4510 Exam 1 Shocks and Burns

The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 1.Hematocrit 60% (0.60) 2.Serum albumin 4.8 g/dL (48 g/L) 3.Serum sodium 144 mEq/L (144 mmol/L) 4.White blood cell (WBC) count 9000 mm3 (9 × 109/L)

1.Hematocrit 60% (0.60) Extensive burns greater than 25% of the TBSA result in generalized body edema in both burned and unburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels are elevated in the first 24 hours after injury as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit level ranges from 37% to 47% (0.37 to 0.47) (female) and 42% to 52% (0.42 to 0.52) (male). The remaining options identify normal laboratory values.

The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 1.Monitor the radial pulse every hour. 2.Keep the extremity in a dependent position. 3.Document any changes that occur in the pulse. 4.Place pressure dressings and wraps around the burn sites.

1.Monitor the radial pulse every hour. In a client with ineffective tissue perfusion related to a circumferential burn injury, peripheral pulses should be assessed every hour for 72 hours. The affected extremities should be elevated, and the primary health care provider (PHCP) should be notified of any changes in pulses, capillary refill, or pain sensation. Pressure dressings and wraps should not be applied around the circumferential burn because they could cause a further alteration in peripheral circulation.

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? 1.Removing all clothing, including gloves, shoes, and any undergarments 2.Determining the antidote for the chemical and placing the antidote on the burn site 3.Leaving all clothing in place until the client is brought to the emergency department 4.Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing

1.Removing all clothing, including gloves, shoes, and any undergarments In a chemical burn injury, the burning process continues as long as the chemical is in contact with the skin. All clothing, including gloves, shoes, and undergarments, is removed immediately, and water lavage is instituted before and during transport to the emergency department. Powdered chemicals are first brushed off the client before lavage is performed.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue

1.Return of distal pulses Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The primary health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank.

14, 940 mL The Parkland (Baxter) formula for estimating fluid requirements is 4 mL × kilograms of body mass × percent total BSA. Half of this total is administered in the first 8 hours after the burn. First, convert pounds to kilograms by dividing 198 lbs by 2.2, which equals 90. Therefore, 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL.

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? 1. Pulsus paradoxus 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

2. Ventricular dysrhythmias Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Pulsus paradoxus is a finding associated with cardiac tamponade.

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? 1.Nerve damage 2.Hypertrophy of collagen fibers 3.Compromised circulation at the burn site 4.Increase in subcutaneous tissue at the burn site

2.Hypertrophy of collagen fibers Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1.Pain level 2.Lung sounds 3.Ability to swallow 4.Laboratory results

2.Lung sounds The priority nursing action would be to assess lung sounds. Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and cause erythema and edema of the airways and mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after a burn injury.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1.Vital signs 2.Urine output 3.Mental status 4.Peripheral pulses

2.Urine output Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? 1.Wash the burn site. 2.Apply the medication with a sterile gloved hand. 3.Apply saline-soaked dressings over the medication. 4.Apply 1/16-inch (1.5-mm) film directly to the burn sites.

3.Apply saline-soaked dressings over the medication. Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in second- and third-degree burns when bacterial resistance to other agents is a potential problem. The burn site is washed before medication application. A film of 1/16 inch (1.5 mm) is applied directly to the burn using a sterile gloved hand. Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned.

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? 1.Assessing heart rate 2.Assessing respiratory rate 3.Assessing peripheral pulses 4.Assessing blood pressure (BP)

3.Assessing peripheral pulses The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment would be to assess for peripheral pulses to ensure that adequate circulation is present. Although the respiratory rate and BP also would be assessed, the priority with a circumferential burn is assessment for the presence of peripheral pulses because the airway is not affected in this case.

The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? 1.Immediately after the injury 2.Within 12 hours after the injury 3.Between 18 and 24 hours after the injury 4.Between 42 and 72 hours after the injury

3.Between 18 and 24 hours after the injury The maximum amount of edema in a client with a burn injury is seen between 18 and 24 hours after the injury. With adequate fluid resuscitation, the transmembrane potential is restored to normal within 24 to 36 hours after the burn. The remaining options are incorrect.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1.Using sterile sheets and linens 2.Performing strict hand-washing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

3.Wearing gloves and a gown only when giving direct care to the client In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.

Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions? 1.Apply once a day and leave it open to the air. 2.Apply twice a day and leave it open to the air. 3.Apply twice a day and cover it with a sterile dressing. 4.Apply once a day and cover it with a sterile dressing.

4.Apply once a day and cover it with a sterile dressing. Collagenase is used in the treatment of dermal lesions and severe burns. Its action is to debride the affected area. It is applied once daily and covered with a sterile dressing. Options 1, 2, and 3 are incorrect application procedures.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels

4.Elevated hematocrit levels The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? 1.Increase the rate of O2 flow 2.Obtain arterial blood gas results 3.Insert an indwelling urinary catheter 4.Increase the rate of intravenous (IV) fluids

4.Increase the rate of intravenous (IV) fluids The MAP and CVP are both low for this client, indicating a shock state. Shock is the result of inadequate tissue perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. Although increasing the rate of O2 flow may be a necessary intervention, perfusion is the first priority. Obtaining arterial blood gas results and inserting an indwelling urinary catheter may be necessary interventions to monitor the client's response to prescribed therapy, but these are not the priority.

