Exam 2

Which drug and dose is recommended for the management of refractory ventricular fibrillation?

Amiodardone 300 mg

A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures?

Apply splints

Type, dose, and length of exposure A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient?

Type, dose, and length of exposure

True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn.

False Alkali burns are harder to treat than acidic chemical burns because the skin will neutralize the acidic burn.

A patient recovering from full-thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. For which type of pain should this patient be treated?

Procedural

A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI)

4) MRI An MRI will be performed if there is a risk for spinal cord injuries, injuries to the muscles, or abdominal injuries.

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1) Maintaining privacy 2) Having suction available 3) Giving supplemental oxygen 4) Assigning a nurse to support family members

4) assigning a nurse to support family members A nursing action that is appropriate during the secondary survey is assigning a nurse, or other team member, to support family members.

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1. Administer digoxin. 2. Defibrillate the client. 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing.

4. prepare for transcutaneous pacing

Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation? A. A survivor with this tag color is seen after patients with the green tag color. B. A survivor with this tag color can have treatment delayed for an hour or less. C. A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so. D. A survivor with this tag color has second priority for treatment of injuries.

A. A survivor with this tag color is seen after patients with the green tag color. This statement is INCORRECT. It should say: A survivor with this tag color is seen after patients with the RED (not green) tag color.

Which action by the nurse changing the dressings on the client who has burns on the right arm, the left arm, and the upper chest is most effective at preventing autocontamination? A Changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area. B Using sterile gloves to remove the old dressings and changing to fresh sterile gloves before applying the new dressings. C Ensuring that the blood pressure cuff used on another client is thoroughly cleaned before using it on this client. D Warning the client's family not to bring fresh fruits and vegetables or house plants into the client's environment.

A. changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify What Is the priority finding to report to the provider?

Difficulty swallowing/airway

A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient?

deep breathing and coughing every hour

A patient recovering from deep and full thickness burns is nauseated. Which medication should the nurse provide to help this patient?

Metoclopramide (Reglan)

Which factors indicate that a client's burn wounds are becoming infected? Select all that apply. a. Dry, crusty granulation tissue b. Elevated blood pressure c. Hypoglycemia d. Swelling of the skin around the wound e. Tachycardia

a. dry, crusty granulation tissue d. swelling of the skin around the wound e. tachycardia

Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? 1) Concussion 2) Ankle sprain 3) Open femur fracture 4) Full-thickness body burns

4) full-thickness body burns A black tag indicates the patient has suffered an extensive injury and is expected, or allowed, to die. Typical examples of black-tagged patients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation.

A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient's risk of developing an infection?

Follow contact precautions

The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected?

Increased potassium

What is the first treatment priority for a patient who achieves ROSC?

Optimizing ventilation and oxygenation

A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply

-Anxiety -Depression -Body image disorder -PTSD

A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply

-Apply bacitracin ointment -Cover with a nonadherent bandage -Wash with antiseptic soap and warm water

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? 1) Determining drug allergies 2) Noting the general appearance 3) Examining the neck for stiffness 4) Auscultating for heart and lung sounds

1) determining drug allergies The priority nursing action during the health history portion of the assessment is to determine drug allergies.

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? 1) Assessing for edema 2) Counting respiratory rate 3) Checking for foreign bodies 4) Monitoring for respiratory distress

2) counting respiratory rate Counting the respiratory rate is a nursing action appropriate during the breathing assessment.

A client is admitted after severe burn injury and is undergoing fluid resuscitation. Which of the following is the most accurate assessment of successful fluid resuscitation? a. UOP >30 mL/hr b. weight gain of 1kg in 8 hours with good capillary refill c. HR of 94 BPM with a BP of 95/55 mmHg d. K+ level from 5.8 to 5.2 mEq/L

a. UOP >30 mL/hr

Which client is at the greatest risk for​ hypothermia? a. An​ 89-year-old client on a fixed income during cold winter months b. A pregnant woman in her first trimester c. A worker who repairs industrial freezers d. A​ 3-hour-old infant swaddled in a​ blanket, wearing a​ hat, and being held by the mother

a. an 89 y/o client on a fixed income during cold winter months

A client's burn injury was caused by a gasoline-fueled explosion. Which laboratory result does the nurse monitor closely for possible signs of organ injury? a. Liver function tests b. Arterial blood gases c. Serum electrolytes d. White blood cell count

a. liver function tests Burns caused by organic compounds such as those found in gasoline and chemical disinfectants are fat-soluble agents that, once absorbed by the skin, can have toxic effects on the kidneys and liver. The nurse should monitor labs that evaluate kidney and liver function. Monitoring arterial blood gas, serum electrolytes, and white blood cell count may be important as part of overall management of the burn-injured client; however, assessing laboratory results specific to kidney and liver function are the priority.

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)

b. 2nd degree (partial thickness) These are the classic characteristics of a 2nd degree (partial-thickness) burn.

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO. B. Notify the Rapid Response Team. C. Slow the IV infusion rate. D. Raise the head of the bed

b. notify the rapid response team

EMS arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and bleeding profusely. What is the first resuscitation intervention to be performed? a. Apply pressure to the bleeding b. Carry out artificial respirations c. Clear the airway d. Place a cervical collar

c. clear the airway

When attending a client with a head and neck trauma following a vehicular accident, the nurse's initial action is to? A. Do oral and nasal suctioning. B. Provide oxygen therapy. C. Initiate intravenous access. D. Immobilize the cervical area.

d. immobilize the cervical area

Atrioventricular Blocks--Differentiated by their PR interval

---First-degree—all sinus impulses eventually reach ventricles ---Second-degree—some sinus impulses reach ventricles, others do not ---Third-degree—no sinus impulses reach ventricles

Management of cardiac arrest

•CPR -Maintain patent airway -Ventilate with mouth-to-mask device -Start chest compressions •Advanced cardiac life support

Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions

2) setting priorities Setting priorities is an essential nursing skill for the triage, or assessment, process that occurs in the emergency department.

The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process? 1) Ankle sprain 2) Hypovolemic shock 3) Open femur fracture 4) Massive head trauma

3. open femur fracture When using a triage tag system, an open femur fracture is an urgent but not life-threatening injury that would be tagged as yellow.

