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 | 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 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.
1. A nurse is caring for a client who weighs 80 kg and has 30% TBSA burns. Using the Parkland Formula, what is the total fluid volume required in the first 24 hours? A. 4,800 mL B. 9,600 mL C. 12,000 mL D. 2,400 mL Answer: B Rationale: Parkland Formula = 4mL x kg x %TBSA. (4 x 80 x 30 = 9,600 mL). The nurse would administer 4,800 mL in the first 8 hours. 2. A nurse is assessing a client in the "Compensatory Stage" of shock. Which finding is expected? A. MAP of 50 mmHg B. Heart rate of 115 bpm and cold, clammy skin C. Lethargy and metabolic acidosis D. Heart rate of 105 bpm and narrowed pulse pressure Answer: D Rationale: In the compensatory stage, the body maintains BP through vasoconstriction (narrowed pulse pressure) and mild tachycardia. Cold/clammy skin and acidosis (B, C) occur in the progressive stage. 3. A client on a mechanical ventilator has a "Low-Pressure" alarm sounding. Which action should the nurse take first? A. Suction the client’s endotracheal tube. B. Check for a disconnection in the ventilator circuit. C. Increase the PEEP setting. D. Administer a sedative. Answer: B
Rationale: Low-pressure alarms indicate a leak or total disconnection. High-pressure alarms indicate an obstruction, which would require suctioning (A).
4. A nurse is triaging victims of a mass casualty incident. Which client should receive a "Red Tag"? A. A client with a sucking chest wound and labored breathing. B. A client with a simple wrist fracture who is walking. C. A client with a massive head injury and no pulse. D. A client with a 2-inch laceration on the thigh. Answer: A Rationale: Red tags are for "Immediate" life-threatening injuries that are survivable with treatment. Sucking chest wounds/tension pneumothorax are priorities. 5. A client in Septic Shock has a BP of 80/40 after receiving 3,000 mL of IV fluids. Which medication is the priority? A. Dobutamine B. Nitroprusside C. Norepinephrine D. Furosemide Answer: C Rationale: Norepinephrine (Levophed) is the first-line vasopressor for septic shock that is "fluid-refractory" to maintain a MAP > 65. 6. A nurse is caring for a client with 40% TBSA burns. Which laboratory result is expected during the "Emergent Phase"? A. Potassium 3.2 mEq/L B. Hematocrit 55% C. Sodium 150 mEq/L D. Albumin 4.5 g/dL Answer: B Rationale: Hemoconcentration occurs in the emergent phase due to massive fluid loss from the vascular space, causing the hematocrit to rise. Potassium would be high (hyperkalemia) due to cell destruction. 7. A nurse is monitoring a client with ARDS. Which finding indicates "Refractory Hypoxemia"? A. PaO2 remains at 58 mmHg despite 100% FiO2. B. PaCO2 is 48 mmHg. C. SaO2 is 92% on room air. D. pH is 7.35. Answer: A Rationale: Refractory hypoxemia is the hallmark of ARDS, where oxygen levels do not improve even with maximum oxygen delivery.
B. Methylprednisolone IV C. Epinephrine IM D. Albuterol Nebulizer Answer: C Rationale: Epinephrine is the priority to cause rapid bronchodilation and increase systemic vascular resistance (BP).
13. A nurse is assessing a client with a "Basilar Skull Fracture." Which finding is a priority? A. Headache B. Periorbital ecchymosis (Raccoon Eyes) C. Nausea D. Increased thirst Answer: B Rationale: Raccoon eyes and Battle's sign are classic indicators of a basilar skull fracture, which carries a high risk for CSF leakage and meningitis. 14. A client has a "MAP" of 55 mmHg. What is the nurse's priority action? A. Document the finding. B. Notify the healthcare provider. C. Re-check the BP in 2 hours. D. Place the client in a high-Fowler's position. Answer: B Rationale: A MAP < 65 indicates that vital organs (kidneys, brain) are not being adequately perfused. 15. A client with "Acute Tubular Necrosis" (ATN) is in the Oliguric Phase. What is the priority nursing diagnosis? A. Fluid Volume Deficit B. Excess Fluid Volume C. Risk for Injury D. Deficient Knowledge Answer: B Rationale: In the oliguric phase of AKI, the kidneys cannot excrete water, leading to edema, hypertension, and risk for heart failure. 16. Which "Rule of 9s" percentage is assigned to the "Back of the Left Leg"? A. 4.5% B. 9% C. 18% D. 1% Answer: B Rationale: Each entire leg is 18%. The front is 9% and the back is 9%.
