2873 Final exam study guide

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) 1. Taking or selling controlled substances 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written physician's order 5. Completing an occurrence report on the unit

1. Taking or selling controlled substances 4. Applying physical restraints without a written physician's order

Acute Burn Phase

Begins with mobilization of extracellular fluid and subsequent diuresis Concludes when •Partial thickness wounds are healed and/or •Full thickness burns are covered by skin grafts Partial-thickness wounds form eschar •Once eschar is removed, re-epithelialization begins

What are S/S of Metabolic Alkalosis

Confusion (can progress to stupor or coma) Hand tremor. Lightheadedness. Muscle twitching. Nausea, vomiting. Numbness or tingling in the face, hands, or feet. Prolonged muscle spasms (tetany)

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery

Monitor for signs of complications. Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure

No pain, waxy white skin, and no blanching with pressure With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

What does Triage mean?

Sorting of patients to determine priority health care needs and the proper site of treatment. •In disaster situations with large numbers of casualties decisions are based on the likelihood of survival and the consumption of resources •Do the greatest good for the greatest number of patients

How often does the Joint Commission require emergency preparedness and practice to happen?

Twice a year

What is terrorism?

Unlawful use of violence or threats of violence against people in order to coerce or intimidate

A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of a. a code blue alert. b. a disaster medical assistance team. c. the local police and fire departments. d. the hospital's emergency response plan

d. the hospital's emergency response plan.

Ventricles(Bundle Branch and Purkinjie FIbers)

o Last chance pacemakers o Rate 20-40 o No P wave o QRS wide >0.12 o Nave of rhythm = Ventricular

AV Node

secondary pacemaker o P wave may be absent o Before QRS o After QRS o May be inverted

What are the 5 steps to intrepret an ECG strip and determine rhythm?

1. Rhythm a. Regular b. Irregular 2. Rate a. Normal b. Fast c. Slow 3. P-Waves a. Normal b. Upright c. 1:1 QRS d. Atrial rate 4. PR Interval a. 0.12-0.20 seconds 5. QRS a. <0.12 b. Narrow c. Wide d. Early e. Ventricular Rate

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? Myocardia injury Myocardial ischemia Myocardial infarction A pacemaker is present

Myocardial ischemia The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.

What does Insulin normally do in the body?

•What does Insulin normally do? •Promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell •Cells break down glucose to make energy •Liver and muscle cells store excess glucose as glycogen •Skeletal muscle and adipose tissue are considered insulin-dependent tissues

Polydipsia and polyuria related to diabetes mellitus are primarily due to a. the release of ketones from cells during fat metabolism. b. fluid shifts resulting from the osmotic effect of hyperglycemia. c. damage to the kidneys from exposure to high levels of glucose. d. changes in RBCs resulting from attachment of excessive glucose to hemoglobin.

b. fluid shifts resulting from the osmotic effect of hyperglycemia.

SA node

Ø Primary pace maker of the heart Ø 60 - 100/min rate Ø First upright wave Ø P wave o Represents atrial depolariazarition (contraction) Ø Leads to narrow QRS Ø First name of rhythm = Sinus If P wave generated

The severity of an ELECTRICAL BURN depends on what 5 things?

1 amount of voltage 2 tissue resistance 3 current pathways 4 surface area 5 duration of the flow

ECG strips

1 square = 0.04 sec 5 squares = 0.2 secs typically in 6 sec strips. To get rates count incidents and multiply by 10.

A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply. 1. Antacids 2. Antidiarrheal 3. H2-histamine blockers 4. Proton pump inhibitors 5. Calcium channel blockers

1, 3, 4 Antacids are used prophylactically to neutralize the acids present in the stomach. H2-histamine blockers (e.g. ranitidine [Zantac]) are used to inhibit histamine, which causes increase in acid levels. Proton pump inhibitors (e.g. esomeprazole [Nexium]) help to inhibit the secretion of hydrochloric acid, which increases as a stress response to the decreased blood flow to the gastrointestinal tract after burns. Antidiarrheal is useful in providing symptomatic relief for diarrhea. It cannot prevent a Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on preventing development of Curling's ulcers.

A nurse assesses four patients. Which patient has greatest risk for hypomagnesemia? 1. A 72-year-old with chronic alcoholism 2. A 79-year-old with bone cancer 3. A 41-year-old with hypernatremia 4. A 46-year-old with respiratory acidosis

1. A 72-year-old with chronic alcoholism

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 5. Explaining how to take daily weights

What assessment does a nurse make before hanging an intravenous (IV) fluid that contains potassium? 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Level of consciousness

1. Urine output

. Which patients does a nurse plan to teach regarding water restriction? 1. A 23-year-old with extracellular fluid volume (ECV) deficit 2. A 34-year-old with hyponatremia 3. A 47-year-old with hypercalcemia 4. A 69-year-old with metabolic acidosis

2. A 34-year-old with hyponatremia

A patient is brought to the emergency department (ED) with a history of inhalation burn injury. The patient has also sustained burns on the face, neck, and hands. Which actions would the nurse perform immediately? Select all that apply. 1 Wait for laboratory reports. 2 Observe for the next two hours. 3 Provide 100% humidified oxygen. 4 Observe for signs of respiratory distress. 5 Check for evidence of inhalation of smoke.

3,4,5 Monitoring for signs of smoke or toxic chemical inhalation is an important step to evaluate burn victims. Also, assessing for signs of respiratory distress including increased agitation, anxiety, restlessness, or a change in the rate or character of breathing is important. Early treatment includes provision of 100% humidified oxygen and anticipating endotracheal intubation. Observing the patient for the next two hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within one to two hours after the injury.

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? 1. Document her findings and treat the patient 2. Instruct the mother on safe handling of a 2-year-old child 3. Contact a child abuse hotline 4. Discuss this story with a colleague

3. Contact a child abuse hotline

A client who sustained burn injuries due to a fire and explosion has a carbon monoxide level of 14%. Which pathophysiologic risk is increased in the client? 1 Stupor 2 Vertigo 3 Convulsions 4 Slight breathlessness

4 Slight breathlessness Slight breathlessness may occur when the carbon monoxide level is 14%. Stupor and vertigo may result when the carbon monoxide level is in between 21% and 40%. When the level of carbon monoxide reaches between 41% and 60%, coma or convulsions may occur.

