CC study 3

Which condition indicates an overdose of lactulose? Watery diarrhea Constipation Hypoactive bowel sounds Fecal impaction

Watery diarrhea Explanation: The client receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Do nothing until the chemical agent is identified. Irrigate the wounds with water. Wash the wounds with soap and water and apply a barrier cream. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

Irrigate the wounds with water.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Have the client avoid physical exertion Emphasize complete bed rest Look for signs of increased intracranial pressure Look for a halo sign

Look for signs of increased intracranial pressure

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter

Monitoring the patency of an indwelling urinary catheter

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? Impaired urinary elimination Toileting self-care deficit Risk for infection Activity intolerance

Risk for infection

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough? Administer oxygen as prescribed. Use mechanical ventilation. Let the airway stay as it currently is. Suction the airway.

Suction the airway.

An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse? "The risk of peritonitis is greater with this type of dialysis." "This type of dialysis will provide more independence." "Peritoneal dialysis will require more work for you." "Peritoneal dialysis does not work well for every client."

"This type of dialysis will provide more independence."

A patient has acute kidney injury (AKI) with a negative nitrogen balance. How much weight does the nurse expect the patient to lose? 0.5 kg/day 1.0 kg/day 1.5 kg/day 2.0 kg/day

0.5 kg/day

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? Superficial Full-thickness Superficial partial-thickness Deep partial-thickness

Superficial

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? "An allograft is a temporary wound covering obtained from cadaver skin." "An allograft is a permanent wound covering taken from a donor site in your body." "An allograft is a temporary wound covering obtained from pig skin." "An allograft is an expensive sheet of skin obtained from a culture."

"An allograft is a temporary wound covering obtained from cadaver skin."

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." "I can work with the social worker to find funding assistance programs to help with my medical expenses."

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? "Monitor urine output every hour." "Infuse I.V. fluids at 83 ml/hour." "Administer oxygen by nasal cannula at 3 L/minute." "Draw samples for hemoglobin and hematocrit every 6 hours."

"Infuse I.V. fluids at 83 ml/hour." Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

A client is believed to be in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse? "You don't want to remember your family member this way." "We have specific visiting hours that must be adhered to." "The health care team has done all that it can, so we will clear the room so you can be with your loved one." "The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them."

"The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them."

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area?

1 In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the client's palm, including the surface area of the digits, is approximately 1% of the total body surface area.

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? Two large-bore IVs and begin crystalloid fluids 100% oxygen via a nonrebreather mask C-spine x-rays Type and cross match

100% oxygen via a nonrebreather mask

A client with chronic kidney disease weighs 209 lbs (95 kg) and is prescribed 1.2 grams of protein per kg per day. Which amount of protein will the client ingest per day?

114

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 1,200 mL 2,400 mL 3,600 mL 4,800 mL

2,400 mL Explanation: The ABA consensus formula provides for the volume of an isotonic solution (e.g., lactated Ringer's [LR]) to be administered during the first 24 hours in a range of 2 mL/kg/percentage TBSA. Half of the calculated total should be given over the first 8 postburn hours, and the other half should be given over the next 16 hours. Thus, the equation to find the minimum amount to infuse for this scenario is as follows: 2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours, with half this amount, 2,400 mL, to be administered in the first 8 hours.

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? Within normal limits Thready 24 Palpable

24

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 9% 18% 27% 36%

27% According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 18% 27% 30% 36%

36% The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? Blood products 5% albumin 6% dextran 6% hetastarch

5% albumin

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? 40% 50% 60% 70%

70%

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A full liquid diet Isotonic enteral nutrition every 6 hours An infusion of crystalloids at an increased rate of flow A continuous infusion of total parenteral nutrition

A continuous infusion of total parenteral nutrition

A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces. Generally caused by decreased blood volume. Due to severe hypersensitivity reaction resulting in massive systemic vasodilation.

