COMPLEX EXAM 3
A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss
a
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility
a
A patient has been admitted with diabetic ketoacidosis, and treatment has been initiated. Which findings would lead the nurse to suspect the patient is dehydrated? a. Poor skin turgor and flat neck veins b. Dyspnea and crackles c. Presence of Chvostek and Trousseau signs d. Extra heart sounds and 3+ edema
a
A patient has been admitted with hyperosmolar hyperglycemic state (HHS). The nurse knows that intravenous insulin is usually administered at what dosage? a. 0.1 U/kg/h b. 1.0 U/kg/h c. 2.0 U/kg/h d. 5.0 U/kg/h
a
A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag
a
A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5
a
A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse would expect the first line treatment to include which intervention? a. Fluid restriction b. Hypotonic intravenous fluid administration c. Administration of D5W d. Administration of vasopressin
a
A patient is admitted after surgery with a history of hyperthyroidism. The nurse suspects the patient may be developing thyroid storm. Which finding would confirm this suspicion? a. Tachycardia b. Hypotension c. Decreased appetite d. Hypothermia
a
A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver sulfadiazine application c. Splint application d. Xenograft application
a
A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres
a
A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the dehydration associated with DKA results from which pathophysiologic mechanism? a. Increased serum osmolality and urea b. Decreased serum osmolality and hyperglycemia c. Ketones and potassium shifts d. Acute renal failure
a
A patient is admitted with diabetic ketoacidosis (DKA). The patient presents with dry, cracked lips and is begging for something to drink. What reply would be the nurse's best response? a. "We can't give you anything to drink until we get your blood sugar under control." b. "You can have one cup of coffee without sugar." c. "You can drink anything you want as long as it's sugar free." d. "You can drink as much water has you can handle."
a
A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine
a
A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement? a. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of LR over the next 16 hours b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours c. 11,900 mL of dextran evenly divided over the first 24 hours d. 11,475 mL of LR evenly divided over the first 24 hours
a
A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Intravenous opiates and assessment of pulses in both arms b. Oral antiinflammatory drugs and preparation for insertion of an arterial line c. Measurement of sedimentation rate and systemic antibiotics d. Application of splints and initiation of total parenteral nutrition
a
A patient is presenting with signs of diabetes insipidus (DI). Which findings would confirm this diagnosis? a. Hyperosmolality and hypernatremia b. Hyperosmolality and hyponatremia c. Hypoosmolality and hypernatremia d. Hypoosmolality and hyponatremia
a
A patient presents with ketoacidosis and a blood glucose level of 125 mg/dL. Diabetic ketoacidosis has been ruled out. The nurse knows that ketoacidosis can occur in which condition? a. Acute pancreatitis b. Drug overdose c. Hyperglycemic hyperosmolar state d. Hyperaldosteronism
a
An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury
a
As a patient with diabetic ketoacidosis (DKA) receives insulin and fluids, the nurse knows careful assessment must be given to which electrolyte? a. Potassium b. Sodium c. Phosphorus d. Calcium
a
Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints
a
Identify in the correct order the five layers of the skin from the surface inward. 1. Stratum granulosum 2. Stratum corneum 3. Stratum germinativum 4. Stratum lucidum 5. Stratum spinosum a. 2, 4, 1, 5, 3 b. 2, 4, 5, 1, 3 c. 4, 2, 5, 1, 3 d. 4, 5, 1, 3, 2
a
The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which medical intervention would the nurse expect to see ordered for this patient? a. Rapid rehydration with intravenous fluids b. Insertion of a pulmonary artery catheter c. Administration of high-dose intravenous insulin d. Hourly monitoring of urine glucose and ketone levels
a
The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system
a
The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia
a
The nurse is caring for a patient with a head injury who has developed diabetes insipidus (DI). What medication would the nurse expect to be prescribed for the patient? a. Vasopressin b. Insulin c. Glucagon d. Propylthiouracil
a
The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia
a
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for this patient? a. Extensive hydration b. Oral hypoglycemic agents c. Large doses of intravenous (IV) insulin d. Limiting food and fluids
a
The nurse is developing a discharge education plan for a patient with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Which topic should be included in the plan? a. Measuring intake and output b. Encouraging fluids c. A low-sodium diet d. Hypothermia management
a
What are the goals of the rehabilitation phase of burn management? a. Recuperation and healing physically and emotionally b. Hydrotherapy and splinting c. Reverse wound isolation and surgical grafting d. Bed rest and splinting
a
A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. Blood cultures ´2 b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential
a, b, c, d
The neuroendocrine stress response produces which findings? (Select all that apply.) a. Elevated blood pressure b. Decreased gastric motility c. Tachycardia d. Heightened pain awareness e. Increased glucose
a, b, c, e
A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) a. NS 1.5 L IV fluid bolus b. Insulin infusion at 5 units/h c. Sodium bicarbonate 50 mmol IV push d. Vasopressin 10 units IM every 3 hours e. Potassium 20 mEq/L of IV fluid
a, b, e
The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone
a, c, d
A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.