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? 1. Give the family the record 2. Discuss the issues that concern the family with them 3. Call the nursing supervisor 4. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

4. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? 1. Sonorous wheezes in the left lower lung 2. Rhonchi mid sternum 3. Crackles only in apex of lungs 4. Inspiratory crackles in lung bases

4. Inspiratory crackles in lung bases

A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? 1. Obtain a court order to give the blood 2. Coerce the husband into giving the blood 3. Call security and have the husband removed from the hospital 4. More information is needed about the wife's preference and if the husband has her medical power of attorney

4. More information is needed about the wife's preference and if the husband has her medical power of attorney

Which patient should the nurse prepare to transfer to a regional burn center? A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% A 39-yr-old patient with a partial-thickness burn to the right upper arm A 53-yr-old patient with a chemical burn to the anterior chest and neck A 42-yr-old patient who is scheduled for skin grafting of a burn wound

A 53-yr-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

Which of the following is an example of a medical malpractice tort liability? A patient is informed of all known side effects of a medication and voluntarily takes the medication. The patient experiences an adverse effect from a medication prescribed by a physician. A nurse follows the standard of care for initiating an intravenous line, but the patient's vein bursts, causing a hematoma and the need for minor surgery to evacuate the fluid. A surgeon does not complete the postprocedure count process, and a sponge is retained in the patient's abdominal cavity. The Department of Justice fines an organization for releasing protected health information to a pharmaceutical company without individual patient consent.

A surgeon does not complete the postprocedure count process, and a sponge is retained in the patient's abdominal cavity. For tort liability to attach, four elements must be satisfied: duty, breach, causation, and harm. An adverse effect experienced by a patient who was informed of all known side effects of a medication, is prescribed the medication, and voluntarily takes the medication is an adverse event, not a tort liability. When a nurse follows the standard of care for initiating an intravenous line, but the patient's vein bursts, this is an adverse event and not a tort liability. Releasing protected health information to a pharmaceutical company without individual patient consent is regulated by federal law enforcement; it is considered employer liability and may be considered to be criminal if proven to be purposeful and egregious.

Which is characteristic of the formal nursing leadership model? Has the same structure in any health care organization Uses one leadership style throughout the organization Always has a chief nursing officer position to lead the nursing staff Adapts to the size and needs of the health care system

Adapts to the size and needs of the health care system The size and complexity of the nursing leadership team depend on the size and needs of the health care agency. Using the same structure in any health care organization does not adjust for the specific needs of the health care agency. Using one leadership style throughout the organization does not adjust for the specific needs of the departments in the health care agency. Always having a chief nursing officer position to lead the nursing staff does not adjust to the specific needs of the health care agency

A patient reports dizziness and shortness of breath and is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? Digoxin Adenosine Metoprolol Atropine sulfate

Adenosine

What is the emergent phase and how do you treat?

EMERGENT: is time required to resolve immediate problems resulting from injury Up to 72 hours Primary concerns are hypovolumic shock and edema Colloidal osmotic pressure decreases More fluid shifting out of vascular space into interstitial spaces Fluid therapy •Two large-bore IV lines for >15% TBSA •Type of fluid replacement Crystalloid (LR, 0.9NS) Colloid (albumin) •Parkland (Baxter) formula for fluid replacement *BURN SHOCK* Blisters Paralytic ileus Shivering Altered mental status

What data can you assess from a burn victim with fluid and electrolyte shift?

Edema Decreased BP Increased Pulse Decreased Urine Output Elevated Hematocrit, RBC hemolyzed

A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? 1 Flame burn 2 Chemical burn 3 Electrical burn 4 Radiation burn

Electrical Burn In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care (select all that apply.)? Escharotomy Administration of diuretics IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent

Escharotomy IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

HYPOventilation vs HYPERventilation

HYPO- Resp. Acidosis because unable to excrete excess CO2 *Have to resolve issue if possible ex COPD or drugs (pain meds) HYPER- breathing out too much CO2 *Usually resolves itself before compensation starts. *None at this point—compensation would not be occurring yet in this acute event. However, buffering of acute respiratory alkalosis may occur with shifting of bicarbonate (HCO3-) into cells in exchange for Cl-. It would take several days for renal compensation to occur

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods

High-calorie and high-protein foods A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

A new nurse needs further teaching when stating a valid consent involves which action? It must be presented to the patient by a nurse. The consent includes information about the risks and benefits of the procedure. The patient must have the capacity to give consent. The patient must voluntarily give consent.

It must be presented to the patient by a nurse. The person presenting the informed consent document must be the provider performing the procedure. To be valid, information for consent must be given by the provider who will be performing the procedure and includes information about the risks and benefits of the procedure. The patient must voluntarily give consent.

What are some exemplars of Leadership styles

Leadership Roles Formal Nurse Leader • Chief nursing officer • Nursing director/assistant director • Nurse manager • Charge nurse/team leader • Dean • Associate dean • State board of nursing executive director Clinical Nurse Leader • Experienced staff nurse • Clinical nurse educator • Experienced advanced practice nurse Interprofessional Leader • Director of clinical service line (e.g., primary care services) • Associate director of infection control department • Chairperson, quality improvement committee (e.g., ER) • Chairperson, reaccreditation steering committee

Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do? 1 Give the client orange juice by mouth. 2 Increase the client's intravenous (IV) flow rate. 3 Moisten the client's lips with a wet 4 × 4 gauze. 4 Offer the client 4 oz (120 mL) of water by mouth

Moisten the client's lips with a wet 4x4 gauze No bowel sounds are present; therefore, the client must remain NPO. Comfort measures may be helpful until bowel sounds return and the primary healthcare provider changes the dietary prescription. Giving the client orange juice or offering 4 oz (120 mL) of water by mouth is unsafe; the client must be kept NPO until bowel sounds are present. The urinary output is adequate; there is no need to increase IV fluids. Also, the nurse cannot increase the IV flow rate without a primary healthcare provider's prescription

ANION GAP

Na-(Cl + HCO3) sodium minus chloride plus bicarv Normal 8-12 mmol/L Increases with acid gain

