Download NUR125 Exam 4 Master Study Guide | Verified Q&A | Parkland Formula & Rule of 9s, Shock St and more Exams Nursing in PDF only on Docsity!
NUR125 Exam 4 Master Study Guide | 35 0 Verified Q&A | Parkland Formula
& Rule of 9s, Shock Stages & Hemodynamics, ARDS & Ventilator Alarms,
AKI/CRRT & Disaster Triage (MCI)
Crush your NUR125 Exam 4 with this 350 question master set covering high-acuity nursing care for Burns, Shock, Respiratory Failure, and Renal emergencies. Each question includes a high-level italicized rationale designed to master the clinical reasoning behind Sepsis bundles, MAP calculations, ABG interpretation, and MODS. This rewritten 2024 – 2026 guide is the ultimate resource for the most difficult exam in the curriculum, ensuring you reach Level 3 proficiency on your first attempt. A nurse is communicating with a patient who has cognitive impairment. Which technique is most effective? A) Providing complex instructions to stimulate the brain B) Giving one simple direction at a time C) Finishing the patient's sentences to save time D) Using abstract metaphors Rationale: Patients with cognitive impairment process information slowly. Single, simple commands reduce frustration and improve comprehension. Which is the primary goal of palliative care? A) To cure the underlying disease B) To provide relief from symptoms and stress of a serious illness C) To provide care only in the last 6 months of life D) To assist with active euthanasia Rationale: Palliative care focuses on quality of life and symptom management at any stage of a serious illness. During the "Orientation Phase" of the helping relationship, the nurse should: A) Review the patient's medical record before meeting B) Establish the tone and expectations for the relationship C) Work together with the patient to meet goals D) Evaluate if goals were met before discharge Rationale: The orientation phase is when the nurse and patient meet, set the contract, and build initial trust. A patient is experiencing sensory overload. Which nursing intervention is a priority? A) Increasing the volume on the television to drown out monitor noise B) Clustering nursing care to provide longer rest periods
C) Keeping the room lights on at maximum brightness D) Encouraging frequent visits from large groups of family Rationale: Clustering care reduces the frequency of stimuli, helping the patient's nervous system recover from overload. Which sense is generally the last to be lost as a patient approaches death? A) Sight B) Taste C) Hearing D) Smell Rationale: Clinical evidence suggests that hearing is often the last sense to fail; therefore, nurses should encourage families to keep talking to their loved ones. The "R" in the SBAR communication tool stands for: A) Reason B) Response C) Recommendation D) Review Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It ensures a clear request for action is made. A patient has expressive aphasia following a stroke. How should the nurse facilitate communication? A) Avoid talking to the patient to prevent embarrassment B) Allow the patient extra time to respond to questions C) Speak in a very loud voice D) Use only written medical pamphlets Rationale: Expressive aphasia affects the ability to produce language. Patients need significantly more time to retrieve words and formulate responses. A nurse is caring for a patient with a high risk of falls due to "Proprioception" issues. This means the patient has trouble with: A) Seeing objects in the distance B) Sensing the position and movement of body parts C) Identifying common objects by touch D) Hearing high-pitched sounds Rationale: Proprioception is the body's ability to sense its location and movements in space without looking. Which type of grief is associated with a "lengthy or denied" period of mourning? A) Normal grief B) Anticipatory grief
D) To ensure the patient is buried in a specific location Rationale: A living will specifically outlines what medical treatments a patient wants or doesn't want if they become incapacitated. A patient experiencing "Olfactory" changes is at risk for: A) Falls B) Failing to detect a gas leak or spoiled food C) Hearing loss D) Social isolation due to inability to see faces Rationale: Olfactory refers to the sense of smell; its loss compromises the ability to detect environmental hazards like smoke or gas. Which nursing action demonstrates "Empathy"? A) Telling the patient, "I know exactly how you feel." B) Saying, "It sounds like you are feeling very frustrated today." C) Crying with the patient for an extended period D) Giving the patient a list of reasons why they should be happy Rationale: Empathy involves understanding and validating the patient's feelings without taking them on as your own. In the "Termination Phase," the nurse should: A) Begin the initial physical assessment B) Summarize the progress made toward goals C) Introduce themselves and their role D) Encourage the patient to call the nurse's personal cell phone Rationale: The termination phase occurs at the end of the relationship, where the nurse evaluates goal achievement and transitions care. A "Disenfranchised Grief" occurs when: A) A person dies after a long illness B) The relationship to the deceased is not socially sanctioned or recognized C) The person cannot accept the reality of the loss D) The person grieves before the actual death occurs Rationale: Examples include the loss of a former spouse, an ex-partner, or a pet where others might not see the grief as "valid." What is the "Numeric Rating Scale" primarily used for? A) Assessing cognitive function B) Assessing pain intensity in adults C) Measuring height and weight D) Determining the risk for pressure ulcers