b
A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination
b
A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor
b
A patient has been admitted with diabetic ketoacidosis (DKA). The nurse knows that the top priority in the initial treatment of DKA is which intervention? a. Lowering the blood sugar as quickly as possible b. Administering intravenous fluids c. Administering sodium bicarbonate d. d. Determining the precipitating cause
b
A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure
b
A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs
b
A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse is administering hypertonic saline. The nurse knows that the serum sodium should not be raised more than how many milliequivalents per day? a. 5 mEq/day b. 10 mEq/day c. 20 mEq/day d. 25 mEq/day
b
A patient has thyroid storm. The nurse is providing medication instruction for home. The patient asks, "If I have a fever, should I take Tylenol or aspirin?" Which response would be the most appropriate? a. "Either one is fine because they do not affect the antithyroid medication." b. "Take Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation." c. "Take aspirin rather than Tylenol because Tylenol increases the amount of free thyroid hormone in circulation." d. "They both prevent the antithyroid medication from working correctly. I would recommend an NSAID."
b
A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial, first-degree burn b. Partial-thickness, second-degree burn c. Deep dermal partial-thickness, second-degree burn d. Full-thickness, third-degree burn
b
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume
b
A patient is admitted with diabetic ketoacidosis (DKA) and is experiencing polyuria. Which electrolyte disturbances would the nurse expect to see at this phase of DKA? a. Decreased calcium and increased phosphorus levels b. Decreased potassium and sodium levels. c. Increased sodium and decreased phosphorus levels d. Decreased calcium and potassium levels.
b
A patient is admitted with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse understands that the hyponatremia associated with this disorder is the result of which mechanism? a. Increased cortisol release b. Excessive water reabsorption c. Excessive sodium excretion d. Decreased glucagon release
b
A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.
b
A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication? a. Tension pneumothorax b. Adult respiratory distress syndrome (ARDS) c. Asthma d. Lung cancer
b
A patient with diabetic ketoacidosis (DKA) has an insulin drip infusing, and the nurse has just administered subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include what findings? a. Kussmaul respirations and flushed skin b. Irritability and paresthesia c. Abdominal cramps and nausea d. Hypotension and itching
b
An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention must be given to which intervention? a. Evaluating clotting factors b. Fluid administration c. Insulin administration d. Sodium replacement
b
Decreased urine osmolality is a sign of which disorder? a. Hyperglycemia b. Diabetes insipidus c. Thyroid crisis d. Syndrome of inappropriate secretion of antidiuretic hormone
b
Patients discharged with antithyroid medications should be alerted to which potential side effect? a. Hyperthermia b. Agranulocytosis c. Tachypnea d. Diaphoresis
b
The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient? a. Hyperglycemia with low serum osmolality b. Severe hyperglycemia with minimal or absent ketosis c. Little or no ketosis in serum with rapidly escalating ketonuria d. Hyperglycemia and ketosis
b
The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65 mm Hg. d. Administer crystalloid fluids.
b
The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure
b
The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. Patient experiences hypometabolism. b. Patient experiences hypermetabolism. c. Patient experiences anorexia. d. Patient has gut dysfunction.