17. A client on a ventilator is being treated with "PEEP." What is a major complication the nurse should monitor for? A. Hypertension B. Pneumothorax (Barotrauma) C. Fluid Volume Deficit D. Bradycardia Answer: B Rationale: Positive End-Expiratory Pressure (PEEP) can over-distend alveoli, leading to rupture and air leaking into the pleural space. 18. A nurse is caring for a client in "Neurogenic Shock." Which finding is unique to this type of shock? A. Tachycardia B. Hypotension C. Bradycardia D. Tachypnea Answer: C Rationale: Neurogenic shock involves a loss of sympathetic tone, leading to the "triad" of hypotension, bradycardia, and poikilothermia (temp dysregulation). 19. A client has "Curling's Ulcers" after a major burn. Which medication is prescribed as a preventative measure? A. Famotidine (H2 Blocker) B. Warfarin C. Metoprolol D. Furosemide Answer: A Rationale: Stress ulcers (Curling’s) are common in burn patients; H2 blockers or PPIs are given prophylactically to reduce gastric acid. 20. A nurse is assessing a client for "Cushing’s Triad" related to increased ICP. What are the three components? A. Tachycardia, hypotension, irregular respirations. B. Bradycardia, hypertension with widened pulse pressure, irregular respirations. C. Tachycardia, hypertension, tachypnea. D. Bradycardia, hypotension, apnea. Answer: B Rationale: Cushing's Triad is a LATE sign of increased intracranial pressure and impending brain herniation. 21. A client is receiving "Dopamine" at a high dose (15 mcg/kg/min). What is the intended effect? A. To increase urine output.
Answer: B Rationale: This prevents air from entering the pleural space while allowing air to escape, preventing a tension pneumothorax.
26. A client in "DKA" has a glucose of 240 mg/dL. The nurse adds D5NS to the infusion. What is the purpose? A. To treat hypoglycemia. B. To prevent cerebral edema. C. To stop the insulin infusion. D. To increase urine output. Answer: B Rationale: A rapid drop in serum osmolality can cause fluid to shift into brain cells. Dextrose is added to slow the drop in blood sugar. 27. A client with "Septic Shock" has "DIC." Which lab result is most expected? A. Increased Platelets B. Increased D-dimer C. Decreased PT/INR D. Increased Fibrinogen Answer: B Rationale: DIC is characterized by microclots and excessive bleeding. D-dimer increases as the body tries to break down these clots. 28. A client has an "Escharotomy" performed on the leg. Which finding indicates the procedure was successful? A. The client reports less pain. B. Distal pulses are now palpable. C. The wound starts to bleed. D. The client can wiggle their toes. Answer: B Rationale: Escharotomy is performed to restore circulation by relieving pressure from the non- elastic burnt tissue. 29. A nurse is assessing a client for "Autonomic Dysreflexia." Which is a common trigger? A. Hunger B. A distended bladder C. Fever D. Loud noises Answer: B Rationale: A full bladder or fecal impaction are the most common triggers for this life- threatening hypertensive crisis in spinal cord injuries.