Mafenide acetate is prescribed for a client with a burn injury to the hand. Which should the nurse include in the instructions to the client regarding the use of this medication? 1.If stinging occurs, discontinue the medication. 2.Apply a thinner film than prescribed to the burn site if the medication stings. 3.If local stinging and burning occur after the medication is applied, notify the health care provider. 4.It is normal to experience local discomfort and stinging and burning after the medication is applied.

4.It is normal to experience local discomfort and stinging and burning after the medication is applied. Mafenide acetate is bacteriostatic for both gram-negative and gram-positive organisms and is used to treat second- and third-degree burns to reduce the number of bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort, stinging, and burning and that this is normal. Therefore, options 1, 2, and 3 are incorrect.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? 1.Allow the client to have full liquids. 2.Give the client small glasses of clear liquids. 3.Order the client a full meal tray with extra liquids. 4.Keep the client on NPO (nothing by mouth) status.

4.Keep the client on NPO (nothing by mouth) status. The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.

10. What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient? A. Assessing, documenting, and avoiding all the patient allergies B. Administering Epinephrine C. Administering Corticosteroids D. Establishing IV access

A. Assessing, documenting, and avoiding all the patient allergies This is the MOST important and easiest step a nurse can take in preventing anaphylactic shock in a patient.

4. You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all that apply: A. Blood pressure 69/38 B. Heart rate 170 bpm C. Blood pressure 250/120 D. Heart rate 29 E. Warm and dry extremities F. Cool and clammy extremities G. Temperature 104.9 'F H. Temperature 95 'F

A. Blood pressure 69/38 D. Heart rate 29 E. Warm and dry extremities H. Temperature 95 F Hallmark signs and symptoms of neurogenic shock are: hypotension, bradycardia, hypothermia, warm/dry extremities (this is due to vasodilation and blood pooling and will be found in the extremities).

3. Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: A. Blood pressure of 70/34 after the fluid bolus B. Serum lactate less than 2 mmol/L C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Central venous pressure (CVP) of 18

A. Blood pressure of 70/34 after the fluid bolus C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement The answers are A and C. To know if the patient is progressing to septic shock, you need to think about the hallmark findings associated with this condition. Septic shock is characterized by major persistent hypotension (<90 SBP) that doesn't respond to IV fluids (refractory hypotension), and the patient needs vasopressors (ex: Norepinephrine) to maintain a mean arterial pressure greater than 65 and their serum lactate is greater than 2 mmol/L. A serum lactate greater than 2 indicates the cell's tissue/organs are not functioning properly due to low oxygen; hence tissue perfusion is poor due to the low blood pressure and mean arterial pressure.

5. In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring: A. Loss of vasomotor tone B. Increase systemic vascular resistance C. Decrease in cardiac preload D. Increase in cardiac afterload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities

A. Loss of vasomotor tone C. Decrease in cardiac preload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities Massive vasodilation is occurring in the body and this is due to the loss of vasomotor tone (remember the sympathetic nervous system loses its ability to stimulate nerves that regulate the diameter of vessels....so vessels are relaxed). This will DECREASE (NOT increase) systemic vascular resistance (which will decrease cardiac afterload) and the blood pressure will fall. Furthermore, there is a pooling of venous blood in the extremities because there isn't any pressure to push it back to the heart. This will cause a decrease in venous blood return to the heart. When this occurs it will decrease cardiac preload (the amount the ventricle stretch at the end of diastole). All of this together will decrease the amount of blood the heart can pump per minute....hence the cardiac output and shock will occur.

8. Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply: A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L D. Blood glucose 120 mg/dL E. CVP (central venous pressure) less than 2 mmHg

A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L E. CVP (central venous pressure) less than 2 mmHg When answering this question, select the options that would indicate the body's organs/tissues are NOT being perfused adequately. A MAP should be 65 or greater for proper tissue perfusion to occur. Urinary output should be at least 30 mL/hr. Serum lactate should be less than 2 mmoL/L....if it's high this indicates cells are not receiving enough oxygen due to low tissue perfusion. A central venous pressure (CVP) should be greater than 2 mmHg. This shows the filling pressure in the right side of the heart. If this number is low there is not enough fluid filling in the heart to maintain cardiac output. This occurs in septic shock due to hypovolemia from increased capillary permeability where fluid shifts from the intravascular to the interstitial space.

10. You're developing a nursing plan of care for a patient with neurogenic shock. As the nurse, you know that due to venous blood pooling from vasodilation a deep vein thrombosis can occur in this type of shock. A patient goal is that the patient will be free from the development of a deep vein thrombosis. Select all the nursing interventions below that can help the patient meet this goal: A. Perform range of motion exercises daily. B. Place a pillow underneath the patient knees as needed. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily.