Rationale: The 0–10 scale is the standard tool for assessing subjective pain intensity in verbal adults. A nurse is using "Clarification" when they say: A) "Everything will be fine, don't worry." B) "I’m not sure I follow; could you tell me more about that?" C) "You shouldn't feel that way about your doctor." D) "Why did you wait so long to come to the hospital?" Rationale: Clarification ensures the nurse understands the patient's message correctly. Which patient is most at risk for "Sensory Deprivation"? A) A patient in a busy emergency room B) A patient in isolation with limited visitors C) A patient in the ICU with multiple alarms D) A patient at a loud family reunion Rationale: Reduced meaningful input, such as being in a private room with minimal contact, leads to deprivation. The "Working Phase" of the nurse-patient relationship focuses on: A) Ending the relationship B) Implementation of nursing interventions to achieve goals C) Establishing trust and boundaries D) Reading the chart before meeting the patient Rationale: This is the active part of the relationship where the "work" of healing and education happens. What is "Rigidity" in the context of post-mortem care? A) The cooling of the body B) Rigor mortis (stiffening of the joints) C) Discoloration of the skin D) The breakdown of cells Rationale: Rigor mortis is the stiffening of the body that occurs 2–4 hours after death. A patient is using "Denial" as a defense mechanism regarding a terminal diagnosis. The nurse should: A) Force the patient to look at their lab results B) Accept the patient's need for the defense mechanism while remaining available C) Tell the patient they are being unrealistic D) Agree with the patient that they aren't actually sick Rationale: Denial is a coping mechanism. The nurse should support the patient without reinforcing the false belief.
C) Grief that is never resolved D) Grief that is hidden from others Rationale: This is common in families of patients with terminal illnesses like cancer or dementia. Which patient behavior indicates "Readiness to Learn"? A) The patient is in severe pain B) The patient starts asking questions about their medications C) The patient is drowsy from anesthesia D) The patient refuses to look at their surgical site Rationale: Question-asking is a key sign of motivation and cognitive readiness. The "Pre-interaction Phase" of a relationship occurs: A) During the first meeting B) Before the nurse meets the patient C) At discharge D) When the patient is sleeping Rationale: This phase involves gathering data and planning for the first encounter. A "Static" sound in a hearing aid usually indicates: A) The patient is cured B) The battery is low or the aid is dirty C) The volume is too low D) The ear canal is too large Rationale: Feedback or static often points to mechanical issues or improper fit. Which is a "Cognitive" domain of learning? A) Learning how to inject insulin B) Recalling the side effects of a medication C) Expressing feelings about a new diagnosis D) Changing a wound dressing Rationale: Cognitive learning involves thinking, knowledge, and comprehension. The "Psychomotor" domain involves: A) Values and attitudes B) Physical skills and coordination C) Memorization of facts D) Problem-solving Rationale: Psychomotor learning is "hands-on" learning, like walking with crutches. A nurse is caring for a visually impaired patient. The nurse should: A) Sneak into the room quietly
B) Identify themselves when entering and leaving the room C) Move the furniture around daily to keep the patient alert D) Use hand gestures to explain the exit Rationale: Verbal identification prevents startling the patient and maintains safety. What is "Self-Concept"? A) How others see the person B) An individual's conceptualization of themselves C) The person's physical height and weight D) The person's job title Rationale: Self-concept is a subjective view of self, including identity, body image, and self-esteem. Which of the following describes "Maturational Loss"? A) Losing a house in a fire B) A child moving away to college C) A sudden heart attack D) A stolen car Rationale: Maturational loss is a part of the normal life transition process. What is "Hospice Care" specifically for? A) Patients who want to continue aggressive chemotherapy B) Patients with a prognosis of 6 months or less to live C) Patients with minor injuries D) Pregnant patients Rationale: Hospice is end-of-life care for patients who are no longer seeking curative treatment. "Aphasia" most commonly results from damage to: A) The spinal cord B) The left hemisphere of the brain C) The peripheral nerves D) The inner ear Rationale: The left hemisphere typically houses the language centers (Broca's and Wernicke's areas). A patient who is "Hard of Hearing" may benefit from: A) Talking louder B) Reducing background noise (turning off the TV) C) Speaking into their "bad" ear D) Using long, complex sentences
