NUR 417 Exam 4 V2 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 4) | Concordia
1. A patient who suffered partial-thickness burns to the chest and abdomen arrives in the
emergency department. Which assessment finding should the nurse prioritize during the
primary survey?
A. Presence of singed nasal hairs and soot in the sputum
B. Pain rated at 10/10 on the numeric scale
C. Reduced range of motion in the upper extremities
D. Blood pressure of 100/60 mmHg
Correct Answer: A
Explanation: Singed nasal hairs and carbonaceous sputum are primary indicators of
inhalation injury, which can cause rapid airway edema and obstruction. Airway
management always takes precedence over pain management or fluid status during the
initial primary survey of a burn victim. Recognizing these signs early allows for proactive
endotracheal intubation before the airway closes.
2. Using the Parkland formula, calculate the total fluid volume needed in the first 24 hours for
a 70 kg patient with 50% total body surface area (TBSA) burns.
A. 14,000 mL
B. 10,500 mL
,C. 7,000 mL
D. 28,000 mL
Correct Answer: A
Explanation: The Parkland formula is calculated as 4 mL x kg x %TBSA burn. For this
patient, the calculation is 4 mL x 70 kg x 50 = 14,000 mL. This total volume is intended to
replace fluid lost to interstitial shifting and maintain vital organ perfusion during the first
24 hours post-burn.
3. A nurse is caring for a patient in the compensatory stage of shock. Which clinical
manifestation is a hallmark of this stage?
A. Metabolic acidosis with a pH of 7.25
B. Cold, clammy skin and mottled extremities
C. Anuria or urine output less than 5 mL/hr
D. Increased heart rate and narrowed pulse pressure
Correct Answer: D
Explanation: During the compensatory stage of shock, the body activates the sympathetic
nervous system to maintain cardiac output and blood pressure. Tachycardia and peripheral
vasoconstriction occur to shunt blood to vital organs. A narrowed pulse pressure is an early
indicator of decreasing stroke volume even if the systolic blood pressure remains within
normal limits.
,4. The nurse receives a patient from a house fire with suspected carbon monoxide (CO)
poisoning. Which action is the priority?
A. Monitor pulse oximetry for oxygen saturation
B. Check the patient’s level of consciousness
C. Obtain a stat arterial blood gas (ABG) to check pH
D. Administer 100% humidified oxygen via a non-rebreather mask
Correct Answer: D
Explanation: Carbon monoxide has a much higher affinity for hemoglobin than oxygen,
leading to cellular hypoxia. Pulse oximetry is unreliable because it cannot distinguish
between carboxyhemoglobin and oxyhemoglobin, often showing a false 100%.
Administering 100% oxygen is the definitive treatment to displace CO from the hemoglobin
molecules.
5. A patient in septic shock has a mean arterial pressure (MAP) of 55 mmHg despite
aggressive fluid resuscitation. Which class of medication should the nurse anticipate
administering next?
A. Loop diuretics to manage fluid overload
B. Beta-blockers to reduce myocardial oxygen demand
C. Vasopressors such as norepinephrine
D. Calcium channel blockers to prevent vasospasm
, Correct Answer: C
Explanation: In septic shock, once fluid resuscitation (30 mL/kg) fails to restore adequate
perfusion, vasopressors are indicated to maintain a MAP of at least 65 mmHg.
Norepinephrine is typically the first-choice vasopressor due to its potent alpha-adrenergic
effects. Achieving an adequate MAP is essential to ensure sufficient blood flow to the
kidneys and brain.
6. Which hemodynamic finding is most characteristic of cardiogenic shock?
A. Decreased Central Venous Pressure (CVP)
B. Decreased Pulmonary Artery Wedge Pressure (PAWP)
C. Increased Cardiac Index (CI)
D. Increased Systemic Vascular Resistance (SVR)
E. Low PAWP and High CVP
Correct Answer: D
Explanation: In cardiogenic shock, the heart fails to pump effectively, leading to a low
cardiac output and cardiac index. The body compensates by increasing Systemic Vascular
Resistance (SVR) through vasoconstriction to maintain blood pressure. Hemodynamic
monitoring would typically show high PAWP and CVP due to fluid backing up from the
failing left ventricle.