A. Perform range of motion exercises daily. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily. Option B would impede blood flow and increase the risk of a DVT. The other options would help prevent a DVT.

9. The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. The patient's blood pressure changes from 75/48 to 110/82. B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed. D. Patient's urinary output is 20 mL/hr.

A. The patient's blood pressure changes from 75/48 to 110/82. In septic shock, the first treatment is to try to maintain tissue perfusion with fluids. If that doesn't work to increase blood pressure and maintain perfusion, vasopressors will be used next. In septic shock, the intravascular space will be depleted of fluid due to an increase in capillary permeability. This will lead to hypovolemia, which will decrease blood pressure and lead to a decrease in blood flow to organs/tissue. If the blood pressure increases to a normal state, that tells us the fluids are working.

2. A 25-year-old female is admitted to the ER in anaphylactic shock due to a bee sting. According to the patient's mother, the patient is severely allergic to bees and was recently stung by one. This type of anaphylactic reaction is known as a? A. Type I Hypersensivity Reaction B. Type II Hypersensivity Reaction C. Type III Hypersensivity Reaction D. Type IV Hypersensivity Reaction

A. Type I Hypersensivity Reaction Type I Hypersensitivity Reactions are immediate and cause anaphylaxis. It occurs when an antigen (the allergen....in this case bee venom) attaches to immunoglobulin E (IgE) antibodies. These antibodies are created due to this allergen and attach to the mast cells and basophils. This leads to a system-wide release of inflammatory mediators (histamine and other inflammatory substances). It is important to note a patient must be sensitized (meaning the immune system has seen the allergen before and produced IgE antibodies in response to the allergen). When the person comes into contact with the foreign substance AGAIN (at a later time) the allergen will attach to that previously created IgE antibody on the mast cell. This will lead to a massive release of histamine and other inflammatory substances that will cause anaphylaxis and lead to anaphylactic shock.

4. You're providing care to four patients. Select all the patients who are at risk for developing sepsis: A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

All the answers are correct. All the patients have risk factors for developing sepsis. Remember the mnemonic: Septic Suppressed immune system (AIDS/HIV, immunosuppressive therapy, steroids, chemo, pregnancy, malnutrition) Extreme age (infants and elderly)... Post-op (surgical/invasive procedures) Transplant recipients Indwelling devices (Foley catheter, central lines, tracheostomies) Chronic diseases (diabetes, hepatitis, alcoholism, renal insufficiency)

3. Anaphylactic shock can occur due to either an immunological or non-immunological cause. Select ALL the CORRECT statements about the differences between an immunological reaction (anaphylactic) and non-immunological reaction (anaphylactoid): A. "In an immunological reaction (anaphylactic) IgE antibodies are created and they attach to mast cells and basophils." B. "An immunological reaction (anaphylactic) requires a patient to be sensitized for anaphylactic shock to occur." C. "A non-immunological reaction (anaphylactoid) causes the same reaction as an anaphylactic reaction, but it's not due to immunoglobulin IgE antibodies." D. "Some common substances that cause a non-immunological reaction (anaphylactoid) are IV contrast dyes and NSAIDS." E. "A patient does not have to be sensitized for a non-immunological reaction (anaphylactoid) to occur and it can happen with first time exposure."

All the answers are correct: A, B, C, D, E

6. Your patient is started on an IV antibiotic to treat a severe infection. During infusion, the patient uses the call light to notify you that she feels a tight sensation in her throat and it's making it hard to breathe. You immediately arrive to the room and assess the patient. While auscultating the lungs you note wheezing. You also notice that the patient is starting to scratch the face and arms, and on closer inspection of the face you note redness and swelling that extends down to the neck and torso. The patient's vital signs are the following: blood pressure 89/62, heart rate 118 bpm, and oxygen saturation 88% on room air. You suspect anaphylactic shock. Select all the appropriate interventions for this patient: A. Slow down the antibiotic infusion B. Call a rapid response C. Place the patient on oxygen D. Prepare for the administration of Epinephrine

B. Call a rapid response C. Place the patient on oxygen D. Prepare for the administration of Epinephrine Option A is wrong because the nurse should STOP the infusion, not slow it down because this could be the reason for the anaphylactic reaction. The nurse would want to call a rapid response, place the patient on oxygen, and prepare for the administration of Epinephrine. This drug is the first-line treatment for anaphylactic shock. It will increase blood pressure, decrease swelling, and dilate the airway.

11. Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Administer Norepinephrine before attempting a fluid resuscitation. B. Collect cultures and then administer IV antibiotics. C. Check blood glucose levels before starting any other treatments. D. Administer Drotrecogin Alpha within 48-72 hours.

B. Collect cultures and then administer IV antibiotics. This is the only correct option. Option A is wrong because fluids are administered first, and if they don't work vasopressors (Norepinephrine) are administered. Option C is wrong because although blood glucose levels should be measured, it does not take precedence over other treatments. Option D is wrong because Drotrecogin alpha should be given within 24-48 hours of septic shock to be the most effective.

14. Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells

B. Crystalloids IV fluid bolus The first treatment in regards to helping maintain tissue perfusion is fluid replacement with either crystalloid or colloid solutions. THEN vasopressors like Norepinephrine are ordered if the fluids don't help.