A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? A rapid, bounding pulse A slow but steady pulse A weak and thready pulse A slow and imperceptible pulse

A rapid, bounding pulse

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A urine output consistently above 40 ml/hour A weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias

A urine output consistently above 40 ml/hour In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

Which type of burn is similar to a sunburn? Superficial partial-thickness Electrical Deep partial-thickness Full-thickness

Superficial partial-thickness

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? Administer recombinant human activated protein C (rhAPC) as prescribed. Begin a continuous IV infusion of insulin per protocol. Initiate enteral feedings as prescribed. Administer norepinephrine as prescribed.

Administer norepinephrine as prescribed.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next Administers oxygen by nasal cannula at 2 liters per minute Re-assesses the vital signs Contacts the admitting physician Calls the Rapid Response Team

Administers oxygen by nasal cannula at 2 liters per minute The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Hormone antagonist drugs Antimetabolite drugs Adrenergic drugs Anticholinergic drugs

Adrenergic drugs

Which colloid is expensive but rapidly expands plasma volume? Albumin Dextran Lactated Ringer solution Hypertonic saline

Albumin

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation? A bloodstain surrounded by a yellowish stain on the head dressing An area of bruising over the mastoid bone Escape of cerebrospinal fluid from the client's ear Escape of cerebrospinal fluid from the client's nose

An area of bruising over the mastoid bone

The nurse is able to identify which condition as uremia? An excess of urea in the blood An excess of protein in the blood An excess of blood in the urine An excess of protein in the urine

An excess of urea in the blood

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? An epidural hematoma An extradural hematoma An intracerebral hematoma A subdural hematoma

An intracerebral hematoma

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is A young female adolescent who developed shock from tampon use during menses An older adult man with end-stage renal disease and an infected dialysis access site An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection A middle-aged woman with metastatic breast cancer and a BMI of 26

An older adult man with end-stage renal disease and an infected dialysis access site

Which type of shock occurs from an antigen-antibody response? Septic Anaphylactic Neurogenic Cardiogenic

Anaphylactic

The nurse is caring for a client with a traumatic brain injury. Which assessment findings indicate to the nurse that the client is developing Cushing's reflex? Select all that apply. Apical pulse is 42 beats per minute Blood pressure is 140/38 mmHg Urine output over 100 mL/hr Systolic blood pressure is 180 mm/Hg Weakness on one side of the body

Apical pulse is 42 beats per minute Blood pressure is 140/38 mmHg Systolic blood pressure is 180 mm/Hg

Which of the following measures can be used to cool a burn? Application of cool water Application of ice directly to burn Wrapping the person in ice Using cold soaks or dressings for at least 1 hour

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. Assess the client who is at risk for shock. Administer vasoconstrictive medications to clients at risk for shock. Administer prophylactic packed red blood cells to clients at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.

Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as? Constructional apraxia Fetor hepaticus Ataxia Asterixis

Asterixis Explanation: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Autonomic dysreflexia Thrombophlebitis Orthostatic hypotension Spinal shock

Autonomic dysreflexia

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Tetraplegia Areflexia Autonomic dysreflexia Paraplegia

Autonomic dysreflexia

When a client is in the compensatory stage of shock, which symptom occurs? Bradycardia Urine output of 45 cc/hour Tachycardia Respiratory acidosis

Tachycardia

When a client is in the compensatory stage of shock, which symptom occurs? Bradycardia Urine output of 45 mL/hr Tachycardia Respiratory acidosis

Tachycardia

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? BUN: 28 mg/dL K+: 5.0 mEq/L Na+: 145 mEq/L Ca: 9 mg/dL

BUN: 28 mg/dL The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? Occipital skull fracture Temporal skull fracture Frontal skull fracture Basilar skull fracture

Basilar skull fracture

The nurse is concerned that a client with a traumatic brain injury is developing an endocrine disorder. Which assessment will the nurse complete for this client? Select all that apply. Hemoglobin Blood glucose Urine acetone Intake and output Serum electrolytes

Blood glucose Urine acetone Intake and output Serum electrolytes

A nurse is caring for a client on bedrest with end-stage kidney disease. What major manifestation of uremia should the nurse expect to decrease with an exercise plan? A decreased serum phosphorus level Hyperparathyroidism Bone demineralization Increased secretion of parathormone