Adult II | Actual Q&A with Rationale (NUR417
Exam 4) | Concordia
1. A patient who suffered partial-thickness burns to the chest and abdomen arrives in the
emergency department. Which assessment finding should the nurse prioritize during the
primary survey?
A. Presence of singed nasal hairs and soot in the sputum
B. Pain rated at 10/10 on the numeric scale
C. Reduced range of motion in the upper extremities
D. Blood pressure of 100/60 mmHg
Correct Answer: A
Explanation: Singed nasal hairs and carbonaceous sputum are primary indicators of
inhalation injury, which can cause rapid airway edema and obstruction. Airway
management always takes precedence over pain management or fluid status during the
initial primary survey of a burn victim. Recognizing these signs early allows for proactive
endotracheal intubation before the airway closes.
2. Using the Parkland formula, calculate the total fluid volume needed in the first 24 hours for
a 70 kg patient with 50% total body surface area (TBSA) burns.
A. 14,000 mL
B. 10,500 mL
,C. 7,000 mL
D. 28,000 mL
Correct Answer: A
Explanation: The Parkland formula is calculated as 4 mL x kg x %TBSA burn. For this
patient, the calculation is 4 mL x 70 kg x 50 = 14,000 mL. This total volume is intended to
replace fluid lost to interstitial shifting and maintain vital organ perfusion during the first
24 hours post-burn.
3. A nurse is caring for a patient in the compensatory stage of shock. Which clinical
manifestation is a hallmark of this stage?
A. Metabolic acidosis with a pH of 7.25
B. Cold, clammy skin and mottled extremities
C. Anuria or urine output less than 5 mL/hr
D. Increased heart rate and narrowed pulse pressure
Correct Answer: D
Explanation: During the compensatory stage of shock, the body activates the sympathetic
nervous system to maintain cardiac output and blood pressure. Tachycardia and peripheral
vasoconstriction occur to shunt blood to vital organs. A narrowed pulse pressure is an early
indicator of decreasing stroke volume even if the systolic blood pressure remains within
normal limits.
,4. The nurse receives a patient from a house fire with suspected carbon monoxide (CO)
poisoning. Which action is the priority?
A. Monitor pulse oximetry for oxygen saturation
B. Check the patient’s level of consciousness
C. Obtain a stat arterial blood gas (ABG) to check pH
D. Administer 100% humidified oxygen via a non-rebreather mask
Correct Answer: D
Explanation: Carbon monoxide has a much higher affinity for hemoglobin than oxygen,
leading to cellular hypoxia. Pulse oximetry is unreliable because it cannot distinguish
between carboxyhemoglobin and oxyhemoglobin, often showing a false 100%.
Administering 100% oxygen is the definitive treatment to displace CO from the hemoglobin
molecules.
5. A patient in septic shock has a mean arterial pressure (MAP) of 55 mmHg despite
aggressive fluid resuscitation. Which class of medication should the nurse anticipate
administering next?
A. Loop diuretics to manage fluid overload
B. Beta-blockers to reduce myocardial oxygen demand
C. Vasopressors such as norepinephrine
D. Calcium channel blockers to prevent vasospasm
, Correct Answer: C
Explanation: In septic shock, once fluid resuscitation (30 mL/kg) fails to restore adequate
perfusion, vasopressors are indicated to maintain a MAP of at least 65 mmHg.
Norepinephrine is typically the first-choice vasopressor due to its potent alpha-adrenergic
effects. Achieving an adequate MAP is essential to ensure sufficient blood flow to the
kidneys and brain.
6. Which hemodynamic finding is most characteristic of cardiogenic shock?
A. Decreased Central Venous Pressure (CVP)
B. Decreased Pulmonary Artery Wedge Pressure (PAWP)
C. Increased Cardiac Index (CI)
D. Increased Systemic Vascular Resistance (SVR)
E. Low PAWP and High CVP
Correct Answer: D
Explanation: In cardiogenic shock, the heart fails to pump effectively, leading to a low
cardiac output and cardiac index. The body compensates by increasing Systemic Vascular
Resistance (SVR) through vasoconstriction to maintain blood pressure. Hemodynamic
monitoring would typically show high PAWP and CVP due to fluid backing up from the
failing left ventricle.