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO. B. Notify the Rapid Response Team. C. Slow the IV infusion rate. D. Raise the head of the bed.

B. notify the rapid response team The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the the head, neck, and upper body). The drooling indicates oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation now.

A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: A. Oxygen nasal cannula 5-6 Liters B. 100% oxygen via non-rebreather mask C. Continuous Bipap D. Venturi mask 6 L oxygen

B. 100% oxygen via non-rebreather mask

Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A. Complete history taking. B. Put the client on ECG monitoring. C. Notify the physician. D. Administer oxygen therapy via nasal cannula.

d. administer O2 therapy via nasal cannula

A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of: 1 A secondary MI 2 Pulmonary edema 3 Cardiogenic shock 4 Fatal dysrhythmias

3. cardiogenic shock

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? A. "He takes medication for glaucoma". B. "I think it has been 10 years or more since he had a tetanus shot." C. "He was told he had COPD last year." D. "He smokes 2 packs of cigarettes a day."

B. "I think it has been 10 years or more since he had a tetanus shot." Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.

You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? A. The nursing assistant elevates the head of the bed above 30 degrees. B. The nursing assistant places a pillow under the patient's head. C. The nursing assistant places rolled towels under the patient's shoulders. D. The nursing assistant covers the patient with sterile linens.

B. The nursing assistant places a pillow under the patient's head. If a patient has severe burns to the neck (head as well) a pillow should NOT be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.

What does dopamine do? How do you know it is working?

BP will increase and they will pee

The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

a. green

During the emergent phase of burn management, you would expect the following lab values: A. Low sodium, low potassium, high glucose, low hematocrit B. High sodium, low potassium, low glucose, high hematocrit C. High sodium, high potassium, high glucose, low hematocrit D. Low sodium, high potassium, high glucose, high hematocrit

D. Low sodium, high potassium, high glucose, high hematocrit Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: Low sodium..why: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood; High potassium...why? damaged cells lysis and leak potassium which increases the leave in the blood; high glucose...why? stress response leads the liver to release glycogen and this increases levels; high hematocrit...why? when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn

a. 1st degree (superficial) burn These are the classic characteristics of a 1st degree, superficial burn.

While educating a patient about AF, the nurse informs the patient that which of following can be symptoms of AF? (Select all that apply.) A. Shortness of breath B. Hypotension C. Weight loss D. Dizziness E. Sweating

a. SOB b. hypotension d. dizziness e. sweating

An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a GCS score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client? a. Level I b. Level II c. Level III d. Level IV

a. level I

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Give atropine per agency dysrhythmia protocol. d. Provide supplemental O2 via non-rebreather mask.

b. start CPR The patient's clinical manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving?

UOP 800 mL over 2 hours

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

a, c, d, f Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient?

"More than two weeks."

A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful? A. The patient can move the extremity. B. The right foot's capillary refill is less than 2 seconds. C. The patient reports a new sensation of extreme pain. D. The patient has a positive babinski reflex.

B. The right foot's capillary refill is less than 2 seconds Escharotomy is performed when a full-thickness burn, due to eschar (which is burned tissue that is hard), is compromising blood flow to the distal extremity. The eschar is cut and this relieves pressure and allows blood to flow to the extremity.

The client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Body temperature assessment B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

C. fluid resuscitation A. Assessment of body temperature is not the priority for this client. B. Although emotional support is important, this is not the priority during the resuscitation phase for this client. C. The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. D. Although sterile dressing changes are important, this is not the priority for this client.

A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning?

Carboxyhemoglobin level

The nurse is triaging for a group of clients in the ED and has the clients listed below signed in to be seen and traiged. Place the following clients in order, from highest priority to lowest priority. a. a 47 y/o female with a dull pain in her central chest that radiates into her back. She is pale but not diaphoretic b. a 62 y/o male with complaints of shoulder pain following surgery 14 days ago. He reports his pain level is 4/10. c. a 23 y/o female with complains of painful burning urination x2 days d. a 44 y/o male with chest pain during deep inspiration. When he holds his breath he has no chest pain. e. a 33 y/o male with chest pain in his central chest. He has myasethenia gravis and first noticed this when he was eating a piece of steak he had grilled. He noted his throat "felt full" when he tried to swallow a piece of meat f. a 56 y/o male with pain in his chest described as crushing. He is pale and diaphoretic

FADECB

A 35 year old male patient has superficial partial-thickness burns to the anterior right arm, posterior left leg, and anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 36% B. 9% C. 18% D. 29%

c. 18% Anterior right arm (4.5%), posterior left leg (9%), and anterior head and neck (4.5%) which equals 18%.

Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? A. IM morphine B. PO morphine C. IV morphine D. Subq morphine

c. IV morphine The best route that is predictable and easily absorbed is via the IV route in burn victims.

A nurse is assigned to triage after a mass casualty due to an explosion. Which of the following clients should be the priority for treatment? a. a client with an open fracture of the left tibia and fibula b. a client who has a head injury, agonal respirations, and a GCS of 3 c. a client with second degree burns on the right forearm d. a client who is crying and screaming and has sustained a 5 cm laceration of the right thigh

a. a client with an open fracture of the left tibia and fibula Individuals with alterations in airway, breathing, or circulation who are most likely to survive should receive priority. This client who has an open fracture, an injury with a good prognosis, should be treated immediately b. GCS of 3 is associated with a poor prognosis, even when treated. Given the agonal respirations, and need for multiple interventions, this client would be in the "expectant" category in a true mass casualty event

Which of the following dysrhythmias requires defibrillation? A. Atrial tachycardia B. Atrial fibrillation C. Ventricular tachycardia with a pulse D. Ventricular fibrillation

c. ventricular fibrillation

The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

c. yellow

A 35 year old male patient has full thickness burns to the anterior and posterior head and neck, front of left leg, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 37% B. 14.5% C. 29% D. 19%

d. 19% Anterior and posterior head and neck (9%), front of left leg (9%), perineum (1%) which equals 19%.

A client is admitted with second degree burns on face, neck, anterior chest, and hands. The nurse's priority action would be: a. cover the burned areas with sterile dressings b. initiate IV fluids c. admin pain meds d. assess for dyspnea and stridor

d. assess for dyspnea and stridor Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress

Symptoms of heat exhaustion

fatigue light-headedness N/V diarrhea feelings of impending doom tachypnea

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

hyperkalemia r/t cell destruction

What is the preferred method of access for epi administration during cardiac arrest in most patients?

Peripheral IV

You have completed 2 minutes CPR. the ECG monitor displays PEA and the patient has no pulse. Member of the team resumes chest compressions, IV placed. What is the management step is the next priority?

admin 1mg epi

A-fib patient-centered collaborative care

-Risk for PE, VTE -Antidysrhythmic drugs -Cardioversion -Percutaneous radiofrequency catheter ablation -Bi-ventricular pacing -Maze procedure

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound? 1) Red 2) Black 3) Green 4) Yellow

1) red The nurse would use a red tag for a patient who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions.

A nurse is responding to a mass casualty incident. Place, in order, the clients to be triaged, from most important to least. (e.g. ABCD) a. a client with a sucking chest wound who is having breathing difficulties b. a client with a broken arm and no other injuries c. a client with a large scalp laceration who is walking around the scene d. a client who was killed in the accident e. a client who is scared and crying about the incident

ACBED Clients with serious injuries but have a chance of survival are seen first, followed by those who need observation and whose treatment could wait until after the emergencies. This is followed by clients who have injuries that will need care at some poiint that can wait until others have been seen, and then those who can be dismissed with little to no medical treatment. The last stage of importance is the client who has died; the nurse in the triage situation must spend time caring for those who have survived first.

The nurse is caring for the client with burns to the face. Which statement by the client requires further evaluation by the nurse? A. "I am getting used to looking at myself." B. "I don't know what I will do when people stare at me." C. "I know that I will never look the way I used to, even after the scars heal." D. "My spouse does not stare at the scars as much as in the beginning."

B. "I don't know what I will do when people stare at me" A. This statement indicates that the client is coping effectively. B. This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. C. This statement indicates that the client is coping effectively. D. This statement indicates that the client is coping effectively.

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day

B. High calorie, high protein and carbohydrate This type of diet promotes wound healing and meets the caloric demands of the body.

Which client response does the nurse interpret as an indication of fluid resuscitation adequacy? A Decreasing pulse pressure B Decreasing urine specific gravity C Decreasing core body temperature D Increasing respiratory rate and depth

B. decreasing urine specific gravity

After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room you note the room temperature to be 75'F. You will: A. Decrease the temperature by 5-10 degrees to prevent hyperthermia. B. Leave the temperature setting. C. Increase the temperature to a minimum of 85'F.

C. Increase the temperature to a minimum of 85'F. Patients with severe burns can NOT regulate their temperature and are at risk for hypothermia. The room temperature should be a minimum of 85'F.

The nurse is evaluating the effectiveness of fluid resuscitation for the client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

C. UOP 40 mL/hr A. A BUN of 36 mg/dL is above normal. B. A creatinine of 2.8 mg/dL is above normal. C. Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr. D. A urine specific gravity of 1.042 is above normal.

Which assessment will the nurse prioritize for the client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

C. signs of infection A. Assessing bowel sounds is not the priority during the acute phase of burn injury. B. Assessing muscle strength is not the priority during the acute phase of burn injury. C. The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. D. Assessing urine output is not the priority during the acute phase of burn injury.

A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient?

Medicate for pain around the clock

Separation of eschar A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment made by the nurse would indicate that wound care treatment has been successful?

Separation of eschar

A victim of a housefire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury?

Singed facial hair

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

a, d Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag

A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 63% B. 81% C. 72% D. 54%

a. 63% Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

a. 921 mL/hr First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia

a. carbonaceous sputum b. hair singeing on the head and nose d. bright red lips e. hoarse voice f. tachycardia These are all signs of a possible inhalation injury. Bright red lips and tachycardia are present in carbon monoxide poisoning as well.

You are about to provide care to a patient with severe burns. You will don: A. gloves B. goggles C. gown D. N-95 mask E. surgical mask F. shoe covers G. hair cover

a. gloves c. gown e. surgical mask f. shoe covers g. hair cover Before providing care to a patient with severe burns the nurse would want to wear protective isolation apparel like: gloves, gown, surgical mask, shoe covers, and hair cover. This protects the patient from potential infection.

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

a. increase in the patient's HR Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

The client is admitted into the ED with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? a. Start an IV with an 18 gauge catheter b. Administer dopamine IV infusion c. Obtain ABGs d. insert an indwelling urinary catheter

a. start an IV with an 18 gauge catheter

A recently graduated RN has been assigned to triage in the ED. As clients present for initial contact with the nurse, who should be given the highest priority? a. a client who fell and has wrist pain with an obvious deformity b. a client with new onset slurred speech and right arm weakness c. a client with dysuria and urinary urgency for a day and a temp of 100.4 d. a client with a small laceration who has not received a recent tetanus shot

b. a client with new onset slurred speech and right arm weakness The highest priority should be clients who have potentially life-threatening problems or conditions that need immediate stabilization, including victims of trauma, individuals in severe respiratory distress, and those with chest pain, acute neuro deficits, chemical splashes to the eyes, or limb amputations.

A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management? A. Emergent B. Acute C. Rehabilitative

b. acute This phase starts when capillary permeability has returned to normal and the patient's vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.

The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.

b. ask a family member to stay with the client Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls.

A client from a local care facility has sustained a cardiac arrest in the ED, and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? (SATA) a. remove all lines and indwelling tubes b. cover the client with a sheet, leaving the face exposed c. Call a chaplain or social worker to accompany the family d. Tell the family that the client "is in a better place now." e. Dim the light in the client's room

b. cover the client with a sheet, leaving the face exposed e. dim the lights in the client's room

Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot? A. Core body temperature B. Electrocardiography C. Depth of burn injury D. Urine output

b. electrocardiography

The nurse is caring for admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? A. Assess and tx pain B. Evaluate airway and circulation C. IV caths for fluid D. rule of nines to estimate percent of body surface area burned

b. evaluate airway and circulation

The client is in the resuscitation phase of burn injury. Which route will the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

b. intravenous A. When administered to the client in the resuscitation phase of burn injury via the intramuscular route, drugs remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. B. During the resuscitation postburn phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. C. Because the skin is too damaged, the sublingual route is not the indicated route for administering drugs to the client in the resuscitation phase of burn injury. D. Because the skin is too damaged, the topical route is not the indicated route for administering drugs to the client in the resuscitation phase of burn injury.