Bone demineralization

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Liver Kidneys Lungs Brain

Brain

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? Hypophysectomy Application of Halo traction Burr holes Insertion of Crutchfield tongs

Burr holes

Which complication is common for victims of electrical burns? Inhalation injury Infection Cardiac dysrhythmia Hypovolemic shock

Cardiac dysrhythmia Explanation: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

A client requires hemodialysis. Which type of drug should be withheld before this procedure? Phosphate binders Insulin Antibiotics Cardiac glycosides

Cardiac glycosides

The nurse is caring for a 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop? Cardiogenic shock Neurogenic shock Septic shock Anaphylactic shock

Cardiogenic shock

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? Change in level of consciousness (LOC) Seizures Restlessness Pupil changes

Change in level of consciousness (LOC)

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? Weight loss of 2 pounds in 3 days Change in the client's handwriting and/or cognitive performance Anorexia for more than 3 days Constipation for more than 2 days

Change in the client's handwriting and/or cognitive performance

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock? Circulatory (distributive) Cardiogenic Hypovolemic Obstructive

Circulatory (distributive)

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Obstructive Hypovolemic Carcinogenic Circulatory (distributive)

Circulatory (distributive)

The nurse is visiting the home of a client who is receiving at-home peritoneal dialysis therapy. Which finding indicates to the nurse that the client is developing peritonitis? Low back pain Bloody effluent Cloudy dialysate effluent Report of pronounced hunger

Cloudy dialysate effluent

Which zone consists of the area where the injury is most severe and deepest? Coagulation Stasis Hyperemia Necrosis

Coagulation Explanation: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.

The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by: Cold, clammy skin and tachycardia. A systolic blood pressure of 75 mm Hg. A heart rate of 140. Crackles and shallow breathing.

Cold, clammy skin and tachycardia.

A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as Cardiogenic Compensatory Progressive Circulatory

Compensatory

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? Initial stage Compensatory stage Progressive stage Irreversible stage

Compensatory stage In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: Constrict blood vessels in the cardiorespiratory system. Decrease heart rate. Relax the bronchioles. Vasodilate the skeletal muscles.

Constrict blood vessels in the cardiorespiratory system.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? Elevate the leg on pillows and reassess the leg in 1 hour. Document the findings and instruct the client to report numbness of the extremity. Contact the primary care provider and prepare for an escharotomy. Apply an elastic stocking to the extremity and administer SQ heparin per order.

Contact the primary care provider and prepare for an escharotomy.

At what point in shock does metabolic acidosis occur? Late Irreversible Early Decompensation (Progressive)

Decompensation (Progressive)

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? Decerebrate Normal Flaccid Decorticate

Decerebrate

A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. Which is the best nursing rationale for this complication? Decrease in the blood flow through the kidneys Obstruction of urine flow from the kidneys Blood clot formed in the kidneys interfered with the flow Structural damage occurred in the nephrons of the kidneys

Decrease in the blood flow through the kidneys

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? Superficial partial thickness Deep partial-thickness Full-thickness Fourth degree

Deep partial-thickness

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? Obstructive Hypovolemic Carcinogenic Distributive

Distributive

The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock? Hypervolemic Distributive Restrictive Cardiotonic

Distributive

Compliance to a renal diet is a difficult lifestyle change for a patient on hemodialysis. The nurse should reinforce nutritional information. Which of the following teaching points should be included? Select all that apply. Limit protein to 1.6 g/kg/day. Eat foods such as milk, fish, and eggs. Restrict sodium to 2,000 to 3,000 mg daily. Increase potassium to prevent cardiac problems. Restrict fluid to daily urinary output plus 500 to 800 mL.

Eat foods such as milk, fish, and eggs. Restrict sodium to 2,000 to 3,000 mg daily. Restrict fluid to daily urinary output plus 500 to 800 mL.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to Encourage the family to touch and talk to the client. Inform the family that everything is being done to assist with the client's survival. Open up discussion among the family members about nursing home placement. Contact a spiritual advisor to provide comfort to the family.

Encourage the family to touch and talk to the client.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue.