When using the "Teach-Back" method, the nurse: A) Quizzes the patient with a written test B) Asks the patient to explain the information in their own words C) Records the patient's response on a video D) Tells the patient the information again Rationale: Teach-back confirms that the patient understands the education provided. "Stereognosis" is the ability to: A) Walk with a steady gait B) Identify an object by touch without seeing it C) Hear a whisper from 10 feet away D) See in the dark Rationale: Testing this involves placing a key or coin in a patient's hand while their eyes are closed. "Palliative Sedation" is used to: A) Speed up the dying process B) Manage unendurable pain/distress in the final days of life C) Wake the patient up for family visits D) Treat an infection Rationale: It is the controlled use of medication to reduce consciousness to relieve refractory symptoms. "Body Image" is: A) How much a person weighs B) A person's perceptions of their physical appearance C) A person's clothing style D) The person's athletic ability Rationale: Body image is a component of self-concept and can be affected by surgery, aging, or illness.
1. A nurse is caring for a client in the compensatory stage of shock. Which finding should the nurse expect? A. Metabolic acidosis B. Tachycardia and narrowed pulse pressure C. Cold, mottled skin D. Decreased level of consciousness Answer: B
Rationale: In the compensatory stage, the SNS triggers tachycardia and vasoconstriction to maintain CO. Metabolic acidosis and mottled skin occur in later stages.
2. A client has deep partial-thickness burns to the anterior trunk and both anterior arms. Using the Rule of Nines, what is the %TBSA? A. 18% B. 27% C. 36% D. 45% Answer: B Rationale: Anterior trunk (18%) + Anterior right arm (4.5%) + Anterior left arm (4.5%) = 27%. 3. Which is the priority assessment for a client with circumferential chest burns? A. Pain level B. Urine output C. Airway and chest excursion D. Peripheral pulses Answer: C Rationale: Circumferential burns can cause "restriction" of the chest wall, leading to immediate respiratory failure. 4. A ventilator high-pressure alarm sounds. Which action should the nurse take first? A. Check for a leak in the cuff. B. Suction the client's airway. C. Call the respiratory therapist. D. Check for a disconnected tube. Answer: B Rationale: High-pressure alarms are caused by resistance, such as biting the tube, kinks, or secretions (suctioning). 5. A client in septic shock has a BP of 82/46 after a 3L fluid bolus. Which medication is anticipated next? A. Nitroprusside B. Furosemide C. Norepinephrine D. Atropine Answer: C Rationale: Norepinephrine is the first-line vasopressor for septic shock when fluid resuscitation fails to maintain a MAP > 65. 6. Which lab value indicates effective treatment in a client with MODS? A. Increased Lactic Acid B. Decreased Serum Creatinine C. Decreased Platelets
11. A client with ARDS is placed in the prone position. What is the primary goal? A. To decrease the work of breathing. B. To improve oxygenation by recruiting alveoli. C. To prevent pressure ulcers. D. To facilitate easier suctioning. Answer: B Rationale: Prone positioning shifts perfusion to under-ventilated lung areas, improving V/Q matching in ARDS. 12. A nurse is caring for a client with an AV fistula. Which action is appropriate? A. Take blood pressure in the arm with the fistula. B. Draw blood samples from the fistula. C. Palpate for a thrill and auscultate for a bruit. D. Wrap the arm tightly with a compression sleeve. Answer: C Rationale: A palpable thrill and audible bruit indicate the fistula is patent. Never use the fistula arm for BP or blood draws. 13. A client is in anaphylactic shock. What is the first-line medication? A. Diphenhydramine B. Albuterol C. Epinephrine D. Methylprednisolone Answer: C Rationale: Epinephrine IM is the priority to cause bronchodilation and vasoconstriction during anaphylaxis. 14. A nurse is assessing a client with a suspected inhalation injury. Which finding is the priority? A. Generalized edema B. Singed nasal hairs and soot in the sputum C. Pain at the burn site D. Hypotension Answer: B Rationale: Singed nasal hairs and soot are "red flags" for upper airway burns that can cause rapid swelling and obstruction. 15. A client's ABG results: pH 7.28, PaCO2 50, HCO3 24. What is the interpretation? A. Metabolic Acidosis B. Respiratory Alkalosis C. Respiratory Acidosis D. Metabolic Alkalosis
Answer: C Rationale: Low pH (<7.35) and high CO2 (>45) indicate respiratory acidosis.
