrine to a patient in shock?
A. To decrease heart rate
B. To promote fluid retention
C. To increase mean arterial pressure
D. To dilate peripheral blood vessels
Ans: C
Explanation: Norepinephrine is a potent vasoconstrictor used to increase systemic vascular resistance
and blood pressure in shock states. The primary clinical objective is to achieve a mean arterial pressure
greater than 65 mmHg to ensure adequate organ perfusion. It is typically utilized after fluid resuscitation
has failed to restore hemodynamic stability. Nurses must monitor the infusion site closely for
extravasation which can cause tissue necrosis. Titration is based on continuous hemodynamic monitoring
to achieve the desired therapeutic effect.
4. During the triage process of a mass casualty incident, which color tag is assigned to a patient who has a
patent airway but is unable to follow commands due to a head injury?
A. Green
B. Red
, C. Yellow
D. Black
Ans: B
Explanation: In mass casualty triage, a red tag indicates an immediate priority for treatment of life-
threatening injuries. A patient who is unable to follow simple commands often signifies a serious
neurological impairment or shock. These patients require stabilization within a very short timeframe to
improve their chances of survival. Red-tagged individuals are prioritized over those with delayed or
minor injuries. This systematic approach ensures that resources are allocated to those who need them
most urgently.
5. A patient with acute kidney injury is found to have a serum potassium level of 6.8 mEq/L. Which
medication is the priority to stabilize the cardiac membrane?
A. Calcium gluconate
B. Sodium polystyrene sulfonate
C. Insulin and dextrose
D. Furosemide
Ans: A
Explanation: Severe hyperkalemia can lead to life-threatening cardiac arrhythmias and cardiac arrest.
Intravenous calcium gluconate is administered immediately to protect the heart by stabilizing the
myocardial cell membrane. While calcium does not lower the potassium level, it antagonizes the cardiac
effects of high potassium. Following calcium administration, other medications like insulin and glucose
are given to shift potassium back into the cells. This multi-step approach is critical for the safety of
patients with significant electrolyte imbalances.
Adults III V1 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient arrives in the emergency department with severe burns. Using the Rule of Nines, what
percentage is assigned to an adult with burns on both entire legs?
A. 36%
B. 18%
C. 9%
D. 27%
Ans: A
Explanation: The Rule of Nines is a standardized method used to quickly estimate the total body surface
area affected by burns. In an adult, each leg represents 18 percent of the total body surface area.
Therefore, burns covering both entire legs would equal 36 percent. This calculation is vital for
determining the volume of fluid resuscitation needed in the early stages of treatment. Proper estimation
helps prevent complications associated with under-resuscitation or over-resuscitation.
2. Which clinical finding is most indicative of the early stage of septic shock?
A. Bradycardia
B. Warm, flushed skin
C. Hypertension
D. Low cardiac output
Ans: B
,Explanation: In the early or hyperdynamic phase of septic shock, the patient often exhibits warm and
flushed skin due to vasodilation. This phase is characterized by a high cardiac output and a decrease in
systemic vascular resistance. Tachycardia is also typically present as a compensatory mechanism to
maintain tissue perfusion. Recognizing these early signs is essential for implementing the sepsis bundle
and improving patient outcomes. Later stages typically present with cold, clammy skin as the patient
enters a hypodynamic state.
3. What is the primary goal of administering a vasopressor like norepinephrine to a patient in shock?
A. To decrease heart rate
B. To promote fluid retention
C. To increase mean arterial pressure
D. To dilate peripheral blood vessels
Ans: C
Explanation: Norepinephrine is a potent vasoconstrictor used to increase systemic vascular resistance
and blood pressure in shock states. The primary clinical objective is to achieve a mean arterial pressure
greater than 65 mmHg to ensure adequate organ perfusion. It is typically utilized after fluid resuscitation
has failed to restore hemodynamic stability. Nurses must monitor the infusion site closely for
extravasation which can cause tissue necrosis. Titration is based on continuous hemodynamic monitoring
to achieve the desired therapeutic effect.
4. During the triage process of a mass casualty incident, which color tag is assigned to a patient who has a
patent airway but is unable to follow commands due to a head injury?
A. Green
B. Red
, C. Yellow
D. Black
Ans: B
Explanation: In mass casualty triage, a red tag indicates an immediate priority for treatment of life-
threatening injuries. A patient who is unable to follow simple commands often signifies a serious
neurological impairment or shock. These patients require stabilization within a very short timeframe to
improve their chances of survival. Red-tagged individuals are prioritized over those with delayed or
minor injuries. This systematic approach ensures that resources are allocated to those who need them
most urgently.
5. A patient with acute kidney injury is found to have a serum potassium level of 6.8 mEq/L. Which
medication is the priority to stabilize the cardiac membrane?
A. Calcium gluconate
B. Sodium polystyrene sulfonate
C. Insulin and dextrose
D. Furosemide
Ans: A
Explanation: Severe hyperkalemia can lead to life-threatening cardiac arrhythmias and cardiac arrest.
Intravenous calcium gluconate is administered immediately to protect the heart by stabilizing the
myocardial cell membrane. While calcium does not lower the potassium level, it antagonizes the cardiac
effects of high potassium. Following calcium administration, other medications like insulin and glucose
are given to shift potassium back into the cells. This multi-step approach is critical for the safety of
patients with significant electrolyte imbalances.