b
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA? a. Irritability b. Excessive thirst c. Rapid weight gain d. Peripheral edema
b
The nursing management plan for a patient with full-thickness burns includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission
b
Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum.a. 28% b. 23.5% c. 45.5% d. 16%
b
Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL
b
What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure
b
When a patient with diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects a drop in the serum levels of which electrolytes? a. Sodium and potassium b. Potassium and phosphate c. Bicarbonate and calcium d. Sodium and phosphate
b
Which finding is expected in the patient with hypothyroidism? a. Increased T4 b. Anemia c. Decreased thyroid stimulating hormone d. Hyperglycemia
b
Which pathophysiologic mechanism occurs in the patient with type 2 diabetes? a. Lack of insulin production b. Imbalance between insulin production and use c. Overproduction of glucose d. Increased uptake of glucose in the cells
b
Which pathophysiologic mechanism occurs in the syndrome of inappropriate antidiuretic hormone (SIADH)? a. Massive diuresis, leading to hemoconcentration b. Dilutional hyponatremia, reducing sodium concentration to critically low levels c. Hypokalemia from massive diuresis d. d. Serum osmolality greater than 350 mOsm/kg
b
A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure
b, c, d
According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.) a. Arms b. Perineum c. Chest d. Genitalia e. Face
b, d, e
A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing, which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase c. Proliferative phase d. Maturation phase
c
A patient has been admitted after surgery for removal of a brain tumor. The nurse suspects the patient may be developing diabetes insipidus (DI). Which findings would confirm the nurse's suspicion? a. Hyperglycemia and hyperosmolarity b. Hyperglycemia and peripheral edema c. Intense thirst and passage of excessively large quantities of dilute urine d. Peripheral edema and pulmonary crackles
c
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response
c
A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to note to support this diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase
c
A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion
c
A patient in diabetic ketoacidosis (DKA) is comatose with a temperature of 102.2° F. The nurse suspects the patient may have which secondary disorder? a. Head injury b. Hypothalamus infarction c. Infection d. Heat stroke
c
A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? a. Superficial partial-thickness burn b. Moderate partial-thickness burn c. Deep dermal partial-thickness burn d. Full-thickness burn
c
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels
c
A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? a. Rhabdomyolysis b. Stress ulcers c. Pneumothorax d. Venous thromboembolism
c
A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? a. Continue as planned; everything looks good. b. IV rate should be decreased and colloids started. c. IV rate should be increased and fluid status closely watched. d. Fluids should be switched to packed red blood cells.
c
A patient is admitted with a long history of mental illness. The patient's spouse states the patient has been drinking up to 10 gallons of water each day for the past 2 days and refuses to eat. The patient is severely dehydrated and soaked with urine. The nurse suspects the patient has which problem? a. Central diabetes insipidus (DI) b. Nephrogenic DI c. Dipsogenic DI d. Iatrogenic DI
c
A patient is admitted with diabetic ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? a. Initiate oxygen therapy via a face mask. b. Administer sodium bicarbonate. c. Administer insulin and fluids intravenously. d. Prepare for intubation.
c
A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intraaortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)
c
A patient weighs 140 kg and is 60 inches tall. The patient's blood sugar is being controlled by glipizide. Which topic would be important for the nurse to include in the patient's discharge education plan? a. Signs of hyperglycemia b. Proper injection technique c. Weight loss d. Increased caloric intake
c
A patient with bronchogenic oat cell carcinoma has a drop in urine output. The laboratory reports a serum sodium level of 120 mEq/L, a serum osmolality level of 220 mOsm/kg, and urine specific gravity of 1.035. The nurse suspects the patient may be developing what problem? a. Diabetes ketoacidosis (DKA) b. Diabetes insipidus (DI) c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Hyperaldosteronism
c
A patient with hyperglycemic hyperosmolar state (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138 mEq/L. What is the intravenous fluid of choice? a. D5W b. 0.45% NS c. 0.9% NS d. d. D5/NS
c
Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an increased risk of developing which disorder? a. Type 1 diabetes b. Thyrotoxicosis c. Diabetes insipidus d. Myxedema coma
c
The nurse is caring for a critically ill patient with type 1 diabetes. The nurse understands that the patient is at risk for developing diabetic ketoacidosis (DKA) secondary to what etiology? a. Excess insulin administration b. Inadequate food intake c. Physiologic and psychologic stress d. Increased release of antidiuretic hormone (ADH)
c
The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient? a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact of body fluids. b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient. c. Changing gloves and handwashing should be done when moving from area to area on the same patient. d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination.
c
The nurse is caring for a patient with myxedema coma. The patient's temperature is 93° F. Which intervention would the nurse include in the plan of care for this patient? a. Give aggressive therapy that includes warm peritoneal lavage. b. Allow the patient to maintain this body temperature to decrease oxygen demands. c. Use warming blankets to slowly warm the patient. d. Wait until the patient shivers to start warming.