Epidermis and a portion of deeper dermis. A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? Epinephrine Benadryl Proventil Prednisone

Epinephrine

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client Prevent infection Fluid resuscitation Endotracheal tube placement Strict intake and output

Fluid resuscitation

A nurse is assessing a client with acute renal failure. What medications should the nurse identify as a nephrotoxic drug? Select all that apply. Penicillin Gentamycin Tobramycin Neomycin Ceftriaxone

Gentamycin Tobramycin Neomycin

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: Coma Absence of brain stem reflexes Apnea Glasgow Coma Scale of 6

Glasgow Coma Scale of 6

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. Remove his burned pants so that the air can help cool the wound. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client? Hemodialysis Peritoneal dialysis Continuous arteriovenous hemofiltration (CAVH) Continuous venovenous hemofiltration (CVVH)

Hemodialysis The client is hemodynamically stable and hemodialysis would be most appropriate. Hemodialysis is used for clients who are acutely ill and require short-term dialysis for days to weeks until kidney function resumes and for clients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) who require long-term or permanent renal replacement therapy. Peritoneal dialysis (PD) may be the treatment of choice for clients with renal failure who are unable or unwilling to undergo hemodialysis or kidney transplantation. CAVH and CVVH are used for client who are hemodynamically unstable.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? Hepatic encephalopathy Portal hypertension Asterixis Cirrhosis

Hepatic encephalopathy

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? Hepatic encephalopathy Esophageal varices Hepatitis C Portal hypertension

Hepatic encephalopathy The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst Moderate to severe pain Urine output of 70 ml the first hour Hoarseness of the voice

Hoarseness of the voice

The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take? Administer the medications as ordered. Hold the medications until after dialysis. Check with the dialysis nurse about the medications. Ask if the client wants to take the medications.

Hold the medications until after dialysis.

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? Autografts Heterografts Homografts Xenografts

Homografts

A client with chronic kidney disease becomes confused and reports abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which lab value? Elevated urea levels Hyperkalemia Hypocalcemia Elevated white blood cells

Hyperkalemia

Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. Hyperkalemia Metabolic alkalosis Anemia Hyperalbuminemia Hypocalcemia

Hyperkalemia Anemia Hypocalcemia

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hyperkalemia. Hypernatremia. Hypocalcemia. Hypoglycemia.

Hyperkalemia. Explanation: Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

Which of the following types of shock will a nurse observe in a client with extensive burns? Anaphylactic shock Neurogenic shock Septic shock Hypovolemic shock

Hypovolemic shock

The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for? Abdominal distention owing to reflex cessation of intestinal peristalsis Hypovolemic shock caused by hemorrhage Paralytic ileus caused by manipulation of the colon during surgery Pneumonia caused by shallow breathing because of severe incisional pain

Hypovolemic shock caused by hemorrhage

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. Hypovolemic shock; blood loss Obstructive shock; kidney stone Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection Neurogenic shock; diabetes

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? Classification by the appearance of blisters Identification by the destruction of the dermis and epidermis Not associated with edema formation Usually very painful because of exposed nerve endings

Identification by the destruction of the dermis and epidermis

A child tips a pot of boiling water onto his bare legs. The mother should: Avoid touching the burned skin and take the child to the nearest emergency department. Cover the child's legs with ice cubes secured with a towel. Immerse the child's legs in cool water. Liberally apply butter or shortening to the burned areas.

Immerse the child's legs in cool water.

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? Shock begins in the decompensation stage. In the compensation stage, catecholamines are released. Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage. The renin-angiotensin-aldosterone system fails in the compensation stage.

In the compensation stage, catecholamines are released.

A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia? Increase fat intake and limit carbohydrates. Eliminate fat intake and increase protein intake. Increase carbohydrates and limit protein intake. Increase protein, carbohydrates, and fat intake.

Increase carbohydrates and limit protein intake.