5. You're providing education to a patient, who has a severe peanut allergy, on how to recognize the signs and symptoms of anaphylactic shock. Select all the signs and symptoms associated with anaphylactic shock: A. Hyperglycemia B. Difficulty speaking C. Feeling dizzy D. Hypertension E. Dyspnea F. Itchy G. Vomiting and Nausea H. Fever I. Slow heart rate

B. Difficulty speaking C. Feeling dizzy E. Dyspnea F. Itchy G. Vomiting and Nausea Patients who are in anaphylactic shock will have signs and symptoms associated with the effects of histamine. Remember histamine affects the respiratory, cardiac, GI, and skin. The patient can have the following: Respiratory: dyspnea and wheezing (bronchoconstriction), swelling of upper airways due to edema "tightness"...can't speak, coughing, stuffy nose, watery eyes Cardiac: tachycardia, hypotension (vasodilation)...loss of consciousness, dizzy GI: vomiting, nausea, pain Skin: vasodilation...red, swollen, itchy, hives

7. A patient in neurogenic shock is ordered intravenous fluids due to severe hypotension. During administration of the fluids, the nurse will monitor the patient closely and immediately report? A. Increase in blood pressure B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) C. Urinary output of 300 mL in the past 5 hours D. Mean arterial pressure (MAP) 85 mmHg

B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) Option B would indicate the patient is in fluid volume overload. Remember that patients in neurogenic shock usually have a normal blood volume. If fluids are ordered to help increase blood pressure, they should be used with extreme caution because fluid overload can occur. An increase in the CVP and PAWP would indicate this. These pressures show the filling pressure in the heart.

9. You're assessing a patient's knowledge on how to use their EpiPen in case of an anaphylactic reaction. You're using an EpiPen trainer device to teach the patient. What demonstrated by the patient shows the patient knows how to administer the medication? Select all that apply: A. The patient injects the medication into the subcutaneous tissue of the abdomen. B. The patient massages the site after injection. C. The patient administers the injection through the clothes. D. The patient aspirates before injecting the medication.

B. The patient massages the site after injection. C. The patient administers the injection through the clothes. EpiPen is an auto-injector that is administered in the middle of outer thigh. It is not given in the abdomen. The patient should massage the site for 10 seconds after administration to increase absorption. It can be administered through clothes, if needed. Aspiration is not required for administration of this medication.

A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock? A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension. B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. C. The patient's parasympathetic nervous system is unopposed by the sympathetic nervous system, which leads to severe hypotension. D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.

B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. The sympathetic nervous system (which is a division of the autonomic nervous system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there's a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.

5. A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: A. Absolute hypovolemia B. Vasodilation C. Increased capillary permeability D. Increased systemic vascular resistance E. Clot formation in microcirculation F. A significantly decreased cardiac output

B. Vasodilation C. Increased capillary permeability E. Clot formation in microcirculation Septic shock occurs due to sepsis. Sepsis is the body's reaction to an infection and will lead to septic shock if this reaction is not treated. This reaction is the activation of the body's inflammatory system, but it's MAJORLY amplified and system-wide. Cardiac output is not the problem in septic shock as with other types of shocks like hypovolemic or cardiogenic. CO is actually high or normal during the early stages of septic shock. It only decreases to the end of septic shock when heart function fails. The issue is with what is going on beyond the heart in the vessels. Substances are released by the microorganism that has invaded the body. This causes the immune system to release substances that will cause system wide vasodilation of the vessels (this will cause a DECREASE in systemic vascular resistance, blood to pool, and this decreases blood flow to the organs/tissues) along with an increase in capillary permeability (this causes fluid to leave the intravascular system and depletes the circulatory system of fluid and further decreases blood flow to the organs/fluids...this is RELATIVE (not absolute) hypovolemia). Furthermore, clots will form in the microcirculation due to plasma activating factor being released. This will cause platelets to aggregate and block blood flow even more to the organs/tissues. All of this will lead to decreased tissue perfusion and deprive cells of oxygen.

4. During anaphylactic shock the mast cells and basophils release large amounts of histamine. What effects does histamine have on the body during anaphylactic shock? Select all that apply: A. Decreases capillary permeability B. Vasodilation of vessels C. Decreases heart rate D. Shifts intravascular fluid to interstitial space E. Constricts the airways F. Stimulates contraction of GI smooth muscles G. Inhibits the production of gastric secretions H. Itching

B. Vasodilation of vessels D. Shifts intravascular fluid to interstitial space E. Constricts the airways F. Stimulates contraction of GI smooth muscles H. Itching Histamine: INCREASES capillary permeability (not decreases) by shifting the intravascular fluid to the interstitial space...this causes swelling and lowers blood pressure, vasodilates vessels...this lower blood pressure and causes red skin, increases heart rate (not decreases), constricts the airway...this causes difficulty breathing and wheezes, stimulates contraction of GI smooth muscles and stimulates (not inhibits) the production of gastric secretions...this leads to vomiting, nausea, and pain, and there is also itching.