c
The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? a. Arachidonic acid metabolite b. Platelet-activating factor c. Tumor necrosis factor d. Interleukin
c
The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)
c
The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis (DKA), the intravenous (IV) line should be changed to a solution containing glucose when what happens? a. Patient becomes more alert b. IV insulin has been infusing for 4 hours c. Blood glucose drops to 200 mg/dL d. Blood glucose drops to 100 mg/dL
c
The nurse understands that the onset of seizures in the patient with diabetes insipidus (DI) is indicative of which situation? a. Increased potassium levels b. Hyperosmolality c. Severe dehydration d. Toxic ammonia levels
c
The nursing management plan for a patient with thyrotoxicosis would include which intervention? a. Providing diversional stimuli b. Restricting fluids c. Maintaining a quiet, restful environment d. Administering thyroid supplements at the same time each day
c
What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.
c
Which nursing intervention should be initiated on all patients with the syndrome of inappropriate antidiuretic hormone (SIADH)? a. Placing the patient on an air mattress b. Forcing fluids c. Initiating seizure precautions d. Applying soft restraints
c
A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% high-flow oxygen via a nonrebreathing mask.
d
A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center?a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputumd. The medical history of the patient and the size and depth of the burn injury
d
A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable to what cause? a. Blood loss associated with burns and pain b. Hemodynamic stability related to adequate fluid resuscitation. c. Overresuscitation related to overestimation of the burn area involved d. Underresuscitation because of probable wound conversion
d
A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the lack of insulin results in which process? a. Decreased glucagon release b. Decreased glycogenolysis c. Decreased ketone production d. Increased gluconeogenesis
d
A patient is admitted with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes that has been well controlled with an insulin pump. The patient states, "I know it could not be my diabetes because my pump gives me 24-hour control." Which reply would be the nurse's best response? a. "You know a lot about your pump, and you are correct." b. "You're right. This is probably a virus." c. "We'll get an abdominal CT and see if your pancreas is inflamed." d. "We'll check your serum blood glucose and ketones."
d
A patient is admitted with severe hyperglycemia. The patient is very lethargic and has a "fruity" odor to his breath. The nurse knows the odor on the patient's breath is indicative of which situation? a. Alcohol intoxication b. Lack of sodium bicarbonate c. Hypokalemia d. Presence of acetone
d
A patient was admitted with diabetic ketoacidosis (DKA) an hour ago and is on an insulin drip. Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The nurse notifies the practitioner. The nurse would anticipate an order for which intervention? a. A lidocaine bolus b. Stopping the insulin drip c. Synchronizing cardioversion d. Obtaining serum electrolytes
d
A patient with a history of type 2 diabetes was admitted after aneurysm repair. The patient's serum glucose levels have been elevated for the past 2 days, and the patient is concerned about becoming dependent on insulin. Which statement is the nurse's best response to the patient's concerns? a. "This surgery may have damaged your pancreas. We will have to do more evaluation." b. "Perhaps your diabetes was more serious from the beginning." c. "You will need to discuss this with your physician." d. "The stress on your body has temporarily increased your blood sugar levels."
d
A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine
d
A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect
d
A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is given. Which findings support this diagnosis? a. Decreased serum glucose and increased serum ketones b. Increased urine ketones and decreased serum osmolality c. Increased serum osmolality and increased serum potassium d. Increased serum osmolality and increased serum glucose
d
In caring for a patient with a thyrotoxicosis, the nurse would expect to observe which neurologic symptom? a. Lethargy b. Depression c. Seizures d. Agitation
d
Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance
d
Roughly 80% of burns in children are classified as what type of burn? a. Radiation b. Chemical c. Electrical d. Thermal
d
The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? a. Autografts are procured from both live and deceased donors. b. Autografts can placed at the bedside or in the operating room. c. Autografts can transmit disease and be rejected. d. Autografts provide permanent coverage and are the least expensive.
d
The nurse is caring for a patient incardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index
d
The nurse is caring for a patient with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Which findings would confirm this diagnosis? a. Decreased ADH level and hyperkalemia b. Decreased ADH level and hypernatremia c. Increased ADH level and serum ketones d. Increased ADH level and low serum osmolality
d
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating potassium supplements with the patient's insulin therapy? a. Potassium replaces losses incurred with diuresis. b. The patient has been in a long-term malnourished state. c. Intravenous (IV) potassium renders the infused solution isotonic. d. Insulin drives the potassium back into the cells.
d
Which medication can place a patient at risk for developing syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? a. Adenosine b. Diltiazem c. Heparin sodium d. Acetaminophen
d
Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? a. Pure silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine
d