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? Slow the heart rate Increase the force of myocardial contraction Depress the central nervous system Dilate the bronchial tree

Increase the force of myocardial contraction

What is a characteristic of the intrarenal category of acute kidney injury (AKI)? Decreased creatinine Increased BUN High specific gravity Decreased urine sodium

Increased BUN

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Ineffective cerebral tissue perfusion related to increased intracranial pressure Disturbed thought processes related to brain injury Ineffective airway clearance related to brain injury

Ineffective airway clearance related to brain injury

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Pericardiocentesis Thoracotomy with chest tube insertion Administration of oxygen via venture mask Intubation and mechanical ventilation

Intubation and mechanical ventilation

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? Precompensatory Compensatory Progressive Irreversible

Irreversible

The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. It causes respiratory distress syndrome. It begins when peripheral blood flow is inadequate. It is a component of any trauma.

It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? It results from inadequate delivery of nutrients and oxygen to the cells. It results from initial damage to the brain from the traumatic event. It refers to the permanent deficits seen after the rehabilitation process. It refers to the difficulties suffered by the client and family related to the changes in the client.

It results from initial damage to the brain from the traumatic event.

The nurse helps a client to correctly perform peritoneal dialysis at home. The nurse must educate the client about the procedure. Which educational information should the nurse provide to the client? Wear a mask while handling any dialysate solutions Keep the catheter stabilized to the abdomen, below the belt line Keep the dialysis supplies in a clean area, away from children and pets Clean the catheter insertion site daily with soap

Keep the dialysis supplies in a clean area, away from children and pets

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? 0.9% sodium chloride Lactated Ringer's Albumin Dextran

Lactated Ringer's

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? Albumin Dextrose 5% in water (D5W) Lactated Ringer's solution Normal saline solution with 20 mEq of potassium per 1,000 ml

Lactated Ringer's solution Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? Spironolactone Cholestyramine Lactulose Kanamycin

Lactulose

A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first Maintains the head of the bed at 30 degrees Lays the client flat with the feet elevated Administers a bolus of intravenous (IV) fluids Assesses the client's blood glucose level

Lays the client flat with the feet elevated

The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output? 1.5 L 1.0 L Less than 400 mL Less than 50 mL

Less than 400 mL

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? Encouraging coughing and deep breathing Promoting carbohydrate intake Limiting fluid intake Providing pain-relief measures

Limiting fluid intake

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Lung sounds Skin perfusion Bowel sounds Mental status

Lung sounds

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which organ? Brain Lungs Liver Kidneys

Lungs

The most important nursing priority of treatment for a patient with an altered LOC is to: Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. Maintain a clear airway to ensure adequate ventilation. Position the patient to prevent injury and ensure dignity.

Maintain a clear airway to ensure adequate ventilation.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? Limit interaction with visitors. Avoid heavy meals. Maintain activity restriction to bedrest. Arrange personal care supplies nearby.

Maintain activity restriction to bedrest.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? Position the client in the supine position Maintain cerebral perfusion pressure from 50 to 70 mm Hg Restrain the client, as indicated Administer enemas, as needed

Maintain cerebral perfusion pressure from 50 to 70 mm Hg Explanation: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? Controlling bleeding Maintaining the airway Maintaining fluid volume Relieving the client's anxiety

Maintaining the airway

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? Central venous pressure of 6 mm Hg Mean arterial pressure of 70 mm Hg Urine output of 0.2 mL/kg/hr ScvO2 of 60%

Mean arterial pressure of 70 mm Hg

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? Modified Trendelenburg Trendelenburg Semi-Fowler's Supine

Modified Trendelenburg

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Symptoms will evolve over a period of 1 week. Monitoring is needed as rapid neurologic deterioration may occur. The crash cart with defibrillator is kept nearby. Bleeding continues into the intracerebral area.

Monitoring is needed as rapid neurologic deterioration may occur.