It has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audible and the wheezing has now stopped. What nursing action is appropriate? A. check the pt's SpO2 level B. Notify the physician immediately C. Re-assess breathing in 1 hour D. Document improvement in patient's condition

b. notify the provider immediately

A client with burns has developed sepsis. Which sign or symptom in the client indicates fungal infection? a. Severe disorientation b. Occasional diarrhea c. Hypothermia d. Lethargy

b. occasional diarrhea Sepsis, often present due to open burn wounds, can be caused due to fungi, gram-positive bacteria, and gram-negative bacteria. Signs and symptoms of fungal infection are the presence of occasional diarrhea, mild disorientation, and fever. Severe disorientation and lethargy are symptoms of gram-positive bacterial infection. Hypothermia is a symptom of gram-negative bacterial infection.

A nurse is caring for a client who was just admitted to the emergency department with a severe burn injury. Which of the following orders would the nurse question for this client? a. water b. potassium c. LR d. plasma expanders

b. potassium The patient will have hyperkalemia from potassium being released from damaged cells.

A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. What may this change indicate? A The patient's infection is improving. B The patient is having an allergic reaction to the silversulfadiazine. C The patient has kidney disease. D The patient has an electrolyte imbalance

b. the patient is having an allergic reaction to the silversulfadiazine

The nurse is administering mafenide acetate to a client with burns. Which statements about this drug are correct? (select all that apply) a. effective for 1st degree burns b. used to eradicate pseudomonas aeruginosa c. causes pain d. contains sulfonamide e. the brand name is Silvadene d. causes ototoxicity g. is diffused gradually and slowly in the skin

b. used to eradicate pseudomonas aeruginosa c. causes pain d. contains sulfonamide An antibiotic, such as mafenide acetate (Sulfamylon) is administered intended to eradicate infectious agents such as pseudomonas aeruginosa. This drug is usually applied as a topical cream for second or third-degree burns. It causes pain upon application and is rapidly diffused and absorbed systemically. It can cause renal failure and hypersensitivity reaction in some patients.

A 66 year old female patient has deep partial-thickness burns to both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 72% B. 63% C. 81% D. 45%

c. 81% Both of the legs on the back (18%), front and back of the trunk (36%), both arms on the front and back (18%), front and back of the head and neck (9%) which equals 81%.

Which of the following clients should the ED nurse in triage immediately prioritize for assessment and care? a. a client with flank pain rated 10/10 and a history of renal colic b. a 40 y/o client with diarrhea and vomiting that began 6 hours after a picnic c. a 3 week old infant who has been feeding poorly with a temp of 100.5 and a sunken fontanel d. a 30 y/o G1P0 client at 7 weeks gestation who complains of "spotting" with a HR of 72 and BP 120/80

c. a 3 week old infant who has been feeding poorly with a temp of 100.5 and a sunken fontanel life threatening sign of sepsis in infants.

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Irregular pulse. B. Ecchymosis in the flank area. C. A deviated trachea. D. Unequal pupils.

c. a deviated trachea

A nurse is caring for a client who has a third degree burn. Which of the following would the nurse expect to find when assessing the burn? (select all that apply) a. pain b. erythema c. edema d. eschar e. fluid-filled vesicles

c. edema d. eschar Third degree burns are full-thickness burns that involve the epidermal, dermal, and subcut layers and nerve endings. They are characterized by edema, eschar, and little or no pain, due to the loss of sensory nerve endings.

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? A. Red B. Yellow C. Green D. Black

c. green Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded".

The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? A. Increased pH B. Increased sodium C. Increased potassium D. Decreased hematocrit

c. increased potassium A. Acidosis or a decreased pH can occur because of a loss of bicarbonate ions. B. Decreased sodium is expected because large amounts of sodium are lost to third spacing, wound draining, and shifting into cells as potassium is released. C. Hyperkalemia is expected because of massive cellular trauma causing the release of potassium into extracellular fluid. D. An elevated hematocrit is expected because plasma is lost to extravascular spaces, leaving the remaining blood very viscous.

You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first? A. Green B. Yellow C. Red D. Black

c. red The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.

A client has a 32% burn injury to the chest, arms, and legs with the following assessment data. After reviewing the assessment data, the nurse contacts the provider to evaluate the client for the possible development of which potential complication associated with burn injury? Data: RR 32, Temp 101.5, HR 110, BP 110/62, urine output<30mL/hr, BG 220vomiting x1, pt alert, anxious, wounds converted from partial thickness to full thickness in some areas, increased burn wound drainage a. Acute respiratory distress syndrome b. Hypovolemic shock c. Systemic infection d. Acute kidney injury

c. systemic infection Burn-injured clients are at increased risk of local and systemic infection. Signs of infection include elevated temperature, tachycardia, tachypnea, decreased blood pressure, hyperglycemia, decreased gastric function, altered mental status, and the conversion of burn wounds to include increased drainage and poor healing. Acute respiratory distress syndrome, hypovolemic shock, and acute kidney injury are potential complications for burn-injured clients, but the assessment data in the client's chart do not indicate these conditions.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you'd like."

d. "you seem upset. I have time to talk if you'd like" Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client's options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP)

d. apply the transcutaneous pacemaker (TCP) The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.

A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

d. communicate the client's death to the family in a simple and concrete manner When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

A nurse in the emergency department is caring for a client with a spinal cord injury. Which intervention should the nurse prioritize? a. place a small pillow under the client's head for comfort b. move the client gently to decrease pain c. restrain the client's arms and legs to limit movement d. immobilize the client's head and neck

d. immobilize the client's head and neck

A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: A. Increase the IV fluids B. Continue to monitor the patient C. Decrease the IV fluids D. Notify the physician of this finding

d. notify the physician of this finding The patient's urinary output is too low and needs more fluids. It should be at least 30 mL/hr. Therefore, the nurse must notify the physician for further orders. The nurse can NOT increase or decrease IV fluids without a physician's order.