Nursing implications in caring for acute thyrotoxicosis

Needs treated aggressivly Meds given to block thyroid hormone production and SNS Monitor for dysrhythmias Ensure adequate O2 Fluid and electrolyte replacement

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? Fully compensated respiratory alkalosis Partially compensated respiratory acidosis Normal acid-base balance with hypoxemia Normal acid-base balance with hypercapnia

Partially compensated respiratory acidosis A low pH (normal, 7.35-7.45) indicates acidosis. In a patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal, 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

What are some Recommended Competencies for Nursing Leaders

Personal qualities • Interpersonal skills • Thinking skills • Setting the vision • Communicating • Initiating change • Developing people • Health care knowledge (clinical, technical, as a business) • Management skills (e.g., planning, organizing) • Business skills (e.g., finance, marketing)

The nurse observes ventricular tachycardia (VT) on the patient's monitor. What evaluation made by the nurse led to this interpretation? Unmeasurable rate and rhythm Rate 150 beats/min; inverted P wave Rate 200 beats/min; P wave not visible Rate 125 beats/min; normal QRS complex

Rate 200 beats/min; P wave not visible VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands

Reddening of the skin The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

A patient is admitted with metabolic acidosis. Which system is not functioning normally? Renal system Buffer system Endocrine system Respiratory system

Renal system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes HCl acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.

What are some S/S and physical manifestations of COPD?

Signs of COPD o Polycythemia and cyanosis o Hypoxemia o Increased production of RBC o Bluish-red color of skin o Hemoglobin concentration may reach 20g/dL (200 g/L) or more o Complication o Cor pulmonale-hypertrophy of the R side of the heart § Result of pulmonary HTN § Late o Physical manifestations o Barrel chest (using accessory muscles, lungs get bigger) o Clubbed fingers o Low O2 sats o Sputum production o Prolonged breathing o Wheezes, coughing, fractured ribs o Exacerbations o Associated with poor outcomes o Primary causes § Bacterial and viral infections o Signs of severity § Use of accessory muscles § Central cyanosis

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)? Singed nasal hair Generalized pallor Painful swallowing Burns on the upper extremities History of being involved in a large fire

Singed nasal hair Generalized pallor Painful swallowing History of being involved in a large fire Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters. Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.

Skin is shiny and red with clear, fluid-filled blisters. Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

Which of the following statements is true? Communication is the least important function of leadership. Task leaders will communicate the most effective ways to accomplish the work. Autocratic leaders value feedback from their followers. Leaders who have little communication with their staff are socioemotional leaders.

Task leaders will communicate the most effective ways to accomplish the work. All answers except "Task leaders will communicate the most effective ways to accomplish the work" are false because communication is the most important function of leadership. Autocratic leaders do not seek feedback from their followers, because they make all the decisions. Socioemotional leaders communicate frequently to gage followers' feelings and emotions.

A nurse protecting a patient's right to consent to a procedure is represented in which of the following answers? Finding that the informed consent document is not with the chart, the nurse gives the patient another consent document to sign before the procedure. When the nurse finds that the informed consent document is not yet complete, she holds the patient's pre-procedure narcotics until the physician can obtain patient consent. The nurse finds that the consent form is unsigned in the chart and waits until after the procedure to get the document signed. Knowing the patient is not competent to sign a consent form, the nurse asks the friend who came with the patient to sign it.

When the nurse finds that the informed consent document is not yet complete, she holds the patient's pre-procedure narcotics until the physician can obtain patient consent. To be valid, information for consent must be given prior to the procedure by the provider who will be performing the procedure and the information given must include a description of the procedure, a description of the risks and benefits of the procedure, and a discussion of any alternatives to the proposed procedure. Consent by the patient must be voluntarily given, and the person who consents must have the capacity to consent. Capacity can be determined by the health care provider and may be affected by drugs or the current or underlying medical condition. If the patient is unable to give consent directly, he or she may designate a person who can give consent on his or her behalf. If such a person is not designated by the patient, most states provide a statutory solution or a law that lists "statutory surrogates."

An older man arrives in triage disoriented and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a. assess his vital signs. b. obtain a brief medical history from his wife. c. start supplemental O2 and have the ED physician see him. d. determine the kind of insurance he has before treating him.

a. assess his vital signs.

A plan of care for the patient with COPD could include (select all that apply) a. exercise such as walking. b. high flow rate of O2 administration. c. low-dose chronic oral corticosteroid therapy. d. use of peak flow meter to monitor the progression of COPD. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

a. exercise such as walking. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: a. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations c. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. d. At birth, the neonate of a diabetic mother is no longer at any greater risk

b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations

A patient has a core temperature of 90° F (32.2° C). The most appropriate rewarming technique would be a. passive rewarming with warm blankets. b. active internal rewarming using warmed IV fluids. c. passive rewarming using air-filled warming blankets. d. active external rewarming by submersing in a warm bath.

b. active internal rewarming using warmed IV fluids.

An older woman arrives in the ED complaining of severe pain in her right shoulder. The nurse notes that her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a. Dementia b. Possible cancer c. Family violence d. Orthostatic hypotension

c. Family violence

A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of a. polyuria. b. severe dehydration. c. rapid, deep respirations. d. decreased serum potassium.

c. rapid, deep respirations.

Nursing Implications for treating a patient with DKA

o Ensure patient airway o Establish IV o NaCl 0.45% or 0.9% o Add 5% to 10% dextrose when blood glucose reaches 250mg/dL o Continuous regular Insulin drip 0.1 U/kg/hr o Potassium replacement as needed o Note: Potassium levels may stay normal or elevated in DKA because of shifting of Potassium from the inside of the cell to out- BUT when treatment starts to be initiated with insulin- Potassium moves back into the cell... watch Potassium levels closely § CEREBREAL EDEMA o Nursing management o Monitor § Iv fluids § Insulin therapy § Electrolytes o Assess § Renal status

Metabolic Acidosis

o Excesses carbonic acid or base bicarb o Ketoacidosis o Lactic acid accumulation o Severe diarrhea o Kidney disease o Copensatory Mechanisms o Increased CO2 excretion by lungs o Kussmaul resps- deep and rapid o Kidneys excrete acid +PO4 is typically low

What is Junctional Tachy

o Regular o Rate 80 o P waves - none o PR interval - none o QRS 0.12 Ø Associated with o CAD o HF o Myocardial Infarction o Open heart surgery o Dig Toxicity o Cardiomyopathy Ø Treatments o Stop drugs § Ex metropolol - suppressing AV node

What is a Juctional Rhythm

o Rhythm- regular o Rate 40 o P wave - inverted after the T wave o PR - none o QRS 0.12 Ø Sends the impulse up and down (from the middle) Ø Causes o CAD o HF o Myoardial Infarction o Open Heart surgery o Dig toxicity o Cardiomyopathy Ø Treat o Only if symptomatic o Atropine or pacing

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as metabolic acidosis. respiratory acidosis. respiratory alkalosis. within normal limits

within normal limits The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.