16. A client in the emergent phase of a burn injury is most at risk for which electrolyte imbalance? A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hypernatremia Answer: B Rationale: Massive cell destruction releases intracellular potassium into the bloodstream during the first 24–48 hours. 17. What is the "Sepsis Bundle" priority within the first hour? A. Intubation B. CT scan C. Obtain blood cultures then start broad-spectrum antibiotics D. Perform a wound debridement Answer: C Rationale: Cultures must be drawn BEFORE antibiotics to identify the pathogen, but antibiotics should not be delayed. 18. A client has a MAP of 58 mmHg. What is the nurse's priority? A. Continue to monitor. B. Notify the provider; vital organs are not being perfused. C. Document as a normal finding. D. Lower the head of the bed. Answer: B Rationale: A MAP of at least 65 mmHg is required to maintain adequate tissue and organ perfusion. 19. A nurse is caring for a client with cardiogenic shock. Which treatment is contraindicated? A. Inotropic agents (Dobutamine) B. Diuretics C. Rapid 2L fluid bolus D. Intra-aortic balloon pump (IABP) Answer: C Rationale: In cardiogenic shock, the heart is failing as a pump. A fluid bolus would worsen pulmonary edema and heart failure. 20. Which assessment is priority for a client with a C6 spinal cord injury in Neurogenic Shock? A. Temperature 98.6°F
25. A client with ARDS has a PaO2 of 55 despite being on 100% FiO2. What is this called? A. Respiratory compensation B. Refractory hypoxemia C. Metabolic alkalosis D. Normal recovery Answer: B Rationale: Refractory hypoxemia is the inability to improve oxygenation despite high concentrations of O2; it is a hallmark of ARDS. 26. A client in the progressive stage of shock has "DIC." What is the priority assessment? .A. Blood glucose B. Presence of petechiae and bleeding from IV sites C. Deep vein thrombosis (DVT) D. Level of pain Answer: B Rationale: Disseminated Intravascular Coagulation (DIC) causes micro-clotting followed by depletion of clotting factors and massive bleeding. 27. A nurse is assessing a client with Acute Tubular Necrosis (ATN). What is the most common cause? A. Hypertension B. Prolonged ischemia or nephrotoxic medications C. High protein diet D. Kidney stones Answer: B Rationale: ATN is usually caused by lack of blood flow (ischemia) or toxins (Gentamicin, contrast dye). 28. Which medication is given to treat "Hyperkalemia" quickly in an emergency? A. Furosemide B. Kayexalate C. IV Insulin and Dextrose D. Spironolactone Answer: C Rationale: Insulin shifts potassium into the cells. Dextrose is given to prevent hypoglycemia. Kayexalate (B) is used for non-emergencies. 29. A client on a ventilator is "fighting the vent." What is the first action? A. Increase the sedation. B. Check for kinks in the tubing. C. Assess the client's respiratory status and oxygenation.
D. Paralyze the client. Answer: C Rationale: Always assess the client first to ensure they aren't experiencing distress or hypoxia before adjusting settings or meds.