A nurse is assigned to the emergency room during a disaster drill. Clients have been triaged and color-tagged for treatment. Which of the following client groups will the nurse begin treating? a. black b. green c. yellow d. red

d. red Clients in the immediate category have life-threatening injuries and will be assigned red codes. These clients require some intervention to survive. If the nurse does not provide care soon, they may deteriorate and die.

The nurse is caring for a client who has a severe burn injury and is receiving fluid resuscitation. The nurse should assess which laboratory findings to determine the client's response to the therapy? Select all that apply. A. Liver enzyme levels B. Red blood cell count C. White blood cell count D. Serum creatinine levels E. Blood urea nitrogen levels

d. serum creatinine e. BUN Fluid shifts and fluid loss occur in clients with severe burns. Fluid resuscitation is implemented to maintain fluid balance in the client's body. Serum creatinine levels are measured to assess fluid balance in the body, whereas blood urea nitrogen levels give information about kidney function. Fluid resuscitation will not affect the liver enzyme levels, red blood cell count, or white blood cell count. Therefore, it is not necessary to monitor these laboratory values while evaluating the effects of fluid resuscitation.

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. c. ventricular fibrillation. b. sinus tachycardia. d. ventricular tachycardia.

d. ventricular tachycardia The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

There has been an explosion at a local refinery. Numerous serious and life-threatening injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment? a. Child with an open fracture of the arm b. Man with contusion on the head c. Teenager with a closed fracture of the leg d. Woman bleeding heavily

d. woman bleeding heavily

The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply

-Lime -Gasoline -Bleach -Hydrofluoric acid

In assessing the client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Acute Pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

c. reduced self-image A. Acute Pain is relevant in the resuscitation phase of burn injury. B. Potential for inadequate oxygenation is relevant in the resuscitation phase of burn injury. C. In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. D. Potential for infection is relevant in the acute phase of burn injury.

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. 1) Airway 2) Disability 3) Breathing 4) Circulation 5) Cervical spine

1) airway 5) cervical spine Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment.

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? 1) Documenting the patient's care 2) Formulating the patient's plan of care 3) Reassessing the patient's level of consciousness 4) Transferring the patient to the general medical unit

1) documenting the patient's care The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all patient care and administering tetanus prophylaxis.

The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment? 1) Having suction available 2) Assessing pupil size and reactivity 3) Immobilizing any obvious deformities 4) Obtaining blood samples for type and crossmatch

1) having suction available The priority nursing actions related to breathing when conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen.

A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this patient? 1) Implementing decontamination measures 2) Performing a head-to-toe physical examination 3) Placing a special bracelet with a disaster number 4) Taking a digital photo and placing it on the medical record

1) implementing decontamination measures The priority nursing action for a green-tagged patient who arrives at the ED after exposure to radiation is implementing decontamination measures. These measures are the priority because it is essential that members of the health-care team and patients are not exposed to the radiation while providing care.

The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? 1) Two 2) Three 3) Four 4) Five

1) two While it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year.

Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. 1) Treatment 2) Stabilization 3) Evaluation of interventions 4) Formulation of nursing diagnosis 5) Decontamination for suspected contamination

1, 2, 5 Victims need to be treated and stabilized and, if there is known or suspected contamination, decontaminated at the scene

What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply. 1) Airway maintenance 2) Obtaining medical history 3) Ventilation assistance 4) Hemorrhage control 5) Hypothermia prevention

1, 3, 4, 5 Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection.

What is the appropriate interval for an interruption in chest compressions?

10 seconds

The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient?

12-lead electrocardiogram

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound

2) immobilizing the cervical spine 4) preparing for chest tube insertion 5. applying direct pressure to a wound The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.

Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? 1) Less than 10 seconds 2) Less than 15 seconds 3) Less than 30 seconds 4) Less than 60 seconds

2) less than 15 seconds Triage of victims of an emergency or an MCI must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate.

Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful?1) Urine is clear and odorless from indwelling catheter 2) Moves all four extremities independently, feeds self, and participates in partial bath 3) Unable to move independently in bed 4) Rests in bed with lights and television turned off

2) moves all four extremities independently, feeds self, and participates in partial bath The patient sustained neck injuries from a motor vehicle accident. With these types of injuries, there is a risk for paralysis. Evidence that interventions have been successful for this patient includes moving all four extremities independently, feeding self, and participating in partial bath care. This means the patient has mobility, which is a successful outcome.

What is the appropriate dose of dopamine for a patient with bradycardia when the initial dose of atropine was ineffective?

2-10 mcg/kg/min

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness

2. status of airway

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

2. ventricular dysrhythmias

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Call the health care provider. 3. Check the client's status and lead placement 4. Press the recorder button on the electrocardiogram console.

3. check the client's status and lead placement

A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax

4) tension pneumothorax A tension pneumothorax is life threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.

The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) A patient with a leg laceration requiring sutures 2) A patient with abdominal pain rated as a 7 on a numeric pain scale 3) A patient who has multiple trauma due to a motor vehicle accident 4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute

4, 3, 2, 1 When using the Five-Level Emergency Severity Index (ESI), an ESI-1 is the highest priority while an ESI-5 is the lowest priority. The patient who took an overdose of opioids and is experiencing bradypnea (respiratory rate of less than 10 breaths per minute) is the priority at ESI-1. The patient who has multiple trauma due to a motor vehicle accident is an ESI-2. The patient with abdominal pain rated as a 7 using the numeric pain scale is an ESI-3. A patient with a leg laceration requiring sutures is an ESI-4.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1. Ensure that the client has been intubated. 2. Set the defibrillator to the "synchronize" mode. 3. Administer an amiodarone bolus intravenously. 4. Confirm that the rhythm is actually ventricular fibrillation.

4. confirm that the rhythm is actually v-fib

Which action increases the chance of successful conversion of v-fib?

providing quality compressions immediately before defib attempts

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1. Allows bony healing to begin before surgery and involves pins and screws 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

4. provides comfort by reducing muscle spasms, providing fracture immobilization, and involves pulleys and wheels

A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number. ______

6,460 mL

A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred?