30. Which "ABG" result indicates "Respiratory Acidosis"? A. pH 7.50, PaCO2 30 B. pH 7.30, PaCO2 55 C. pH 7.28, HCO3 18 D. pH 7.48, HCO3 30 Answer: B Rationale: Acidosis = pH < 7.35. Respiratory = CO2 > 45. 31. A client has a "Tension Pneumothorax." Which finding is a late, classic sign? A. Tachycardia B. Hypotension C. Tracheal deviation D. Tachypnea Answer: C Rationale: Tracheal deviation toward the unaffected side indicates the heart and great vessels are being pushed by pressure. 32. A client with "Heart Failure" has a "PAWP" of 4 mmHg. What does this indicate? A. Fluid Overload B. Dehydration/Hypovolemia C. Normal finding D. Pulmonary Embolism Answer: B Rationale: Normal PAWP is 6–12 mmHg. A low value (4) indicates a lack of volume. 33. A nurse is caring for a client with "Myxedema Coma." Which intervention is the priority? A. Cooling blanket B. Administering IV Levothyroxine C. Fluid restriction D. Giving a beta-blocker Answer: B Rationale: Myxedema coma is severe hypothyroidism. Thyroid hormone replacement is necessary to restore metabolic function. 34. A client in the "Diuretic Phase" of AKI is most at risk for? A. Hypertension B. Hypovolemia and Hypokalemia C. Heart failure D. Hyperkalemia Answer: B Rationale: The kidneys can finally make urine but cannot concentrate it yet, leading to the loss of massive amounts of water and potassium.
40. A client with "SIADH" has a sodium of 115 mEq/L. Which is a priority assessment? A. Hunger B. Seizure activity C. High urine output D. Dry skin Answer: B Rationale: Severe hyponatremia (<120) puts the client at extreme risk for cerebral edema and seizures. 41. A client with "Acute Pancreatitis" has "Grey Turner’s Sign." Where is this located? A. Around the belly button. B. On the flanks (sides). C. On the face. D. On the legs. Answer: B Rationale: This indicates retroperitoneal bleeding, a severe complication of pancreatitis. 42. Which "Trauma" assessment comes first? A. Breathing B. Airway with C-spine stabilization C. Circulation D. Disability/Neurological Answer: B Rationale: Airway is always the absolute priority in trauma (ABCDE). 43. A client on "TPN" has a glucose of 250. What is the priority? A. Stop the TPN. B. Administer sliding-scale insulin. C. Speed up the rate of TPN. D. Give the client orange juice. Answer: B Rationale: High glucose is a common complication of TPN; insulin is used to manage it without stopping the nutrition. 44. A nurse is assessing a client for "Brain Death" via the "Oculocephalic Reflex" (Doll's Eyes). What is a "positive" (normal) finding? A. Eyes stay fixed in the center. B. Eyes move in the opposite direction of the head turn. C. Eyes move in the same direction as the head turn. D. The client blinks. Answer: B Rationale: "Doll's eyes" present (moving opposite the head) indicates the brainstem is intact.
45. A client has "Evisceration" of the abdomen after surgery. What is the first action? A. Push the organs back in. B. Cover with sterile, saline-soaked gauze. C. Call the family. D. Put the client in a chair. Answer: B Rationale: The priority is to keep the organs moist and sterile until surgery can be performed. 46. Which electrolyte is most important to monitor in "Refeeding Syndrome"? A. Sodium B. Phosphorus C. Calcium D. Chloride Answer: B Rationale: Hypophosphatemia is the hallmark of refeeding syndrome and can cause heart failure. 47. A client with "AKI" has a potassium of 6.5. Which medication is given to "Shift" potassium into the cells quickly? A. Kayexalate B. IV Insulin and Dextrose C. Furosemide D. Spironolactone Answer: B Rationale: Insulin shifts K+ into cells. Dextrose prevents hypoglycemia. 48. A client has a "Pulmonary Embolism." Which hemodynamic change is expected? A. Low PAP B. High PAP (Pulmonary Artery Pressure) C. High PAWP D. Low CVP Answer: B Rationale: The blockage in the lung increases the pressure the right heart has to pump against. 49. A nurse is caring for a client with a "Flail Chest." What is a hallmark sign? A. Tracheal deviation. B. Paradoxical chest wall movement. C. Hypertension. D. Bradycardia. Answer: B Rationale: The broken segment of the chest moves in during inspiration and out during expiration.