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? Septic Anaphylactic Neurogenic Cardiogenic

Neurogenic The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? Nitroprusside Dopamine Epinephrine Methoxamine

Nitroprusside

A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase? Diuresis Oliguria Acute tubular necrosis Restored glomerular function

Oliguria

The nurse cares for a client with acute kidney injury (AKI). The client is experiencing an increase in the serum concentration of urea and creatinine. The nurse determines the client is experiencing which phase of AKI? Initiation Oliguria Diuresis Recovery

Oliguria Explanation: The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The initiation periods begins with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? Liver dysfunction Organ damage Weight loss Unsteady gait

Organ damage

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Oxygen at 2 L/min by nasal cannula Morphine 2 mg intravenously NS at 60 mL/hr via an intravenous line Dopamine (Intropin) intravenous solution

Oxygen at 2 L/min by nasal cannula

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? Pad the side rails on the bed Apply soft wrist restraints Raise all four side rails on the bed Prevent visitors, so as not to agitate the client

Pad the side rails on the bed Explanation: Padding the side rails can reduce injury if the client becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint, and this would not be an initial measure to implement. Family and friends generally assist in calming a client.

A client is admitted to the health care center with hyperglycemia, a 15-pound weight loss, and reports of vague upper and midabdominal pain that increases in intensity at night. The client' health history indicates alcoholism, smoking of a pack of cigarettes daily, and diabetes for the past 20 years. Upon examination the nurse finds swelling in the feet and abdominal ascites. Based on the clinical manifestations, which condition is the most likely diagnosis? Pancreatic pseudocysts Acute pancreatitis with edema Pancreatic carcinoma Cholecystitis

Pancreatic carcinoma Explanation: Pain, jaundice, and weight loss are considered classic signs of pancreatic carcinoma. Other signs include rapid, profound, and progressive weight loss as well as vague upper or midabdominal pain or discomfort unrelated to any gastrointestinal function that is often difficult to describe. It is often more severe at night and is accentuated when lying supine. The formation of ascites is common. An important sign is the onset of symptoms of insulin deficiency: glucosuria, hyperglycemia, and abnormal glucose tolerance. Therefore, diabetes may be an early sign of carcinoma of the pancreas.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

Paralytic ileus Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

When assessing the impact of medications on the etiology of acute renal failure, the nurse recognizes which of the following as the drug that is not nephrotoxic? Penicillin Gentamicin Tobramycin Neomycin

Penicillin Explanation: The three nephrotoxic drugs are aminoglycerides.

A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order. You Selected: Place the client in the modified Trendelenburg position. Initiate an intravenous (IV) site and prescribed IV fluids. Assess the capillary blood glucose level. Collect a stool specimen for culture.

Place the client in the modified Trendelenburg position. Initiate an intravenous (IV) site and prescribed IV fluids. Assess the capillary blood glucose level. Collect a stool specimen for culture.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Age Weight Preexisting conditions Family history

Preexisting conditions Explanation: Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client?

Presence of soot around nasal passages If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as Hypovolemic Progressive Neurogenic Compensatory

Progressive

The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in? Initial Compensatory Progressive Irreversible

Progressive

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? Refractory Compensatory Irreversible Progressive

Progressive

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pulmonary system Cardiovascular system Pain Nutrition

Pulmonary system

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? Cure the cirrhosis. Treat the esophageal varices. Reduce fluid accumulation and venous pressure. Promote optimal neurologic function

Reduce fluid accumulation and venous pressure. Explanation: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? Cure the cirrhosis. Treat the esophageal varices. Reduce fluid accumulation and venous pressure. Promote optimal neurologic function.

Reduce fluid accumulation and venous pressure. Explanation: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

Morphine sulfate has which of the following effects on the body? Reduces preload Increases preload Increases afterload No effect on preload or afterload

Reduces preload

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Measure hourly urinary output. Replace lost fluids and electrolytes. Prevent renal shutdown. Monitor cardiac status.

Replace lost fluids and electrolytes. After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.

Which of the following are the immediate complications of spinal cord injury? Respiratory arrest Tetraplegia Spinal shock Paraplegia Autonomic dysreflexia

Respiratory arrest

The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do? Decreases peripheral blood flow Increases catecholamine secretion Increases the production of antidiuretic hormone Restores blood pressure

Restores blood pressure

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? Risk for Impaired Gas Exchange Acute Pain Infection Risk Altered Tissue Perfusion

Risk for Impaired Gas Exchange

The nurse anticipates that a client who is immunosuppressed is at the greatest risk for developing which type of shock? Neurogenic Septic Cardiogenic Anaphylactic

Septic

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: Mild TBI. Moderate TBI. Severe TBI. Brain death.