7. A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply: A. Urinary output of 60 mL over 4 hours B. Warm and flushed skin C. Tachycardia D. Bradypnea

B. Warm and flushed skin C. Tachycardia In the early or compensated stage of septic shock, the patient is in a hyperdynamic state. This is different from the other types of shock like hypovolemic or cardiogenic (vasoconstriction is occurring in these types of shock). In septic shock, vasodilation is occurring and this leads to WARM and FLUSHED skin in the early stage. However, in the late stage, the skin will be cool and clammy. Tachycardia and TACHYpnea (not bradypnea) occur in the early stage too as a compensatory mechanism. Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail.

2. As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume. A. <30% B. >25% C. >15% D. >10%

C. >15% As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose 15% or more of their blood volume.

4. A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to? A. An increase in cardiac preload B. An increase in stroke volume C. A decrease in cardiac preload D. A decrease in cardiac contractility

C. A decrease in cardiac preload Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once they're filled with blood. The ventricle won't be stretching too much because there isn't enough fluid to fill them. This will decrease stroke volume and in turn, decrease cardiac output.

8. A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? A. Adenosine B. Warfarin C. Atropine D. Norepinephrine

C. Atropine Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn't working the way it should, it can NOT oppose the parasympathetic system....which will take over and lead to bradycardia.

1. Your patient is having a sudden and severe anaphylactic reaction to a medication. You immediately stop the medication and call a rapid response. The patient's blood pressure is 80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is noted along with facial redness and swelling. As the nurse you know that the first initial treatment for this patient's condition is? A. IV Diphenhydramine B. IV Normal Saline Bolus C. IM Epinephrine D. Nebulized Albuterol

C. IM Epinephrine IM or subq Epinephrine is the first-line treatment for anaphylaxis. Epinephrine will cause vasoconstriction (this will increase the blood pressure and decrease swelling) and bronchodilation (this will dilate the airways). This patient's cardiovascular and respiratory system is compromised. Therefore, epinephrine will provide fast relief with anaphylaxis.

7. A patient is in anaphylactic shock. The patient has a severe allergy to peanuts and mistakenly consumed an egg roll containing peanut ingredients during his lunch break. The patient is given Epinephrine intramuscularly. As the nurse, you know this medication will have what effect on the body? A. It will prevent a recurrent attack. B. It will cause vasoconstriction and decrease blood pressure. C. It will help dilate the airways. D. It will help block the effects of histamine in the body.

C. It will help dilate the airways. The answer is C. Epinephrine acts as a vasopressor and will actually dilate the airway. Epinephrine performs vasoconstriction which will INCREASE blood pressure. It does not prevent a recurrent attack (corticosteroids may help with this), and it does not block the effects of histamine (antihistamine helps with this).

6. You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority? A. Keeping the head of the bed greater than 45 degrees at all times. B. Repositioning the patient every thirty minutes. C. Keeping the patient's spine immobilized. D. Avoiding log-rolling the patient during transport.

C. Keeping the patient's spine immobilized. It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient's spine should be immobilized. Example: usage of a cervical collar, log-rolling, usage of a backboard.

8. You're providing care to a patient in anaphylactic shock. What is NOT a typical medical treatment for this condition, and if ordered the nurse should ask for an order clarification? A. IV Diphenhydramine B. Epinephrine C. Corticosteroids D. Isotonic intravenous fluids E. IV Furosemide

E. IV Furosemide Furosemide is a loop diuretic. This medication removes extra fluid from the blood volume. This is NOT used as a treatment in anaphylactic shock. Patients with this condition actually need fluids because of the shift of fluid from the intravascular space to the interstitial space. All the other medications may be ordered for this condition depending on the patient's condition.

1. True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment.

FALSE Hypovolemic shock occurs where there is low fluid volume in the INTRAVASCULAR (not interstitial) system.

True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

FALSE The statement should say: The sympathetic (NOT parasympathetic) nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

1. True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body.

FALSE. This statement is incorrect because there is a DECREASE (not increased) in systemic vascular resistance in septic shock due to vasodilation. In septic shock, vasodilation is system-wide. In addition, septic shock causes increased capillary permeability and thrombi formation in the microcirculation throughout the body. The vasodilation, increased capillary permeability, and clot formation in the microcirculation all leads to a decrease in tissue perfusion. This causes organ and tissue dysfunction, hence septic shock.

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? 1. Administration of digoxin 2. Administration of whole blood 3. Administration of intravenous fluids 4. Administration of packed red blood cells

1. Administration of digoxin The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.

An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used.

1. Assess for airway patency. 2. Initiate an intravenous (IV) line and begin fluid replacement as prescribed. 3. Administer oxygen as prescribed. 4. Obtain vital signs. 5. Elevate the extremities. 6. Keep the client warm. The primary goals for a burn injury are to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen. The type of oxygen delivery system is prescribed by the primary health care provider. Oxygen is necessary to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which is needed for comparison of subsequent vital signs once fluid resuscitation is initiated. The nurse then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated (if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using sterile linens) and is placed on NPO status because of the altered gastrointestinal function that occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the fluid resuscitation can be carefully monitored. Once these actions are taken, the nurse performs a complete assessment, stays with the client, and monitors the client closely. In addition, tetanus toxoid may be prescribed for prophylaxis.