What is Acute Thyrotoxicosis?

•(also called thyrotoxic crisis or thyroid storm) is an acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation. •Though considered a life-threatening emergency, death is rare when treatment is initiated early. •It is thought to result from stressors (e.g., infection, trauma, surgery) in a patient with preexisting hyperthyroidism. •Patients undergoing thyroidectomy are at risk because manipulation of the hyperactive thyroid gland results in an increase in hormones released.

Radiation Exposure

•Acute radiation syndrome (ARS): dose of radiation determines if ARS will develop •All body systems are affected by ARS •Presenting signs and symptoms determine predicted survival •Probable survivors have no initial symptoms or only minimal symptoms. •Possible survivors present with nausea and vomiting that persists for 24-48 hours •Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock. Neurologic symptoms suggest lethal dose. Survival time is variable DECONTAMINATION •Triage outside the hospital •Cover floor and use strict isolation precautions to prevent the tracking of contaminants •Air ducts and vent are sealed •Waste is double bagged and labeled "radiation waste" •Staff protection •Water resistant gowns, two pairs of gloves, caps, goggles, masks, and booties •Decontaminate each patient outside the ED with a shower •Water, tarps, towels, soap, gowns, all patient belongings, etc. must be collected and contained •Patients are resurveyed and re-showered as necessary •Showering should be performed to not contaminate clean areas with runoff from the showering •Biologic samples—nasal and throat swabs, blood •Internal contamination requires additional treatment—catharsis, gastric lavage with chelating agents

Burn Drug therapy

•Analgesics and sedatives Morphine Hydromorphone (Dilaudid) Haloperidol (Haldol) Lorazepam (Ativan) Midazolam •Antimicrobial agents Topical agents Silver sulfadiazine Mafenide acetate Systemic agents are not usually used in controlling burn flora Initiated when diagnosis of invasive burn wound sepsis is made

Chemical Vesicant Agents

•Chemicals that cause blistering and burns, conjunctivitis, bronchitis, pneumonia, hematopoetic suppression, and death • •Phosgene •Colorless gas normally used in chemical manufacturing •If inhaled at high concentrations for long enough period, causes severe respiratory distress, pulmonary edema, and death •Mustard gas Yellow to brown in color with garlic-like odor DECONTAMINATION •with soap and water; do not scrub •Eye exposure requires copious irrigation

Burn wound care

•Cleansing •Debridement •Once-daily shower Infection is most serious threat to further tissue injury •NO PILLOWS •USE TOWEL ROLLED UP •EARS DON'T TOUCH ANYTHING • •MAKE sure eyelashes are flipped out

Clinical manifestations of DKA

•Dehydration occurs in DKA with manifestations of poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. •Early symptoms may include lethargy and weakness. •As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyes become soft and sunken. •As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyes become soft and sunken. •Abdominal pain may be present and accompanied by anorexia, nausea, and vomiting. •Kussmaul respirations (rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. •Acetone is noted on the breath as a sweet, fruity odor.

COPD FYI

•Even when the patient has adequate caloric intake, weight loss is experienced. •Fatigue is a highly prevalent symptom that affects the patient's activities of daily living. •Can experience R foot edema

Blast injuries

•Factors affecting patient outcome •Distance •Enclosed space •Composition of explosive •Building collapse • •Pressure wave (blast wave) +•Physical Injuries++ •Blast lung -Pulmonary contusions, pneumothorax, hemothorax •Tympanic membrane rupture - most common •Abdominal and head injuries - hemorrhage •Fractures, traumatic amputations •Burns

Biological Terrorism- Anthrax

•Gram (+) lives in soil as a spore, odorless, invisible, travels miles •Animals can be vaccinated against - cattle •Incubation 1-6 days, replicating bacteria > releases toxins > hemorrhage >edema > necrosis •Contact, Ingestion, Inhalation •Symptoms - flu like, skin lesions, ulcerations, respiratory distress, mortality near 100% •Cremation after death to kill spores •Treatment - 60 days Cipro

What er the triage categories during a mass casualty incident?

•Immediate (RED)- Life-threatening but survivable with minimal intervention- Priority 1 •Delayed(YELLOW)- Significant injuries, require care but can wait without threat to life or limb- Priority 2 •Minimal(GREEN)- Injuries are minor - treatment can be delayed for hours or days, separate from main treatment- Priority 3 •Expectant(BLACK) - Injured are extensive and survival is unlikely, should be separated but not abandoned, comfort measures- Priority 4

Type 1 DM onset of disease

•In type 1 diabetes, the islet cell autoantibodies responsible for β-cell destruction are present for months to years before the onset of symptoms. •Manifestations of type 1 diabetes develop when the person's pancreas can no longer produce sufficient amounts of insulin to maintain normal glucose levels. •Once this occurs, the onset of symptoms is usually rapid, and patients often present with impending or actual ketoacidosis. •The patient usually has a history of recent and sudden weight loss, as well as the classic symptoms of polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (excessive hunger). •The individual with type 1 diabetes requires insulin from an outside source (exogenous insulin) to sustain life. Without insulin, the patient will develop diabetic ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis. •Patients with newly diagnosed type 1 diabetes may experience a remission, or "honeymoon period," for 3 to 12 months after treatment is initiated. During this time, the patient requires very little injected insulin because β-cell insulin production remains sufficient for healthy blood glucose levels. Eventually, as more β-cells are destroyed and blood glucose levels increase, the honeymoon period ends, and the patient will require insulin on a permanent basis.