6,640 mL First calculate the patient's weight in kg by dividing the weight in lbs. by 2.2 or 187/2.2 = 85 kg. Next use the formula 4 mL x kg of body weight x TBSA % to calculate the total fluid amount needed. For this patient that would be 4 mL x 85 x 38 = 12,920 mL. Since one-half of the total fluid amount should be provided in the first 8 hours, divide the total amount of fluid by 2 or 12,920/2 = 6460 mL. The patient should receive 6460 mL of fluid in the first 8 hours after the burn injury.

The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 hours after fluid resuscitation was started. What is the nurse's best action? A. Assess the client's blood pressure and urine output. B. Notify the physician or the Rapid Response Team. C. Document the report as the only action. D. Increase the IV infusion rate.

A .assess the client's BP and UOP Rationale: The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to assess whether the fluid resuscitation at the current rate is adequate. The best ways to determine adequacy by noninvasive measures is by blood pressure measurement and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, it may need adjustment and the physician should be called.

Heat exhaustion nursing interventions

remove constrictive clothing move to cool area place moist sheet on patient oral fluids electrolyte replacement NS if oral fluids arent tolerated

What is the primary purpose of a medial emergency team (MET) or rapid response team (RRT)?

Identifying and treating early clinical deterioration

It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient?

Open or closed blisters, mild edema, easily blanches

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? A. Large incisions will be made in the eschar to improve circulation B. I can call the doctor back if you want me to C. A piece of skin will be removed and grafted over the burned area D. Dead tissue will be surgically removed

a. large incisions will be made in the eschar to improve circulation

How long must a client with burns wear pressure garments after undergoing biological dressing? a. Once per week b. 24 hours per day c. Daily for a month d. Three hours per day

b. 24 hours per day A client who has undergone biological dressing must wear pressure dressings to help heal grafts and prevent contractures and hypertrophic scars. The client is advised to wear them at least 23 hours per day, every day, until scar tissue is mature (12 to 24 months).

The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his father's arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound

a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries.

Which statement made by a client who experienced 45% total body surface area burns to the face, neck, chest, and arms indicates positive adjustment to the injury? a. "I am planning on returning to work gradually so that I don't get too tired." b. "I am working with my family so they can do all of the chores I used to do." c. "I hope the home care nurse can change my dressings so that I do not have to look at my wounds." d. "My wife and I have decided to go to movies instead of baseball games so that people can't see me."

a. "I am planning on returning to work gradually so that I don't get too tired." Reintegrating into the family situation, assuming the roles and responsibilities performed before the injury, and gradual reintegration back into the community and work are positive signs of beginning successful adjustment. Not looking at the wounds and not participating in family life are indicators of poor adjustment. Although it is good that the client is venturing outside of the home, the fact that he wants to remain unseen is a less positive indicator of adjustment.

A client with severe hypothermia has been stabilized and is now rewarming. Which diagnostic test should the nurse expect to assess the effects of the​ hypothermia? (Select all that​ apply.) a. Arterial blood gas​ (ABG) b. Complete blood count​ (CBC) c. Electrocardiogram​ (ECG) d. Electroencephalogram​ (EEG) e. Cardiac enzymes

a. ABGs b. CBC c. EKG e. cardiac enzymes

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? 1. Prothrombin time of 12.5 seconds 2. Activated partial thromboplastin time of 60 seconds 3. Activated partial thromboplastin time of 28 seconds 4. Activated partial thromboplastin time longer than 120 seconds

2. activated partial thromboplastin time (PTT) of 60 seconds

The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms?1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Hypertension and headache

3. hypotension and dizziness

Which statement made by the client who experienced burns to the head and neck indicates positive adjustment to the injury? A. "I am planning on cutting the grass in the mornings when the sun isn't as strong." B. "I am working with my family so they can do all of the chores I used to do." C. "I hope the home care nurse can change my dressings so that I do not have to look at my wounds." D. "My wife and I have decided to go to movies instead of baseball games so that people can't see me."

A Rationale: Reintegrating into the family situation and assuming the roles and responsibilities performed before the injury are positive signs of beginning successful adjustment. Not looking at the wounds and not participating in family life are indicators of poor adjustment. Although it is good that the client is venturing outside of the home, the fact that he wants to remain unseen is a less positive indicator of adjustment.

A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to: A. Elevate and extend the extremities B. Elevate and flex the extremities C. Keep extremities below heart level and extended D. Keep extremities level with the heart level and flexed

A. Elevate and extend the extremities This position will decrease edema, which will help prevent compartment syndrome.

Which action is a component of high quality chest compressions?

Allowing the chest to completely recoil

You're providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition? A. "Patients are most likely to present with cyanosis around the lips and face." B. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." C. "Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia." D. "Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning."

B. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body."

A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. What signs and symptoms can present with this condition? A. Swelling and pain on the area distal to the burn B. Burning, gnawing sensation pain in the stomach and vomiting C. Dark red or gray sores on the soles of the feet D. Difficulty swallowing and gagging

B. Burning, gnawing sensation pain in the stomach and vomiting This is a type of ulcer that occurs in the stomach, duodenum, due to a high amount of stress on the body from a burn. The blood supply to the factors that help protect the stomach lining from gastric erosion decreases and this allows for ulcers to form.

A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this ventricular fibrillation on the monitor and immediately takes which action?

CPR, call code, D-fibPT is in V-fib

The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off, the longer it will take me to heal." What is the nurse's best response? A. "Do you want some pain medication before I begin?" B. "The only things I am removing are blocks of bacteria growth, not skin." C. "Don't worry, I have worked the burn unit for years and know what I am doing." D. "This tissue is no longer living and as long as it is present, real healing cannot start."

D Rationale: Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful

For which type of burn injury is it most important for the nurse to assess the client for a respiratory injury? A Hot liquid scald burn B Liquid chemical burn C Electrical burn D Dry heat burn

D. Dry heat burn

A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg, Heart rate: 140 beats/min, Respiratory rate: 35 breaths/min, Bleeding from stabbing wound site, Client is lethargic. Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV

a. level I The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible.

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply: a. AKI b. dysrhythmias c. iceberg effect d. hypernatremia e. bone fractures f. fluid volume overload

a. AKI b. dysrhythmia c. iceberg effect e. bone fractures Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.