Severe TBI.

A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following?

Severe burning pain for up to 20 minutes The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored.

You are assessing a 6-year-old girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child? She is having an allergic reaction and going into cardiogenic shock. She is having an allergic reaction and going into anaphylactic shock. She is having an allergic reaction and going into neurogenic shock. She is having an allergic reaction and going into obstructive shock.

She is having an allergic reaction and going into anaphylactic shock.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?

Skin grafting will be necessary. In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines? T3 and T4 Myoglobin and CK-MB BUN and creatinine Sodium and glucose levels

Sodium and glucose levels

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? Encourage oral fluids. Administer furosemide (Lasix) 20 mg IV Start hemodialysis after a temporary access is obtained. Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

Which condition occurs when blood collects between the dura mater and arachnoid membrane? Intracerebral hemorrhage Epidural hematoma Extradural hematoma Subdural hematoma

Subdural hematoma

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? Temperature increase from 98.0°F to 99.6°F Urinary output increase from 40 to 55 mL/hr Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air

Temperature increase from 98.0°F to 99.6°F

A nurse is caring for a client who's ordered continuous ambulatory peritoneal dialysis (CAPD). Which finding should lead the nurse to question the client's suitability for CAPD? The client is blind in his right eye. The client has a history of severe anemia during hemodialysis. The client has a history of diverticulitis. The client is on the kidney transplant waiting list

The client has a history of diverticulitis. Explanation: A history of diverticulitis contraindicates CAPD because CAPD has been associated with the rupture of diverticulum. A history of severe anemia while on hemodialysis or being on the transplant waiting list doesn't contraindicate CAPD. The client who's blind or partially blind can still learn to perform CAPD.

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has cerebral spinal fluid (CSF) leaking from the ear. The client has ecchymosis in the periorbital region. The client has an elevated temperature. The client has serous drainage from the nose.

The client has cerebral spinal fluid (CSF) leaking from the ear.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The client is in hypovolemic shock. The client has experienced extensive full-thickness burns. The paramedic administered high doses of opioids during transport. The client has experienced partial-thickness burns.

The client has experienced extensive full-thickness burns

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

The client's urinary output is 0.5 to 1 mL/kg/hour. Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? The client has periorbital edema and ecchymosis. The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The client's level of consciousness has improved. The client prefers to rest in the semi-Fowler's position.

The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: The digestion of dietary and blood proteins. Excessive diuresis and dehydration. Severe infections and high fevers. Excess potassium loss subsequent to prolonged use of diuretics.

The digestion of dietary and blood proteins.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? Examine the skin for any area of pressure or irritation. Examine the rectum for a fecal mass. Empty the bladder immediately. Raise the head of the bed and place the patient in a sitting position.

aise the head of the bed and place the patient in a sitting position.

Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? Transcranial Doppler Computed tomography (CT) Magnetic resonance imaging (MRI) Cerebral angiography

Transcranial Doppler

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will stain my skin permanently." "This medication will help my burn heal."

This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal."

A patient with suspected esophageal varices is scheduled for an upper endoscopy with moderate sedation. After the procedure is performed, how long should the nurse withhold food and fluids? For 2 hours after the last dose of medication is given Until the gag reflex returns Until the patient expresses thirst For 6 hours after the procedure

Until the gag reflex returns

Which clinical finding should a nurse look for in a client with chronic renal failure? Hypotension Uremia Metabolic alkalosis Polycythemia

Uremia

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? Blood urea nitrogen (BUN) level of 22 mg/dl Serum creatinine level of 1.2 mg/dl Temperature of 100.2° F (37.8° C) Urine output of 250 ml/24 hours

Urine output of 250 ml/24 hours

How should vasoactive medications be administered? Using a central venous line Through a peripheral IV line Intramuscularly (IM) By rapid intravenous (IV) push

Using a central venous line

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? Spironolactone Vasopressin Nitroglycerin Cimetidine

Vasopressin

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply. Vital signs Nutrition Skin color Gait Urine output Peripheral pulses

