ARDS, burns, emergency nursing
The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black? 1. The client with a sucking chest wound who is alert. 2. The client with a head injury who is unresponsive. 3. The client with an abdominal wound and stable vital signs. 4. The client with a sprained ankle which may be fractured.
2. This client has a very poor prognosis, and even with treatment, survival is unlikely.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.
1. Although this is a potential problem, it is priority because the body's protective barrier, the skin, has been compromised and there is an impaired immune response.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change central lines once a week. 5. Administer antibiotics as prescribed.
1,2,3,5 1. Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn. 2. Aseptic techniques minimize risk of cross-contamination and spread of bacteria. 3. Aseptic techniques minimize risk of cross- contamination and spread of bacteria. 5. Antibiotics reduce bacteria.
The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP)? Select all that apply. 1. A plan for practice drills. 2. A deactivation response. 3. A plan for internal communication only. 4. A preincident response. 5. A security plan.
1,2,5 1. Practice drills allow for troubleshoot-ing any issues before a real-life incident occurs. 2. A deactivation response is important so resources are not overused, and the facility can then get back to daily activities and routine care. 5. A coordinated security plan involving facility and community agencies is the key to controlling an otherwise chaotic situation.
The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position.
1,3,4,5 1. Altered level of consciousness is the earliest sign of hypoxemia. 3. The client is at risk for complications of immobility; therefore, the nurse should turn the client at least every two (2) hours to prevent pressure ulcers. 4. The client is at risk for fluid volume overload, so the nurse should monitor and maintain the fluid intake. 5. Fowler's position facilitates lung expansion and reduces the workload of breathing.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.
1. After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes.
Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)? 1. Caring for a two (2)-year-old child who died from severe physical abuse. 2. Performing CPR on a middle-aged male executive who died. 3. Responding to a 22-victim bus accident with no apparent fatalities. 4. Being required to work 16 hours without taking a break.
1. CISM is an approach to preventing and treating the emotional trauma affecting emergency responders as a consequence of their job. Performing CPR and treat- ing a young child affects the emergency personnel psychologically, and the death increases the traumatic experience.
Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts?1. Gastric distention can occur as a result of ventilation. 2. It is needed to assist when intubating the client. 3. This equipment will ensure a patent airway. 4. It keeps the vomitus away from the health-care provider.
1. Gastric distention occurs from overventilating clients. When compressions are per- formed, the pressure will cause vomiting, which may cause aspiration into the lungs.
Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one (1) month to recuperate.
1. Not smoking is vital to prevent further lung damage.
Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)? 1. The custodian spilled a chemical solvent in the hallway. 2. A visitor slipped and fell on the floor that had just been mopped. 3. A bottle of antineoplastic agent broke on the client's floor. 4. The nurse was stuck with a contaminated needle in the client's room.
1. The MSDS provides chemical information regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical found in the hospital.
Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital? 1. The hospital chaplain. 2. The social worker. 3. The respiratory therapist. 4. The director of nurses.
1. The chaplain should be called to help address the client's family or significant others. A small community hospital does not have a 24-hour on-duty pastoral service. A chaplain is part of the code team in large medical center hospitals.
The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.
1. The classic sign of ARDS is decreased arterial oxygen level (Pao2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.
1. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client's recovery.
The unlicensed assistive personnel (UAP)is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.
1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the nurse should demonstrate the proper way to bathe a client in the bed.
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.
1. These arterial blood gases are within normal limits, and, therefore, the nurse should not take any action except to continue to monitor the client.
The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED? 1. It analyzes the rhythm and shocks the client in ventricular fibrillation. 2. The client will be able to have synchronized cardioversion with the AED. 3. It will keep the health-care provider informed of the client's oxygen level. 4. The AED will perform cardiac compressions on the client.
1. This is the correct statement explaining what an AED does when used in a code.
The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father? 1. Talk to the father in a calm and low voice. 2. Tell the father to wait in the waiting room. 3. Notify the child's mother to come to the ED. 4. Call the police department to come and arrest him.
1. This will help diffuse the escalating situation and attempt to keep the father calm.
The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.
1. When peak airway pressure is increased, the nurse should implement the intervention least invasive for the client. This alarm goes off with a plugged airway, "bucking" in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.
Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant. 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug.
2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.
Which equipment must be immediately brought to the client's bedside when a code is called for a client who has experienced a cardiac arrest? 1. A ventilator. 2. A crash cart. 3. A gurney. 4. Portable oxygen.
2. The crash cart is the mobile unit with the defibrillator and all the medications and supplies needed to conduct a code.
The triage nurse is working in the emergency department. Which client should be assessed first? 1. The 10-year-old child whose dad thinks the child's leg is broken. 2. The 45-year-old male who is diaphoretic and clutching his chest. 3. The 58-year-old female complaining of a headache and seeing spots. 4. The 25-year-old male who cut his hand with a hunting knife.
2. The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life threatening.
The client is scheduled to have a xenograft toa left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."
2. A xenograft or heterograft consists of skin taken from animals, usually porcine.
The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.
2. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.
2. Daily cleaning reduces bacterial colonization.
The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.
2. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema.
During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement? 1. Have security escort the reporter off the premises. 2. Direct the reporter to the disaster command post. 3. Tell the reporter this is a violation of HIPAA. 4. Request the reporter to stay out of the way.
2. Emergency operations plans will have a designated disaster plan coordinator. All public information should be routed through this person.
The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client's lung sounds.
2. If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation (Ambu) bag until the problem is resolved.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.
3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation.
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.
3. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.
Which federal agency is a resource for the nurse volunteering at the American Red Cross who is on a committee to prepare the community for any type of disaster? 1. The Joint Commission (JC). 2. Office of Emergency Management (OEM). 3. Department of Health and Human Services (DHHS). 4. Metro Medical Response Systems (MMRS).
3. Federal resources include organizations such as DHHS and the Department of Justice. Each of these federal departments oversees hundreds of agencies, including the American Red Cross, which respond to disasters.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, Pao2 98, Paco2 38, and HCO3 20. 4. The client is able to perform active range-of- motion exercises.
3. Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.2.
3. The client needs to know that it will take time to adjust to life after burns and that returning to work, family role, sexual intimacy, and body image will take time.
The triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse? 1. The nurse documents the tag number in the disaster log. 2. The unlicensed assistive personnel documents vital signs on the tag. 3. The health-care provider removes the tag to examine the limb. 4. The LPN securely attaches the tag to the client's foot.
3. The tag should never be removed from the client until the disaster is over or the client is admitted and the tag becomes a part of the client's record. The HCP needs to be informed immediately of the action.
The client who smokes two (2) packs of cigarettes a day develops ARDS after a near- drowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."
3. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble breathing.
The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? 1. Check the client for breathing. 2. Assess the carotid artery for a pulse. 3. Shake the client and shout. 4. Notify the rapid response team.
3. This is the first intervention the nurse should implement after finding the client unresponsive on the floor.
Which intervention is most important for the nurse to implement when participating in a code? 1. Elevate the arm after administering medication. 2. Maintain sterile technique throughout the code. 3. Treat the client's signs/symptoms; do not treat the monitor. 4. Provide accurate documentation of what happened during the code.
3. This is the most important intervention. The nurse should always treat the client based on the nurse's assessment and data from the monitors; an intervention should not be based on data from the monitors without the nurse's assessment.
The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? 1. Cardiac death occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time the HCP officially declares the client dead. 3. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms. 4. The death is caused by myocardial ischemia resulting from coronary artery disease.
3. Unexpected death occurring within one (1) hour of the onset of cardiovascular symptoms is the definition of sudden cardiac death.
The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? 1. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. The 60-year-old client exhibiting asymptomatic sinus bradycardia. 3. The 53-year-old client exhibiting ventricular fibrillation. 4. The 65-year-old client exhibiting supraventricular tachycardia.
3. Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death; ventricular fibrillation is responsible for 65% to 85% of sudden cardiac deaths.
A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room? 1. Attempt to talk to the person who has the gun. 2. Explain to the person the police are coming. 3. Stand between the client and the man with the gun. 4. Get out of the line of fire and protect self.
4. Self-protection is priority; the nurse is not required to be injured in the line of duty.
The nurse is caring for a client with deep partial- thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4oF, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in 2 hours.
4. Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention.
Which statement best describes the role of the medical-surgical nurse during a disaster? 1. The nurse may be assigned to ride in the ambulance. 2. The nurse may be assigned as a first assistant in the operating room. 3. The nurse may be assigned to crowd control. 4. The nurse may be assigned to the emergency department.
4. New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and may be required to work in unfamiliar settings.
Which intervention is the most important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation? 1. Perform the jaw thrust maneuver to open the airway. 2. Use the mouth to cover the client's mouth and nose. 3. Insert an oral airway prior to performing mouth to mouth. 4. Use a pocket mouth shield to cover the client's mouth.
4. Nurses should protect themselves against possible communicable disease, such as HIV and hepatitis, and should be protected if the client vomits during CPR.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.
4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi.
The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? 1. A person is ventilating with an Ambu bag. 2. A person is performing chest compressions correctly. 3. A person is administering medications as ordered. 4. A person is keeping an accurate record of the code.
4. The chart is a legal document, and the code must be documented in the chart and provide information needed in the intensive care unit.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Ensure adequate peripheral circulation to both feet.
4. The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes.
According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)? 1. Injuries are extensive and chances of survival are unlikely. 2. Injuries are minor and treatment can be delayed hours to days. 3. Injuries are significant but can wait hours without threat to life or limb. 4. Injuries are life threatening but survivable with minimal interventions.
4. This is called the Immediate Category. Individuals in this group can progress rapidly to Expectant if treatment is delayed.
The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse? 1. The UAP has hand placement on the lower half of the sternum. 2. The UAP performs cardiac compressions and allows for rescue breathing. 3. The UAP depresses the sternum 0.5 to one (1) inch during compressions. 4. The UAP asks to be relieved from performing compressions because of exhaustion.
The sternum should be depressed one and one-half (1.5) to two (2) inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP.