NUR2755 Final Exam Actual Exam Style
V3 | NUR 2755 Multidimensional Care IV /
MDC 4 | Rasmussen
1. A patient arrives in the emergency department with deep partial-thickness burns to the
chest, abdomen, and the entire right arm. Using the Rule of Nines, what is the estimated total
body surface area (TBSA) burned?
A. 27%
B. 18%
C. 36%
D. 45%
Answer: A
Rationale: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18% of the TBSA. The entire right arm accounts for 9%, bringing the total to
27%. Accurate calculation is essential for determining fluid resuscitation needs in the
emergency phase.
2. A client is in the compensatory stage of shock. Which clinical manifestation should the
nurse expect to find?
A. Cold, clammy skin and lethargy
B. Tachycardia and narrowed pulse pressure
,C. Anuria and profound hypotension
D. Metabolic acidosis and petechiae
Answer: B
Rationale: In the compensatory stage of shock, the body attempts to maintain homeostasis
through the activation of the sympathetic nervous system. This results in an increased
heart rate (tachycardia) and vasoconstriction, which narrows the pulse pressure. Early
recognition at this stage allows for interventions that can reverse the shock process before
organ damage occurs.
3. Which lab result is most indicative of the development of Disseminated Intravascular
Coagulation (DIC) in a septic patient?
A. Increased Platelet count
B. Elevated Fibrin Degradation Products (FDPs)
C. Decreased D-dimer levels
D. Shortened Prothrombin Time (PT)
Answer: B
Rationale: DIC is characterized by the systemic activation of blood coagulation, which
depletes clotting factors and results in excessive fibrinolysis. Elevated FDPs and D-dimer
levels indicate that the body is trying to break down numerous clots. This condition is a
medical emergency that requires treating the underlying cause while managing bleeding
and clotting simultaneously.
, 4. A patient with ARDS is being mechanically ventilated with high levels of PEEP. Which
assessment finding would be a major concern for the nurse?
A. Respiratory rate of 18 breaths per minute
B. Improved oxygen saturation
C. Decreased cardiac output
D. Inspiratory crackles
Answer: C
Rationale: High Positive End-Expiratory Pressure (PEEP) increases intrathoracic pressure,
which can impede venous return to the heart. This reduction in preload leads to decreased
cardiac output and potential hypotension. Nurses must closely monitor hemodynamic
stability whenever PEEP settings are increased in critically ill patients.
5. During the emergent phase of a burn injury, which electrolyte imbalance is the nurse most
likely to observe?
A. Hypokalemia
B. Hypernatremia
C. Hypocalcemia
D. Hyperkalemia
Answer: D
V3 | NUR 2755 Multidimensional Care IV /
MDC 4 | Rasmussen
1. A patient arrives in the emergency department with deep partial-thickness burns to the
chest, abdomen, and the entire right arm. Using the Rule of Nines, what is the estimated total
body surface area (TBSA) burned?
A. 27%
B. 18%
C. 36%
D. 45%
Answer: A
Rationale: According to the Rule of Nines, the anterior trunk (chest and abdomen)
accounts for 18% of the TBSA. The entire right arm accounts for 9%, bringing the total to
27%. Accurate calculation is essential for determining fluid resuscitation needs in the
emergency phase.
2. A client is in the compensatory stage of shock. Which clinical manifestation should the
nurse expect to find?
A. Cold, clammy skin and lethargy
B. Tachycardia and narrowed pulse pressure
,C. Anuria and profound hypotension
D. Metabolic acidosis and petechiae
Answer: B
Rationale: In the compensatory stage of shock, the body attempts to maintain homeostasis
through the activation of the sympathetic nervous system. This results in an increased
heart rate (tachycardia) and vasoconstriction, which narrows the pulse pressure. Early
recognition at this stage allows for interventions that can reverse the shock process before
organ damage occurs.
3. Which lab result is most indicative of the development of Disseminated Intravascular
Coagulation (DIC) in a septic patient?
A. Increased Platelet count
B. Elevated Fibrin Degradation Products (FDPs)
C. Decreased D-dimer levels
D. Shortened Prothrombin Time (PT)
Answer: B
Rationale: DIC is characterized by the systemic activation of blood coagulation, which
depletes clotting factors and results in excessive fibrinolysis. Elevated FDPs and D-dimer
levels indicate that the body is trying to break down numerous clots. This condition is a
medical emergency that requires treating the underlying cause while managing bleeding
and clotting simultaneously.
, 4. A patient with ARDS is being mechanically ventilated with high levels of PEEP. Which
assessment finding would be a major concern for the nurse?
A. Respiratory rate of 18 breaths per minute
B. Improved oxygen saturation
C. Decreased cardiac output
D. Inspiratory crackles
Answer: C
Rationale: High Positive End-Expiratory Pressure (PEEP) increases intrathoracic pressure,
which can impede venous return to the heart. This reduction in preload leads to decreased
cardiac output and potential hypotension. Nurses must closely monitor hemodynamic
stability whenever PEEP settings are increased in critically ill patients.
5. During the emergent phase of a burn injury, which electrolyte imbalance is the nurse most
likely to observe?
A. Hypokalemia
B. Hypernatremia
C. Hypocalcemia
D. Hyperkalemia
Answer: D