A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.

a. Allow the student to participate on the soccer team In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal

On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained ventricular tachycardia (VT). The nurse checks the patient and finds him alert and oriented with no reports of chest pain, but feeling slightly short of breath. His blood pressure is 108/70. What is the nurse's first action? A. Administration of oxygen and observation of the heart rhythm B. Administration of IV amiodarone (Cordarone) and dextrose C. Synchronized cardioversion D. CPR and immediate defibrillation

a. administration of oxygen and observation of the heart rhythm Rationale: Current advanced cardiac life support (ACLS) guidelines recommend administration of oxygen and observation of heart rhythm first, followed by administration of an IV antidysrhythmic agent such as amiodarone mixed with dextrose 5%. Synchronized cardioversion would be the next step. CPR and immediate defibrillation would be used only to treat unstable VT.

An escharotomy must be performed in a client admitted for burns. Which statement accurately describes this procedure? a. An incision is made through the burn eschar. b. Anesthesia is administered to the client for pain. c. Analgesia is not administered with this procedure. d. The procedure is performed in the surgical suite

a. an incision is made through the burn eschar Escharotomy is a surgical procedure that is performed to treat inadequate tissue perfusion in the client with severe burns. In this procedure, an incision is made through the burn eschar. It helps to relive the pressure caused due to fluid accumulation near the chest and improves circulation. It is not necessary to administer anesthesia to the client as the nerve endings are destroyed due to the injury. The client is given sedation and analgesia to reduce anxiety. Although escharotomy is a surgical procedure, it is often performed in a treatment room.

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about a. anticoagulant therapy. c. emergency cardioversion. b. permanent pacemakers. d. IV adenosine (Adenocard).

a. anticoagulant therapy Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first? a. Assess that the client is breathing adequately b. Insert a large-bore intravenous line c. Place the client on a cardiac monitor d. Assess for best neurologic response

a. assess that the client is breathing adequately The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be breathing inadequately with the device in place.

Which of the following is an appropriate response by a nurse in the ICU to a family member who will not leave the client's room during a resuscitation? a. assign a staff member to stay with the family member to answer questions and provide explanations while the code proceeds b. tell the family member that universal medical guidelines prevent family members from being present during emergencies in the ICU c. notify security and ask them to escort the family member from the ICU d. ask the family member to remain in an area outside of the room

a. assign a staff member to stay with the family member to answer and provide any explanations while the code proceeds During an emergency resuscitation/code, family members should be allowed to stay in the room if they are not disrupting client care. Staff members should be assigned to stay with the family member to explain the interventions during a code. Family members may benefit from witnessing efforts at resuscitation, even if the result is poor. If a family member becomes disruptive, the charge nurse should escort the person from the room.

Which symptom does the nurse that may indicate a pulmonary injury from the inhalation? SATA a. Brassy cough b. Drooling c. Clear speech d. Audible wheezes e. clear breath sounds

a. brassy cough b. drooling d. audible wheezes

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action? A. Direct the clients to the decontamination area. B. Direct the clients to the cold or clean zone for immediate treatment. C. Measure vital signs and auscultate lung sounds. D. Immediately remove other clients and visitors from the area. E. Instruct personnel to don personal protective equipment.

a. direct the clients to the decontamination area

A nurse is assessing a client who is in the resuscitation phase of a deep partial-thickness burn over 40% of his body. Which of the following findings should the nurse expect during this phase of the burn injury? (select all that apply) a. dyspnea b. bradycardia c. hyperkalemia d. hyponatremia e. decreased hematocrit

a. dyspnea c. hyperkalemia d. hyponatremia Dyspnea can occur during the resuscitation phase following a burn due to the direct or indirect airway injury. Retention of fluid though cellular shifts and leakage results in excess fluid in the lungs, disrupting gas exchange and causing shortness of breath. Hyperkalemia occurs during the resuscitation phase following a burn as a result of leakage of fluid from the intracellular space, tissue damage, and RBC hemolysis. Hyponatremia occurs during the resuscitation phase of a burn as a result of sodium retention in the interstitial space and fluid losses due to tissue leakage.

The client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

a. encouraging participation in wound care A. Encouraging participation in wound care will offer the client some sense of control. B. Encouraging visitors may be a good distraction but will not help the client achieve a sense of control. C. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. It does nothing to help the client achieve a sense of control. D. Telling the client that his or her feelings are normal may be reassuring but does not address the issue of restoring a sense of control.

What are some patient priorities during the emergent phase of burn management? A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition

a. fluid volume b. respiratory status This phase starts from the onset of the burn and ends with the restoration of capillary permeability. Wound closure, and nutrition would be during the acute phase, and would continue into the rehabilitative phase. Psychosocial would be in the rehab phase.

The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? A. Furosemide (Lasix) B. Digoxin (Lanoxin) C. Dopamine (Inotropin) D. Morphine sulfate

a. furosemide (Lasix) A. Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs. B. Digoxin may be used to strengthen the force of myocardial contractions in older adult clients. C. Dopamine may be given to increase cardiac output in older adult clients. D. Morphine sulfate may be indicated for pain management.

As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: a. hemoglobin and myoglobin b. free iron and WBCs c. protein and RBCs d. K+ and Urea

a. hemoglobin and myoglobin Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient's urine for these substances.

Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a client with burn injury? a. Hyperkalemia b. Hypernatremia c. Hypochloremia d. Hypoglycemia

a. hyperkalemia Hyperkalemia may occur during the resuscitation phase of burn injury because of the tissue destruction, disruption of the sodium-potassium pump, and red blood cell hemolysis. Hyponatremia (not hypernatremia), hyperchloremia (not hypochloremia), and hyperglycemia (not hypoglycemia) may also occur.

A client who was successfully resuscitated after a burn injury begins diuresis 3 days after admission. For which assessment findings does the nurse observe during this phase of the injury? Select all that apply. a. Hyponatremia b. Hyperkalemia c. Hypotension d. Weight gain e. Metabolic acidosis f. Metabolic alkalosis

a. hyponatremia c. hypotension 3. metabolic acidosis Fluid remobilization starts at about 24 hours postinjury and the diuretic phase begins at about 48-72 hours after burn injury. Interstitial fluids mobilize and diuresis results in hypotension, hyponatremia, hypokalemia, weight loss, and possible metabolic acidosis from loss of bicarbonate in the urine and increased metabolism.