BIo terrorism- Smallpox

•Incubation 12 days, Extremely contagious •Direct contact, droplets after fever down and rash appears •Small pox vaccine •1977 eradicated, USA stopped vaccinating in 1972 •Symptoms - Fever, headache, backache, rash, 30% fatality •Treatment - Antibiotics, isolation, autoclave, cremation

What are some lab findings for patients with DKA?

•Laboratory findings include a blood glucose level of 250 mg/dL (13.9 mmol/L) or higher, arterial blood pH less than 7.30, serum bicarbonate level less than 16 mEq/L (16 mmol/L), and moderate to high ketone levels in the urine or serum.

Metabolic Alkalosis

•Metabolic alkalosis (base bicarbonate excess) occurs when a loss of acid (prolonged vomiting or gastric suction) or a gain in HCO3− (e.g., ingestion of baking soda) occurs. •Renal excretion of HCO3− occurs in response to metabolic alkalosis. •The lung's compensatory response is limited. The respiratory rate decreases in order to increase plasma CO2. However, once hypoxemia occurs or plasma CO2 reaches a certain level, stimulation of chemoreceptors increases respirations.

Chemical Nerve Agents

•Sarin, Soman, or organophosphates •Inhibit cholinesterase causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death •Treatment: supportive care, atropine, benzodiazepine and pralidoxime •Decontaminate with copious amounts of soap and water or saline for at least 20 minutes •Blot, do not wipe off •Plastic equipment will absorb Sarin gas

What is Type 1 DM?

•Type 1 diabetes is an autoimmune disorder in which the body develops antibodies against insulin and/or the pancreatic β cells that produce insulin. This eventually results in not enough insulin for a person to survive. •Autoantibodies to the islet cells cause a reduction of 80% to 90% of normal function before hyperglycemia and other manifestations occur. •A genetic predisposition and exposure to a virus are factors that may contribute to the pathogenesis of immune-related type 1 diabetes. Genetic Link •Predisposition to type 1 diabetes is related to human leukocyte antigens (HLAs). Theoretically, when an individual with certain HLA types is exposed to a viral infection, the β cells of the pancreas are destroyed, either directly or through an autoimmune process. The HLA types associated with an increased risk for type 1 diabetes include HLA-DR3 and HLA-DR4. •Idiopathic diabetes is a form of type 1 diabetes that is strongly inherited and not related to autoimmunity. It only occurs in a small number of people with type 1 diabetes, most often of Hispanic, African, or Asian ancestry. •Latent autoimmune diabetes in adults (LADA), a slowly progressing autoimmune form of type 1 diabetes, occurs in adults and is often mistaken for type 2 diabetes.

Nursing Roles in a Disaster

•Variable •Depends on your experience •Triage Officer •Public Information Officer •Coordination with other agencies •Manage Behavioral Issues

Gestational Diabetes

•Women with gestational diabetes are at higher risk of needing cesarean delivery, and their babies have increased risk for perinatal death, birth injury, and neonatal complications. Women who are at high risk for gestational diabetes are screened at the first prenatal visit. •Those at high risk include women who are obese, are of advanced maternal age, and have a family history of diabetes. •Women with an average risk for gestational diabetes are screened with an OGTT at 24 to 28 weeks of gestation. •Most women with gestational diabetes have normal glucose levels within 6 weeks post partum. •Be aware that women with a history of gestational diabetes have up to a 63% chance of developing type 2 diabetes within 16 years.

What is Diabetes Mellitus

•a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both.

How does Thyrotoxicosis Manifest?

•all the symptoms of hyperthyroidism are prominent and severe. (buldging eyes, increased perspiration, abnormal heart rhythm, increased appetite, N/V/D, hand tremors, irritability, hyperactivity, high blood sugar, intolerance to heat) •Manifestations include severe tachycardia, heart failure, shock, hyperthermia (up to 106º F [41.1º C]), agitation, delirium, seizures, abdominal pain, vomiting, diarrhea, and coma.

What drugs are commonly given to treat thyrotoxic states?

•antithyroid drugs, iodine, and β-adrenergic blockers. • These drugs are useful in treating thyrotoxic states, but they are not considered curative.

What is DKA

•no insulin present to take the glucose into the cells so the body can use it for fuel.....patient will then experience hyperglycemia and the cells look for energy elsewhere •The body tries an attempt to use glucose sores that are in the liver because it doesn't know there is a bunch of glucose floating around in the blood, causes the liver to release glucagon—patient becomes more hyperglycemic Ketosis-by product of fat breakdown happens-patient experiences increased ketones in the body..causing blood to become acidic, (metabolic acidosis), and dehydration. Because of osmotic diuresis -too much glucose that cannot be reabsorbed-leaks into urine-polyuria and excretion of electrolytes. •It is most likely to occur in people with type 1 diabetes but may be seen in people with type 2 diabetes in conditions of severe illness or stress when the pancreas cannot meet the extra demand for insulin.

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall?

1 Partial-thickness burns require grafting before they can heal. Correct 2 Partial-thickness burns are often painful, reddened, and have blisters. 3 Partial-thickness burns cause destruction of both the epidermis and dermis. 4 Partial-thickness burns often take months of extensive treatment before healing. Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the epidermis and only part of the dermis. Recovery from partial-thickness burns with no infection occurs in 2 to 6 weeks.

A patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to follow the six rights of medication administration 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

1. Failure to document a change in assessment data 5. Failure to notify a health care provider about a change in the patient's condition

A patient has severe hypercalcemia. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 3. Encouraging increased fluid intake 4. Monitoring for constipation

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) 1. The nurse does not need any representation. 2. The patient must prove injury, damage, or loss occurred. 3. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. 4. The patient must prove that a breach in the prevailing standard of care caused an injury. 5. The burden of proof is always the responsibility of the nurse.

2. The patient must prove injury, damage, or loss occurred. 3. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. 4. The patient must prove that a breach in the prevailing standard of care caused an injury

The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? A 62-yr-old man with a fever and sinus tachycardia with a rate of 110 beats/min A 72-yr-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute A 42-yr-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/min

A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute Frequent premature ventricular contractions (PVCs) (>1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute myocardial infarction indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A patient with a traumatic brain injury A patient with type 1 diabetes mellitus A patient with acute respiratory failure A patient with nasogastric tube suction

A patient with nasogastric tube suction Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.