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Refer to chart. 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm

1. Cardiogenic shock Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine output; and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. Hyperventilation 2. Elevated blood pressure 3. Local rash at the burn site 4. Local pain at the burn site

1. Hyperventilation Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription? 1. Gastric lavage 2. Intravenous (IV) fluid therapy 3. Nothing by mouth (NPO) status 4. Preparation for laboratory studies

1. Gastric lavage The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

A client taking calcium carbonate chewable tablets and ranitidine is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1.Gastric pH of 3 2.Absence of abdominal discomfort 3.GI drainage that is guaiac negative 4.Presence of hypoactive bowel sounds

1. Gastric pH of 3 The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.

A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions are a priority? Select all that apply. 1. Stop the infusion. 2. Raise the head of the bed. 3.Administer protamine sulfate. 4.Administer diphenhydramine. 5. Call for the Rapid Response Team (RRT).

1. Stop the infusion. 4.Administer diphenhydramine. 5. Call for the Rapid Response Team (RRT). The client is experiencing an anaphylactic reaction. Therefore, the priority action is to stop the infusion and notify the RRT. The client may be treated with antihistamines. Raising the head of the bed would not be helpful, as that may exacerbate the hypotension. Protamine sulfate is the antidote for heparin, so it is not useful for a client receiving alteplase.

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 1.9600 mL of lactated Ringer's solution 2.4800 mL of 0.9% normal saline solution 3.2400 mL of 0.45% normal saline solution 4.1200 mL of 5% dextrose in water solution

1.9600 mL of lactated Ringer's solution The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication? 1.Acidosis 2.Alkalosis 3.Hypotension 4.Hypertension

1.Acidosis Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for acidosis, and if the acidosis becomes severe, the medication should be discontinued for 1 to 2 days. An elevated blood pressure may be expected in the client with pain. Alkalosis and hypotension are not associated with the use of this medication.

A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? 1.Call the primary health care provider immediately. 2.Document these findings, which are expected. 3.Re-evaluate the neurovascular status in 1 hour. 4.Increase the rate of the intravenous nitroglycerin infusion.

1.Call the primary health care provider immediately. The nursing interventions for the client with an intra-aortic balloon pump are the same as for any client who has had cardiovascular surgery. The peripheral circulation to the affected limb is monitored for signs of occlusion, such as coolness, mottling, pain, tingling, and decreased or absent distal pulse. Adverse changes are reported immediately. The remaining options are incorrect.

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? 1.Cooling the injury with water 2.Removing all clothing immediately 3.Removing the tar from the burn injury 4.Leaving any clothing that is saturated with tar in place

1.Cooling the injury with water Scald burns and tar or asphalt burns are treated by immediate cooling with saline solution or water, if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present. The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 1.Eschar 2.Intact blisters 3.Liquefaction necrosis 4.Cherry-red, firm tissue

3. Liquefaction necrosis Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.

2. Elevate and immobilize the grafted extremity. Autografts placed over joints or on lower extremities are elevated and immobilized after surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1. Superficial 2. Full-thickness 3. Deep partial-thickness 4. Partial-thickness superficial

2. Full-thickness Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.

The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? 1.Monitor vital signs every 4 hours. 2.Monitor mental status every hour. 3.Monitor intake and output every shift. 4.Obtain and record weight every other day.

2. Monitor mental status every hour. During the emergent phase after a burn injury, because of fluid volume deficits secondary to a burn injury, vital signs should be monitored every hour (every 4 hours is too infrequent) until the client is hemodynamically stable. The nurse should monitor the mental status of the client every hour for the first 48 hours. The weight should be obtained and recorded daily or twice daily, and intake and output measurements should be recorded on an hourly basis.

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? 1.White color 2.Pink or red color 3.Weeping blisters 4.Insensitivity to pain and cold

2. Pink or red color Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse minimally suspects which stage of shock based on this data? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2 Shock is categorized by 4 stages. Stage 1 is characterized by restlessness, increased heart rate, cool and pale skin, and agitation. Stage 2 is characterized by a cardiac output that is less than 4 to 6 liters per minute, systolic blood pressure less than 100 mm Hg. Stage 3 is characterized by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4 is characterized as unresponsiveness to vasopressors, profound hypotension, slowed heart rate, and multiple organ failure. Most often, the client will not survive.

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.

22.5% According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.

The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? 1."Flames should be doused with water." 2."The client should be maintained in a standing position." 3."Flames may be extinguished by rolling the client on the ground." 4."Flames may be smothered by the use of a blanket or another cover."

2."The client should be maintained in a standing position." The client should be placed or maintained in a supine position; otherwise, flames may spread to other parts of the body, causing more extensive injury. Flame burns may be extinguished by rolling the client on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water.

