NUR2755 Final Exam Actual Exam Style
V1 | NUR 2755 Multidimensional Care IV /
MDC 4 | Rasmussen
1. During a mass casualty incident, a nurse using the START triage system identifies a patient
with a respiratory rate of 35 breaths/minute. Which color tag should the nurse apply?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: In the START triage system, any adult patient with a respiratory rate greater
than 30 breaths per minute is categorized as Immediate. These patients are assigned a red
tag because they require urgent intervention to survive. This classification helps prioritize
resources for those with life-threatening but treatable conditions.
2. A patient weighing 70kg has sustained deep partial-thickness burns to 40% of their body.
Using the Parkland Formula (4mL/kg/%TBSA), how much fluid should be administered in the
first 8 hours?
A. 5600 mL
B. 11200 mL
,C. 2800 mL
D. 8400 mL
Answer: A
Rationale: The total 24-hour fluid requirement is calculated as 4mL x 70kg x 40, which
equals 11,200 mL. According to the Parkland Formula, half of this total volume must be
administered within the first 8 hours following the injury. Therefore, the nurse should set
the infusion to deliver 5,600 mL in the initial 8-hour window.
3. A nurse is caring for a patient in the ICU who suddenly develops Ventricular Fibrillation on
the monitor. What is the priority nursing action?
A. Administer a 1mg bolus of Epinephrine.
B. Perform immediate defibrillation.
C. Prepare for synchronized cardioversion.
D. Start an Amiodarone infusion.
Answer: B
Rationale: Ventricular fibrillation is a pulseless, life-threatening rhythm that requires
immediate electrical therapy. Defibrillation is the most effective treatment to terminate this
lethal arrhythmia and restore a perfusing rhythm. Delays in defibrillation significantly
decrease the patient’s chances of survival and neurological recovery.
, 4. Which clinical finding is most indicative of the ‘Early/Hyperdynamic’ stage of septic shock?
A. Cool, clammy skin and bradycardia.
B. Severe hypotension and multi-organ failure.
C. Decreased urine output and metabolic alkalosis.
D. High cardiac output and low systemic vascular resistance.
Answer: D
Rationale: In the early stage of septic shock, often called the warm phase, the body
compensates with a high cardiac output. Vasodilation causes low systemic vascular
resistance, making the skin feel warm and flushed. Recognizing these compensatory signs
is crucial for early aggressive fluid resuscitation and antibiotic therapy.
5. A patient with ARDS is being mechanically ventilated. The nurse notes the high-pressure
alarm is sounding. What is the most likely cause?
A. A leak in the ventilator circuit.
B. The patient has disconnected from the machine.
C. The patient is biting the endotracheal tube.
D. The cuff of the endotracheal tube has deflated.
Answer: C
Rationale: High-pressure alarms are triggered by increased resistance to airflow, such as
the patient biting the tube or secretions in the airway. Other causes include bronchospasm
V1 | NUR 2755 Multidimensional Care IV /
MDC 4 | Rasmussen
1. During a mass casualty incident, a nurse using the START triage system identifies a patient
with a respiratory rate of 35 breaths/minute. Which color tag should the nurse apply?
A. Green
B. Yellow
C. Red
D. Black
Answer: C
Rationale: In the START triage system, any adult patient with a respiratory rate greater
than 30 breaths per minute is categorized as Immediate. These patients are assigned a red
tag because they require urgent intervention to survive. This classification helps prioritize
resources for those with life-threatening but treatable conditions.
2. A patient weighing 70kg has sustained deep partial-thickness burns to 40% of their body.
Using the Parkland Formula (4mL/kg/%TBSA), how much fluid should be administered in the
first 8 hours?
A. 5600 mL
B. 11200 mL
,C. 2800 mL
D. 8400 mL
Answer: A
Rationale: The total 24-hour fluid requirement is calculated as 4mL x 70kg x 40, which
equals 11,200 mL. According to the Parkland Formula, half of this total volume must be
administered within the first 8 hours following the injury. Therefore, the nurse should set
the infusion to deliver 5,600 mL in the initial 8-hour window.
3. A nurse is caring for a patient in the ICU who suddenly develops Ventricular Fibrillation on
the monitor. What is the priority nursing action?
A. Administer a 1mg bolus of Epinephrine.
B. Perform immediate defibrillation.
C. Prepare for synchronized cardioversion.
D. Start an Amiodarone infusion.
Answer: B
Rationale: Ventricular fibrillation is a pulseless, life-threatening rhythm that requires
immediate electrical therapy. Defibrillation is the most effective treatment to terminate this
lethal arrhythmia and restore a perfusing rhythm. Delays in defibrillation significantly
decrease the patient’s chances of survival and neurological recovery.
, 4. Which clinical finding is most indicative of the ‘Early/Hyperdynamic’ stage of septic shock?
A. Cool, clammy skin and bradycardia.
B. Severe hypotension and multi-organ failure.
C. Decreased urine output and metabolic alkalosis.
D. High cardiac output and low systemic vascular resistance.
Answer: D
Rationale: In the early stage of septic shock, often called the warm phase, the body
compensates with a high cardiac output. Vasodilation causes low systemic vascular
resistance, making the skin feel warm and flushed. Recognizing these compensatory signs
is crucial for early aggressive fluid resuscitation and antibiotic therapy.
5. A patient with ARDS is being mechanically ventilated. The nurse notes the high-pressure
alarm is sounding. What is the most likely cause?
A. A leak in the ventilator circuit.
B. The patient has disconnected from the machine.
C. The patient is biting the endotracheal tube.
D. The cuff of the endotracheal tube has deflated.
Answer: C
Rationale: High-pressure alarms are triggered by increased resistance to airflow, such as
the patient biting the tube or secretions in the airway. Other causes include bronchospasm