The nurse observing a telemetry monitor notes that a patient that was in sinus rhythm is now in a different rhythm. The electrocardiogram (ECG) now shows no P waves, fine and wavy lines between the QRS complexes, QRS complexes that measure 0.08 sec, and QRS complexes that occur irregularly with a rate of 120 beats/minute. The nurse correctly interprets this rhythm as what?

ATRIAL FIBRILLATION Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not contracting truly, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave, an unmeasurable heart rate, PR, or QRS, and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm; the P wave usually is buried in the QRS complex without a measureable PR interval.

What is burn shock?

At the time of major burn injury, there is increased capillary permeability. All fluid components of the blood begin to leak into the interstitium, causing edema and a decreased blood volume. Hematocrit increases, and the blood becomes more viscous. The combination of decreased blood volume and increased viscosity produces increased peripheral resistance. Burn shock, a type of hypovolemic shock, rapidly ensues and, if not corrected, can result in death

The nurse observes no P waves on the patients monitor strip. There are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. What does the nurse determine the rhythm to be? Sinus tachycardia Atrial fibrillation Ventricular fibrillation Ventricular tachycardia

Atrial fibrillation Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/min with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

The nurse is using a three tier triage system to treat four clients who sustained injuries after a bus accident. Which condition is triaged as urgent among these client conditions? A- Displaced or Multiple fractures B- Skin Rash C- Strains and sprains D- Simple fracture

Client A with displaced or multiple fractures does not have an immediately life-threatening condition, but needs immediate treatment when compared to other clients, so is considered urgent and triaged under as urgent. Client B with a skin rash, client C with strains and sprains, and client D with a simple fracture could wait several hours and are triaged as nonurgent.

What are the purposes of public health laws? Select all that apply. 1 Advocating for the rights of people 2 Prohibiting the purchase or sale of organs 3 Regulating health care and healthcare financing 4 Ensuring professional accountability for the care provided 5 Encouraging healthcare professionals to assist in emergencies

Correct 1 Advocating for the rights of people Correct 3 Regulating health care and healthcare financing Correct 4 Ensuring professional accountability for the care provided The primary purposes of public health laws are advocating for the rights of people, regulating health care and healthcare financing, and ensuring professional accountability for care that is provided. Public health laws help protect the health of the public. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. Good Samaritan laws are enacted to encourage health care professionals to assist in emergencies.

When might a nurse be charged with client abandonment? 1 If a nurse refuses to accept an assignment 2 If a nurse walks out when staffing is inadequate 3 If a client suffers an injury due to the nurse's inattention 4 If a nurse makes a written protest to the nursing administrators

Correct 2 If a nurse walks out when staffing is inadequate The nurse should never walk out when staffing is inadequate because this action may result in client abandonment. If a nurse refuses to accept an assignment, then he or she is considered insubordinate. If a client suffers an injury due to inattention and the nurse had already brought this to the attention of the nursing supervisor, then the caregiver was attempting to act reasonably. If a nurse has to accept unreasonable assignments, he or she needs to make written protests to nursing administrators.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? Serum sodium and potassium increase. Serum sodium and potassium decrease. Edema and arterial blood gases improve. Diuresis occurs and hematocrit decreases.

Diuresis occurs and hematocrit decreases. In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

The nurse observes a flat line on the patient's monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer? Lidocaine and amiodarone Digoxin and procainamide Epinephrine and/or vasopressin β-adrenergic blockers and dopamine

Epinephrine and/or vasopressin

What is unique about electrical burns?

Ice burg effect Patient usually on spinal precaution due to fall Patient at risk for dysrhythmias or cardiac arrest- can be delayed but typically within 24 hours Myoglobinuria- muscle destruction. CK-MB this is the MB. Myoblobin is present in muscle cells as reserve of O2 Can convulse hard enough to break long bones

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 g IV Urine for myoglobulin Lactated Ringer's solution at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours

Lactated Ringer's solution at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider? Antibiotics Loop diuretics Bronchodilators Antihypertensives

Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

A patient with a heart rate of 180 beats/minute has a regular heart rhythm, normal P waves, and normal PR intervals. The nurse expects to see what QRS complex shape on the patient's ECG tracing?

NORMAL A patient with a heart rate of 180 beats/minute has a regular heart rhythm, normal P waves, and normal PR intervals. The nurse expects to see what QRS complex shape on the patient's ECG tracing?

Smoke Inhalation Injuries - Upper Airway

Presence of facial burns Singed nasal hair Hoarseness, painful swallowing Darkened oral and nasal membranes Carbonaceous sputum History of being burned in enclosed space Clothing burns around neck and chest •Injury to mouth, oropharynx, and/or larynx •Thermally produced •Hot air, steam, or smoke •Swelling may be massive and onset rapid Eschar and edema may compromise breathing Swelling from scald burns can be lethal

The nurse provides teaching about the conduction system of the heart to a group of nursing students. The nurse should include that the electrical impulses travel through the heart in what order?

SA NODE INTERMODAL FIGERS AV NODE BUNDLE OF HIS PURKINJE FIBERS The conduction system of the heart consists of specialized neuromuscular tissue. The electrical impulse of the heart begins at the sinoatrial node in the upper right atrium. This impulse travels through the intermodal fibers and spreads over the atrial musculature. This causes atrial contraction. The impulse then reaches the atrioventricular (AV) node. From the AV node the impulse moves down through the bundle of His and ends at the Purkinje fibers. Impulses from the Purkinje fibers cause ventricular contractions.

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? Limit foods high in potassium Calcium gluconate IV piggyback Spironolactone (Aldactone) daily Administer intravenous insulin and glucose

Spironolactone (Aldactone) daily Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. Spironolactone is contraindicated in a patient with hyperkalemia (serum potassium >5.0 mEq/L). Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

Describe a PARTIAL THICKNESS BURN

Superficial partial thickness 1st degree ex sunburn Deep burn 2nd degree ex fluid filled vesicles, severe pain

A patient with paroxysmal supraventricular tachycardia (PSVT) that is receiving intravenous adenosine becomes hemodynamically unstable. The nurse expects what to be included in the patient's immediate treatment plan?