An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range? 1.56% (0.56) 2.48% (0.48) 3.37% (0.38) 4.34% (0.34)

2.48% (0.48) The normal hematocrit level for an adult male is 42% to 52% (0.42 to 0.52). The client who is in shock has an elevated level because of hemoconcentration. The client's level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. Thus, 48% (0.48) is the only correct choice; 56% (0.56) is too high, and 34% (0.34) and 37% (0.37) are low.

A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? 1. Biobrane 2.Autograft 3.Xenograft 4.Homograft

2.Autograft A full-thickness burn will require terminal coverage with an autograft-the client's own skin. Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting.

A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the primary health care provider's (PHCP's) office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? 1.Discontinue the medication. 2.Continue with the treatment, as this is expected. 3.Apply a thinner film than prescribed to the burn site. 4.Come to the office to see the PHCP immediately.

2.Continue with the treatment, as this is expected. Topical mafenide acetate is used to treat partial- and full-thickness burns. It is bacteriostatic for both gram-negative and gram-positive organisms present in avascular tissues. The client should be warned that the medication will cause local discomfort and burning. The nurse does not instruct a client to alter a medication prescription (options 1 and 3). It is not necessary that the client see the PHCP at this time.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1.Maintain the client in a prone position. 2.Elevate and immobilize the grafted extremity. 3.Maintain the grafted extremity in a flat position. 4.Keep the grafted extremity covered with a blanket.

2.Elevate and immobilize the grafted extremity. Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1.Disorientation to time only 2.Heart rate of 95 beats/minute 3.+1 palpable peripheral pulses 4.Urine output of 30 mL over the past 2 hours

2.Heart rate of 95 beats/minute When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

3. 36% According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%.

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? 1."Constricted blood vessels have caused a loss of protein in the blood." 2."Leaking blood vessels have led to increased protein amounts in the blood." 3."Leaking blood vessels have led to decreased protein amounts in the blood." 4."Constricted blood vessels have led to increased protein amounts in the blood."

3."Leaking blood vessels have led to decreased protein amounts in the blood." In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused by the volume and oncotic pressure effects of the large fluid resuscitation volumes required.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Lactated Ringer's solution is an isotonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output, and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the PHCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. There is nothing in the situation that calls for blood replacement, which is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Intravenous 5% dextrose solution is isotonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position

3.Immobilization of the affected leg Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. 1. Urine output 50 mL/hr 2. Hypoactive bowel sounds 3. Temperature of 102° F (38.9° C) 4. Heart rate of 96 beats per minute 5. Mean arterial pressure 65 mm Hg 6. Systolic blood pressure 110 mm Hg

3.Temperature of 102° F (38.9° C) 4.Heart rate of 96 beats per minute 5.Mean arterial pressure 65 mm Hg Sepsis diagnostic criteria with regard to signs and symptoms include the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia (core temperature lower than 97° F [36° C]), tachycardia (heart rate above 90 beats per minute), tachypnea (respiratory rate above 22 breaths per minute), systolic blood pressure (SBP) less than or equal to 100 mm Hg, altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel sounds), and decreased capillary refill or mottling of skin.

A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication? 1.Serum sodium of 120 mEq/L (120 mmol/L) 2.Serum potassium of 3.0 mEq/L (3.0 mmol/L) 3.White blood cell count of 3000 mm3 (3 × 109/L) 4.pH of 7.30, PaCO2 of 32 mm Hg (32 mmHg), HCO3- of 19 mEq/L (19 mmol/L)

3.White blood cell count of 3000 mm3 (3 × 109/L) Transient leukopenia typically occurs after 2 to 3 days of treatment. Knowing this and knowing normal white blood cell values will direct you to option 3. Although options 1, 2, and 4 are abnormal findings, they are not associated with this medication.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1.Immediately before swimming 2.5 minutes before exposure to the sun 3.Immediately before exposure to the sun 4.At least 30 minutes before exposure to the sun

4.At least 30 minutes before exposure to the sun Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication should be applied directly to the wound." 4. "The medication is likely to cause stinging every time it is applied."

4. "The medication is likely to cause stinging every time it is applied." Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/minute 3. Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4. 100% oxygen via a tight-fitting, nonrebreather face mask If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury.

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? 1. Pallor of all extremities 2. Pulse oximetry reading of 93% 3. Peripheral pulses are diminished 4. High pressure alarm keeps sounding on the ventilator

4. High pressure alarm keeps sounding on the ventilator A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1.The entire period of time during which rehabilitation occurs 2.The period from the time the client is stable to the time when all burns are covered with skin 3.The period from the time the burn was incurred to the time when the client is admitted to the hospital 4.The period from the time the burn was incurred to the time when the client is considered physiologically stable

4. The period from the time the burn was incurred to the time when the client is considered physiologically stable The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? 1. Glucose level of 99 mg/dL (5.65 mmol/L) 2. Platelet level of 300,000 mm3 (300 × 109/L) 3. Magnesium level of 1.5 mEq/L (0.75 mmol/L) 4. White blood cell count of 3000 mm3 (3.0 × 109/L)

4. White blood cell count of 3000 mm3 (3.0 × 109/L) Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the primary health care provider is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication and are also within normal limits.

Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication? 1."I will apply the ointment at bedtime and in the morning." 2."I will apply the ointment once a day and leave it open to the air." 3."I will apply the ointment twice a day and leave it open to the air." 4."I will apply the ointment once a day and cover it with a sterile dressing."

4."I will apply the ointment once a day and cover it with a sterile dressing." Collagenase is used to promote debridement of dermal lesions and severe burns. It is applied once daily and covered with a sterile dressing. The remaining options are incorrect.

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1.CO 5 L/min, PCWP low 2.CO 3 L/min, PCWP low 3.CO 4 L/min, PCWP high 4.CO 3 L/min, PCWP high

4.CO 3 L/min, PCWP high The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure.

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? 1.Heparin overdose 2.Vitamin K deficiency 3.Factor VIII deficiency 4.Disseminated intravascular coagulopathy (DIC)

4.Disseminated intravascular coagulopathy (DIC) TSS is caused by infection and often is associated with tampon use. The client's clinical signs in this question are compatible with DIC, which is a complication of TSS. The nurse assesses the client at risk and notifies the primary health care provider promptly when signs and symptoms of DIC are noted. Although signs of bleeding may be seen with each of the conditions listed in the incorrect options, the initial diagnosis of TSS makes DIC the logical correct option.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1.Urine pH of 6 2.Urine that is pale yellow 3.Urine output of 40 mL/hr 4.Urine specific gravity of 1.032

4.Urine specific gravity of 1.032 The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.

54% According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

13. A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication? A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is used when fluid replacement is not unsuccessful." D. "It is considered a vasopressor."

B. "This medication causes vasodilation and decreases systemic vascular resistance." This statement is FALSE because this medication causes vasoconstriction (not vasodilation) which INCREASES systemic vascular resistance.

3. If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss this patient has experienced? A. 25% B. 40% C. 30% D. 10%

B. 40% This patient has lost 40% of blood volume. Based on this amount of fluid loss, this patient would be in class III (stage 3 of hypovolemic shock). Class III occurs when volume loss is 30-40% or 1,500-2,000 mL in an adult.

You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply: A. A 36-year-old with a spinal cord injury at L4. B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. D. A 55-year-old patient is reporting seeing green halos while taking Digoxin.

B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. Any patient who has had a cervical or upper thoracic (above T6) spinal cord injury, receiving spinal anesthesia, or taking drugs that affect the autonomic or sympathetic nervous system is at risk for developing neurogenic shock.

9. Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working? A. Decreased CVP (central venous pressure) B. Mean arterial pressure (MAP) 90 mmHg C. Serum lactate 6 mmol/L D. Blood pH 7.20

B. Mean arterial pressure (MAP) 90 mmHg A MAP of 85-90 mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction. Options A, C, and D would indicate tissue perfusion is decreased.

12. What is the BEST position for a patient in anaphylactic shock? A. Lateral recumbent B. Supine with legs elevated C. High Fowler's D. Semi-Fowler's

B. Supine with legs elevated This position will increase venous return to the heart, which will help increase cardiac output and blood pressure.

2. A patient is diagnosed with septic shock. As the nurse you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock. A. obstructive; hypovolemic and anaphylactic B. distributive; anaphylactic and neurogenic C. obstructive; cardiogenic and neurogenic D. distributive; anaphylactic and cardiogenic

B. distributive; anaphylactic and neurogenic Septic shock is a form of distributive shock. This means there is an issue with the distribution of blood flow in the small blood vessels of the body. This results in a diminished supply of blood to the body's tissues and organs. Anaphylactic and neurogenic shock are also a type of distributive forms of shock. Septic shock isn't occurring due to an issue with cardiac output, which occurs in hypovolemic and cardiogenic shock.

11. A patient is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should take? A. Administer Epinephrine B. Call a Rapid Reponse C. Stop the medication D. Administer a breathing treatment

C. Stop the medication The FIRST step the nurse should take is to immediately remove the allergen. This would be stopping the medication, and then call a rapid response. The nurse should maintain the airway and start CPR (if needed) until help arrives.

10. A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? A. IV corticosteroids B. Colloids C. Dobutamine D. Norepinephrine

D. Norepinephrine Fluids are ordered FIRST in septic shock. If this is unsuccessful, then vasopressors are ordered NEXT. Norepinephrine is used as a first-line agent. Dobutamine may sometimes be used, but for its inotropic effects on the heart.

12. A patient in septic shock is experiencing hyperglycemia. The patient is started on an insulin drip. A blood glucose goal for this patient would be: A. <110 mg/dL B. <80 mg/dL C. >200 mg/dL D. <180 mg/dL

D. <180 mg/dL If a patient is experiencing hyperglycemia an insulin drip may be ordered to control glucose levels. Hyperglycemia affects the immune system and healing. A blood glucose goal in this patient is <180 mg/dL.

6. A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? A. Fungus B. Virus C. Parasite D. Bacteria

D. Bacteria Gram-positive or gram-negative bacteria are the MOST common cause of sepsis.