30. A client with a burn injury has a "Carboxyhemoglobin" level of 15%. What does this indicate? A. Normal oxygenation. B. Carbon monoxide poisoning. C. Iron deficiency. D. Sepsis. Answer: B Rationale: Levels > 10% indicate carbon monoxide poisoning, often from smoke inhalation in an enclosed space. 31. What is the primary cause of death in the emergent phase of a burn? A. Infection B. Hypovolemic Shock C. Renal failure D. Heart attack Answer: B Rationale: Massive fluid shifts (capillary leak) lead to a loss of intravascular volume. 32. A client has a high lactate level (>4 mmol/L). What does this indicate? A. Aerobic metabolism B. Tissue hypoxia and anaerobic metabolism C. Effective organ perfusion D. Hyperglycemia Answer: B Rationale: High lactate is a marker of cellular distress and poor perfusion, common in sepsis and shock. 33. What is the priority nursing diagnosis for a client with MODS? A. Risk for Infection B. Deficient Knowledge C. Altered Tissue Perfusion D. Impaired Skin Integrity Answer: C Rationale: MODS is caused by a failure to perfuse vital organs. 34. A nurse is preparing a client for hemodialysis. Which medication should be held? A. Insulin B. Lisinopril (Antihypertensive) C. Multivitamin
D. Albumin Answer: C Rationale: Isotonic crystalloids are the first-line choice for volume expansion.
40. A client with ARDS is on a ventilator. The nurse notes new subcutaneous emphysema. What is the likely cause? A. Improving condition. B. Barotrauma (pneumothorax). C. Infection. D. Normal finding with PEEP. Answer: B Rationale: High pressures from the vent (PEEP) can rupture alveoli, causing air to leak into the tissues. 41. A client has "Cool, Clammy Skin" and a HR of 110. This indicates which stage of shock? A. Compensatory B. Progressive C. Refractory D. Initial Answer: B Rationale: In the progressive stage, compensatory mechanisms fail, leading to poor peripheral perfusion (cool/clammy). 42. Which assessment finding is unique to Neurogenic Shock? A. Tachycardia B. Dry, warm skin C. Tachypnea D. Hypertension Answer: B Rationale: Loss of SNS tone causes vasodilation and a lack of sweating, resulting in warm, dry skin below the level of the injury. 43. A client has an escharotomy performed. What is the desired outcome? A. Pain relief. B. Return of distal pulses and improved circulation. C. Decreased infection. D. Prevention of scarring. Answer: B Rationale: Escharotomy relieves the pressure from burnt, non-elastic tissue to restore blood flow. 44. A client with Sepsis has "Narrowed Pulse Pressure." What does this indicate? A. Effective treatment.
B. Decreasing stroke volume and increasing systemic vascular resistance. C. Normal recovery. D. High cardiac output. Answer: B Rationale: Narrowed pulse pressure is an early sign of shock indicating the body is trying to compensate for low volume.
45. A client in AKI has a high BUN/Creatinine and itchy skin. What is the cause of the itching? A. Allergic reaction. B. Uremic frost/Uremia. C. Dehydration. D. Infection. Answer: B Rationale: High levels of urea/waste products are excreted through the skin, causing irritation. 46. Which intervention is the priority for a client with "Heat Stroke"? A. Administering aspirin. B. Rapid cooling (ice baths, cooling blankets). C. Starting a high-protein diet. D. Checking bowel sounds. Answer: B Rationale: Heat stroke is a medical emergency; the core temperature must be lowered immediately to prevent brain damage. 47. A client with a burn is in the "Rehabilitative Phase." What is the focus? A. Airway. B. Fluid resuscitation. C. Physical therapy and return to function. D. Wound debridement. Answer: C Rationale: This phase focuses on scar management and regaining independence. 48. What is the major complication of PEEP? A. Hypertension B. Increased cardiac output C. Decreased cardiac output and hypotension D. Bradycardia Answer: C Rationale: PEEP increases intrathoracic pressure, which can compress the heart and decrease venous return. 49. A client is receiving "Dopamine" for shock. What is the intended effect? A. Decrease blood pressure.