Synchronized cardioversion Paroxysmal supraventricular tachycardia is a dysrhythmia starting in an ectopic focus anywhere above the bifurcation of the bundle of His. The standard drug of choice to treat paroxysmal supraventricular tachycardia is intravenous (IV) adenosine. Sometimes the drug therapy is ineffective and the patient becomes hemodynamically unstable. For patients who are unresponsive to treatment, synchronized cardioversion is used. Synchronized cardioversion is low energy shock, which uses a sensor to deliver electricity that is synchronized with the peak of the QRS complex. Drug therapy is not effective for such patients. β -adrenergic blockers and calcium channel blockers do not improve paroxysmal supraventricular tachycardia. Catheter ablation therapy is used in patients with Wolff-Parkinson-White syndrome who have recurring paroxysmal supraventricular tachycardia (PSVT).

Which statement describes the electrical activity of the heart represented by the PR interval on an electrocardiogram (ECG)?

The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium, causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and usually is not measured

Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After the delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? Administer 250 mL of 0.9% saline solution IV by rapid bolus. Assess the apical pulse, blood pressure, and bilateral neck vein distention. Turn the synchronizer switch to the "off" position and recharge the device. Tell the patient to report any chest pain or discomfort and administer morphine sulfate.

Turn the synchronizer switch to the "off" position and recharge the device. Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)? Weakness Paresthesia Facial spasms Muscle tremors Depressed reflexes

Weakness Depressed reflexes Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

In planning for the care of a 30 year old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: a. Mothers age b. Number of years since diabetes was diagnoses c. Amount of insulin required prenatally Degree of glycemic control during pregnancy

a. Degree of glycemic control during pregnancy

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: a. Oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin b. Dietary modifications and insulin are both required for adequate treatment c. Glucose levels are monitored by testing urine 4 times a day and at bedtime d. Dietary management involves distributing nutrient requirements over 3 meals and 2 or 3 snacks

a. Dietary management involves distributing nutrient requirements over 3 meals and 2 or 3 snacks

What are effective interventions to decrease absorption or increase elimination of an ingested poison (select all that apply)? a. Hemodialysis b. Milk dilution c. Eye irrigation d. Gastric lavage e. Activated charcoal

a. Hemodialysis d. Gastric lavage e. Activated charcoal

Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Pregnant women with untreated hypothyroidism are at risk for (SATA) a. Miscarriage b. Macrosomia c. Gestational hypertension d. Placental abruption e. Stillbirth

a. Miscarriage b. Macrosomia d. Placental abruption e. Stillbirth

The major advantage of a Venturi mask is that it can a. deliver up to 80% O2. b. provide continuous 100% humidity. c. deliver a precise concentration of O2. d. be used while a patient eats and sleeps

c. deliver a precise concentration of O2.

Smoke inhalation lower airway injury

•Injury to trachea, bronchioles, and alveoli •Injury is related to length of exposure to smoke or toxic fumes •Pulmonary edema may not appear until 12 to 48 hours after burn Manifests as acute respiratory distress syndrome (ARDS) •Pneumonia

When planning for burn management, which patients should the nurse refer to a burn center? Select all that apply. 1 Patients with hydrochloric acid burns 2 Patients of all ages with first-degree burns 3 Patients of all ages with third-degree burns 4 Patients with 25% deep partial-thickness burns 5 Patients with 5% superficial partial-thickness burns

1,3,4 Patients suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center. All patients with partial-thickness burns more than 10% should be referred to a burn center, because they are severe types of burns and need specialized treatment, care, and isolation. Patients of all ages with first-degree burns can be managed in the hospital and assessed. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." 5. "I will go back to school as soon as I finish orientation."

1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing."

When computing a heart rate on a patient's ECG tracing, the nurse counts 15 small blocks between an R-R interval. The rhythm is regular. What should the nurse document as the patient's heart rate?

100 BPM Because each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represent one minute. By dividing the number of small blocks (15 in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100). Sixty beats/minute, 75 beats/minute, and 150 beats/minute are incorrect answers.

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? 1. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. 2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. 3. The patient cannot make changes in the advance directive once admitted to the hospital. 4. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: 1. Stimulates hyperventilation, causing respiratory alkalosis 2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs 3. Stimulates hypoventilation, causing respiratory acidosis 4. Causes alveoli to overinflate, leading to atelectasis

2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? 1. Antibiotics 2. Frequent change of position 3. Oxygen humidification 4. Chest physiotherapy

2. Frequent change of position

Which of the following skills can the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1. Nasotracheal suctioning 2. Oropharyngeal suctioning of a stable patient 3. Suctioning a new artificial airway 4. Permanent tracheostomy tube suctioning 5. Care of an endotracheal tube

2. Oropharyngeal suctioning of a stable patient 4. Permanent tracheostomy tube suctioning

A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.) 1. Information provided by the head nurse 2. Policies and procedures of the employing hospital 3. State Nurse Practice Act 4. Regulations identified in The Joint Commission manual 5. The American Nurses Association standards of nursing practice

2. Policies and procedures of the employing hospital 3. State Nurse Practice Act 4. Regulations identified in The Joint Commission manual 5. The American Nurses Association standards of nursing practice

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? 1. Family member 2. Surgeon 3. Nurse 4. Nurse manager

2. Surgeon

Which assessment does a nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Presence or absence of edema 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

3. Fullness of neck veins when supine

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? 1. Patient Protection and Affordable Care Act (PPACA) 2. Patient Self-Determination Act (PSDA) 3. Health Insurance Portability and Accountability Act (HIPAA) 4. Emergency Medical Treatment and Active Labor Act

3. Health Insurance Portability and Accountability Act (HIPAA)

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? 1. Discussing patient conditions in the nursing report room at the change of shift 2. Allowing nursing students to review patient charts before caring for patients to whom they are assigned 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

3. Posting medical information about the patient on a message board in the patient's room

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and , 24. The nurse interprets these laboratory values to indicate: 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. Respiratory acidosis. 4. Respiratory alkalosis.