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 C) Complicated grief D) Disenfranchised grief Rationale: Complicated grief involves a prolonged or significantly difficult time moving forward after a loss.
A patient with macular degeneration is being discharged. Which safety intervention is most important? A) Painting the walls a dark color B) Ensuring there is adequate, glare-free lighting in hallways C) Removing all clocks from the home D) Using small area rugs in every room Rationale: Macular degeneration affects central vision; bright, non-glare lighting helps utilize peripheral vision and prevents falls. When a nurse is "Active Listening," they are: A) Formulating their next response while the patient speaks B) Observing the patient's nonverbal behaviors and reflecting on them C) Multi-tasking by documenting while the patient talks D) Interrupting to clarify medical terms immediately Rationale: Active listening involves being fully present, observing nonverbal cues, and showing the patient they are understood. Which of the following is an example of "Non-therapeutic" communication? A) Using silence B) Giving personal opinions or advice C) Asking open-ended questions D) Summarizing the conversation Rationale: Giving advice takes decision-making away from the patient and can inhibit their ability to solve problems. A patient is grieving the loss of a limb. Which type of loss is this? A) Perceived loss B) Actual loss C) Maturational loss D) Disenfranchised loss Rationale: Actual loss occurs when a person can no longer feel, hear, or know a person or object (in this case, a body part). What is the primary purpose of a "Living Will"? A) To distribute the patient's money after death B) To document the patient's wishes regarding life-sustaining treatment C) To assign a power of attorney for finances 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.
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. Which is a physical sign of "Impending Death"? A) Increased appetite B) Clear, rhythmic breathing C) Cheyne-Stokes respirations D) Hypertension
Rationale: Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep, rapid breathing. Which communication technique is "Therapeutic"? A) Asking "Why" questions B) Providing relevant information C) Using clichés like "Everything happens for a reason" D) Changing the subject when the patient gets sad Rationale: Giving information empowers the patient and builds trust. A patient has "Xerostomia." The nurse should provide: A) Earplugs B) Frequent oral care and sips of water C) A magnifying glass D) A high-protein diet Rationale: Xerostomia is dry mouth, often caused by medications or decreased saliva production. "Agnosia" is the inability to: A) Speak B) Swallow C) Recognize familiar objects or people D) Walk Rationale: Agnosia is a sensory deficit where the patient cannot interpret sensory input despite the sense being intact. When performing post-mortem care, the nurse should: A) Leave the patient's eyes open B) Place a small pillow under the head C) Remove the dentures and throw them away D) Keep the patient in a prone position Rationale: A pillow prevents blood from pooling in the face, which can cause discoloration (livor mortis). What is "Anticipatory Grief"? A) Grief that occurs after a sudden accident B) Grief experienced before the actual loss occurs 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.
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 Rationale: Background noise competes with the speaker's voice, making it harder to distinguish words. "Reflection" in communication involves: A) Telling the patient what to do B) Repeating the patient's feelings back to them
C) Thinking about your own dinner plans D) Describing a patient's physical symptoms Rationale: Reflection helps the patient explore their own feelings and shows that the nurse is empathetic. Which is a barrier to learning for an older adult? A) Previous experience B) Decreased visual acuity and hearing C) High motivation D) Ability to read Rationale: Physiological changes in aging can make it harder to see educational materials or hear instructions. What is the "Affective" domain of learning? A) Solving a math problem B) Changes in attitudes, values, and feelings C) Performing a return demonstration of a skill D) Listing the steps of a procedure Rationale: Affective learning deals with the emotional component of education. A patient is "Disoriented." This means they are confused about: A) Their favorite food B) Person, place, time, or situation C) Their social security number D) The names of all the nurses on the floor Rationale: Orientation x4 refers to knowing who they are, where they are, what time it is, and what happened. "Presbycusis" is: A) Loss of vision in old age B) Progressive hearing loss associated with aging C) Loss of taste D) Inability to feel pain Rationale: It is a common type of sensorineural hearing loss in older adults. 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.