Vital signs Skin color Urine output Peripheral pulses

A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? Perform deep-breathing exercises vigorously. Wear a mask when performing exchanges. Auscultate the lungs frequently. Avoid carrying heavy items

Wear a mask when performing exchanges. Explanation: The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? Blood glucose level of 200 mg/dl White blood cell (WBC) count of 20,000/mm3 Potassium level of 3.5 mEq/L Hematocrit (HCT) of 35%

White blood cell (WBC) count of 20,000/mm3 Explanation: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Increased pulse Increased respirations Widened pulse pressure Decreased body temperature

Widened pulse pressure Explanation: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

Which are risk factors for spinal cord injury (SCI)? Select all that apply. Young age Female gender Alcohol use Drug abuse European American ethnicity

Young age Alcohol use Drug abuse

As the first priority of care, a patient with a burn injury will initially need: a patent airway established. an indwelling catheter inserted. fluids replaced. pain medication administered.

a patent airway established. Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? acute chronic subacute intracerebral

acute

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature

body temperature

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? PaCO2 >45 mm Hg compensatory respiratory alkalosis heart rate <100 bpm metabolic acidosis

compensatory respiratory alkalosis

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? concussion laceration contusion skull fracture

concussion

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to increase metabolic rate. increase glucose demands. increase skeletal muscle breakdown. decrease catabolism.

decrease catabolism. Explanation: The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. nitroglycerin nitroprusside dobutamine dopamine epinephrine

dobutamine dopamine epinephrine

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? face, neck, chest perineal hands, major joints legs

face, neck, chest

Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator? Blood pressure Urine protein Serum glucose pH and HCO3

serum glucose

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: nausea and vomiting. dyspnea and cyanosis. fatigue and weakness. thrush and circumoral pallor.

fatigue and weakness.

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. How would the nurse document the depth of burn injury this client has? full thickness (third degree) superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) fourth degree

full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. kidney failure disseminated intravascular coagulation acute respiratory distress syndrome hypoglycemia GERD

kidney failure disseminated intravascular coagulation acute respiratory distress syndrome

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? Mechanical Natural Enzymatic Surgical

natural Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing? cardiogenic hypovolemic anaphylactic neurogenic

neurogenic

Which period of acute renal failure is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys? Initiation Oliguria Diuresis Recovery

oliguria

The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder? pH 7.20, PaCO2 36, HCO3 14- pH 7.31, PaCO2 48, HCO3 24- pH 7.47, PaCO2 45, HCO3 33- pH 7.50, PaCO2 29, HCO3 22-

pH 7.20, PaCO2 36, HCO3 14- Explanation: Metabolic acidosis occurs in end-stage kidney disease (ESKD) because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.

One of the roles of the nurse in caring for clients with chronic kidney disease is to help them learn to minimize and manage potential complications. This would include: restricting sources of potassium. allowing liberal use of sodium. limiting iron and folic acid intake. eating protein liberally.

restricting sources of potassium.

Which of the following would a nurse classify as a prerenal cause of acute renal failure? Polycystic disease Ureteral stricture Prostatic hypertrophy Septic shock

septic shock

Which are characteristics of autonomic dysreflexia? severe hypertension, slow heart rate, pounding headache, sweating severe hypotension, tachycardia, nausea, flushed skin severe hypertension, tachycardia, blurred vision, dry skin severe hypotension, slow heart rate, anxiety, dry skin

severe hypertension, slow heart rate, pounding headache, sweating

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as sodium nitroprusside. norepinephrine. dopamine. furosemide.

sodium nitroprusside.

A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering: sodium polystyrene sulfonate (Kayexalate) Sorbitol IV dextrose 50% Calcium supplements

sodium polystyrene sulfonate (Kayexalate)

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

subnormal serum glucose and elevated serum ammonia levels. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? Take daily weights. Reposition the client frequently. Assess for pupillary response frequently. Assess vital signs frequently.

take daily weights.

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.

vomits.

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: hematuria. weight loss. increased urine output. increased blood pressure.

weight loss.

A nurse receives her client care assignment. Following the report, she should give priority assessment to the client: with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit. who has a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant. who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L. who is experiencing mild pain from urolithiasis.

who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L.