3. Respiratory acidosis.

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? 1. The nurse's automobile insurance 2. The nurse's homeowner's insurance 3. The Good Samaritan law, which grants immunity from suit if there is no gross negligence 4. The Patient Care Partnership, which may grant immunity from suit if the injured party consents

3. The Good Samaritan law, which grants immunity from suit if there is no gross negligence

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the electrocardiogram (ECG)? 1. The length of time it takes to depolarize the atrium 2. The length of time it takes for the atria to depolarize and repolarize 3. The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers 4. The length of time it takes for the electrical impulse to travel from the sinoatrial (SA) node to the atrioventricular (AV) node

3. The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers

What are FULL THICKNESS BURNS?

3rd & 4th degree Dry, waxy white, leathery, or hard skin Insensitivity to pain- nerve destruction Possible involvement of muscles, tendons, and bone

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Americans with Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

4. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

A patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? Administer oxygen Notify the health care provider Rapidly administer more IV fluid Reposition the patient on the right side

Administer oxygen The cap off the central line could allow entry of air into the circulation, causing an air embolus. To manage an air embolus, oxygen is administered; the catheter is clamped, and the patient is positioned on the left side with the head down. Then the health care provider is notified.

The nurse is providing education to a patient who is in the rehabilitation phase of burn recovery after burning the arm with scalding water. Which of these statements by the patient indicates a need for further instruction? 1 "If the area itches, I can apply a water-based moisturizer." 2 "After a month, I will be able to go to the beach to get a tan." 3 "I will need to wear the pressure garment for 24 hours a day." 4 "I will continue the range-of-motion exercises on a regular schedule."

Correct 2 "After a month, I will be able to go to the beach to get a tan." Burn patients must protect healed burn areas from direct sunlight for about three months to prevent hyperpigmentation and sunburn injury. They should always wear sunscreen when they are outside. Water-based moisturizers are appropriate for itching. Pressure garments and masks should never be worn over unhealed wounds and, once a wearing schedule has been established, are removed only for short periods while bathing. Pressure garments are worn up to 24 hours a day for as long as 12 to 18 months. The range-of-motion exercises are important to prevent contractures that may develop as new tissue shortens.

A patient has sustained thermal injuries amounting to approximately 30% of his or her total body surface area. What action should the nurse take first? 1 Cover the burned body area with ice. 2 Immerse the burned body area in cool water. 3 Check for a patent airway, breathing, and circulation. 4 Cover the burned area with a clean, cool, tap water-dampened towel.

Correct 3 Check for a patent airway, breathing, and circulation.

A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next? 1 Insert a Foley catheter and monitor output. 2 Obtain vital signs and a stat arterial blood gas (ABG). 3 Obtain a sputum specimen and send it to the lab stat. 4 Anticipate the need for endotracheal intubation and notify the health care provider.

Correct 4 Anticipate the need for endotracheal intubation and notify the health care provider. Inhalation injury results from exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for endotracheal intubation and mechanical ventilation, because this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time.

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? Subcutaneous (SQ) tetanus toxoid Intravenous (IV) morphine sulfate Intramuscular (IM) hydromorphone Oral oxycodone and acetaminophen

Intravenous (IV) morphine sulfate IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.

The nurse is assessing a patient who has diabetic ketoacidosis. Her assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? Request an order for pain medication and oxygen at 6 L/min. Lubricate the patient's lips and allow continued hyperventilation. Have the patient breathe into a paper bag to stop hyperventilating Contact the physician immediately regarding this complication.

Lubricate the patient's lips and allow continued hyperventilation. Hyperventilation is a compensatory response to metabolic acidosis and should be allowed to continue because it helps move the blood pH toward the normal range. Lubricating the lips is a supportive nursing intervention that prevents drying and cracking of the lips during hyperventilation. Although pain and hypoxia can trigger hyperventilation, they are not the cause in this patient. Interventions to stop hyperventilation are not appropriate when it is a compensatory response. Hyperventilation is an expected beneficial compensatory response to metabolic acidosis and does not require contacting the physician.

The nurse monitors the electrocardiogram (ECG) of a patient diagnosed with acute coronary syndrome. The patient's baseline rhythm is sinus rhythm. Which additional ECG findings are most suggestive of myocardial infarction? Select all that apply.

T-WAVE INVERSION PATHOLOGIC Q WAVE ELEVATED ST SEGMENT Typical ECG changes that are seen in myocardial infarction include ST-segment elevation (not depression), T-wave inversion, and a pathologic Q wave. The patient will not have premature atrial contractions.

How do you decontaminate from chemical burns?

Take off all clothing, jewelry, accessories etc Wash thoroughly with soap and water, DO NOT SCRUB Once you are exposed to contaminate it can stay on the tissues for 72 hours

What determines the severity of injury in relation to THERMAL BURNS?

Temperature of burning agent Duration of contact time

Rehabilitation Phase of Burn injury

The rehabilitation phase begins when: •Wounds have healed •Patient is engaging in some level of self-care •Can occur as early as 2 weeks or as long as 7 to 8 months after a major burn injury Skin and joint contractures •Most common complications during rehab phase. •Positioning, splinting, and exercise should be used to minimize contracture.

Maternal and neonatal risks associated with gestational diabetes mellitus are: a. Maternal premature rupture of membrane and neonatal sepsis b. Maternal hyperemesis and neonatal low birth weight c. Maternal preeclampsia and fetal macrosomia Maternal placenta previa and fetal prematurity

c. Maternal preeclampsia and fetal macrosomia

The electrocardiogram (ECG) of a patient indicates P waves that are hidden in the preceding T waves and normal QRS complexes. The nurse recognizes that the patient is experiencing what condition?

premature atrial contraction occurs at the atrium and occurs before the next sinus beat occurs. A premature atrial contraction occurs in either the left atrium or right atrium and travels along the atria. The electrocardiogram of a premature atrial contraction usually shows hidden P waves in preceding T waves with prolonged PR interval. The QRS complex remains normal. The electrocardiogram of ventricular fibrillation has absent P waves and an undetectable PR interval and QRS complex. The electrocardiogram of junctional dysrhythmia shows a distorted P wave and reduced PR interval. The QRS complex remains normal. The electrocardiogram of premature ventricular contractions shows a rare occurrence of P waves. The PR interval cannot be measured with a disturbed and elongated QRS complex and T wave.