Signs or symptoms of symptomatic ventricular dysrhythmias include which of the following? (Select all that apply.) A. Hypotension B. Dizziness C. Fever D. Shortness of breath E. Hypertension

a. hypotension b. dizziness d. SOB

A client with full-thickness burns to the lower extremities has had emergent fasciotomies. What assessment parameter does the nurse monitor to evaluate the effectiveness of the fasciotomies? a. Improved distal pulses b. Reduced edema c. Improved blood pressure d. Reduced fluid resuscitation needs

a. improved distal pulses When edema is severe under the eschar of a full-thickness wound, blood flow to the area is compromised. Incisions, escharotomies, or fasciotomies are performed to relieve the growing pressure under the eschar. After the escharotomy or fasciotomy is performed, the assessment of improved perfusion is achieved by evaluating pulses distal to the procedure. Edema may not be reduced immediately due to inflammation from the incision. Blood pressure may be slightly elevated secondary to discomfort following the procedure. A fasciotomy does not necessarily indicate that fluid resuscitation will no longer be required.

To position the client's burned upper extremities appropriately, how will the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

a. in a neutral position A. The neutral position is the correct placement of the elbow to prevent contracture development. B. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. C. The slightly flexed position increases the risk for contracture development. D. The slightly hyperextended position is not indicated and can be painful.

A nurse is planning care for a client wh ois in the acute phase of recovery from major burn injuries. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. limit visitors in the client's room b. encourage raw veggies in the client's diet c. instruct the client to increase protein intake d. instruct the client to consume a maximum of 2,000 calories per day e. encourage the client to perform ROM exercises daily.

a. limit visitors in the client's room c. instruct the client to increase protein intake e. encourage the client to perform ROM exercises daily a. limits the risk for infection b. promotes would healing and prevents tissue breakdown c. ROM exercises 3x daily and performing exercises of hands/fingers hourly while awake

A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the EMS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? A. Lorazepam (Ativan) IV. B. Magnesium sulfate IV. C. Carbamazepine (Tegretol) IV. D. Phenytoin and Carbamazepine PO.

a. lorazepam (Ativan) IV

Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)? a. Moderate burn b. Major burn c. Minor burn d. Severe burn

a. moderate burn Deep partial-thickness burns affecting 15% to 25% TBSA are classified as moderate burns. Partial-thickness burns affecting more than 25% of TBSA are classified as major burns. Deep partial-thickness burns affecting less than 15% of TBSA are considered minor burns. Burns are categorized as three types: major, minor, and moderate; there is no "severe" burn category.

The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white blisters B. Painless, brownish-yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

a. painful red and white blisters A. Painful red and white blisters accompany a deep partial-thickness burn. B. Painless, brownish-yellow eschar accompanies a full-thickness burn. C. A painful reddened blister accompanies a superficial partial-thickness burn. D. Painless black skin with eschar accompanies a deep full-thickness burn.

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: A. Place the patient in High Fowler's position. B. Prep the patient for escharotomy. C. Prep the patient for fasciotomy. D. Prep the patient for intubation. E. Place a pillow under the patient's neck. F. Obtain IV access at two sites. G. Restrict fluids.

a. place the patient in high-fowler's position b. prep the patient for escharotomy d. prep the patient for intubation f. obtain IV access at 2 sites After reading this scenario the location of the burns and the patient's presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness....will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient's VS, we see that the respiratory effort is compromised majorly AND that there is a risk of inhalation injury since the patient is coughing up black sooty sputum. Therefore, the nurse should place the patient in high Fowler's position to help with respiratory effort (unless contraindicated with spinal injuries), prep the patient for escharotomy (this will cut the eschar and help relieve pressure and allow for breathing) and prep for intubation to help with the respiratory distress. In addition, obtain IV access in at least two sites for fluid replacement....remember the first 24 hours after a burn a patient is at risk for hypovolemic shock.

A nurse is participating in a disaster simulation in which a toxic substance has been released into a crowded stadium. Multiple clients are transported to the facility. Which of the following actions should the nurse take first? a. prevent cross-contamination of clients b. complete a thorough client assessment c. treat clients arriving at the facility who have yellow triage tags d. maintain a client tracking system

a. prevent cross-contamination of clients a disaster involving the release of a toxic substance indicates that the clients are at greatest risk for cross-contamination between nonexposed clients and exposed clients. Therefore, the priority action is to promote safety of the clients by separating them to prevent cross-contamination and limit the spread of the unknown toxin.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

a. provide a calm location for the family to cope and discuss needs The nurse should first provide emotional support by encouraging relaxation, listening to the family's needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family's needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family's needs.

The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

a. reduction of bacterial growth in the wound and prevention of systemic sepsis A. Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds. B. Topical antimicrobials such as sulfadiazine do not prevent cross-contamination from other clients in the unit. C. Topical antimicrobials such as sulfadiazine do not enhance cell growth. D. Use of topical antimicrobials such as sulfadiazine does not minimize the need for a skin graft.

Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair

a. removing wet clothing c. initiating IV fluids d. endotracheal intubation f. needle decompression The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out.

A client who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the client after providing fluid resuscitation? a. Serum sodium levels b. Hemoglobin levels c. Alanine aminotransferase d. Serum cholesterol levels

a. serum sodium levels Renal failure is caused due to the accumulation of large amounts of proteins and myoglobin in the kidneys as a result of muscle damage. Fluid resuscitation must be provided to the client in order to maintain a rate of 30 to 50 mL of urine output. Serum sodium levels, serum creatinine levels, and specific gravity of the urine must be monitored every hour after providing fluid resuscitation to the client—it helps to assess kidney function. Hemoglobin levels can be monitored in case of anemia; hemoglobin levels are not an indicator of kidney function. Alanine aminotransferase is an enzyme that is secreted by the liver and is an indicator of hepatic functioning.

The nurse is caring for a client diagnosed with frostbite. The nurse understands that which process occurs when tissue​ freezes? (Select all that​ apply.) a. Tissues and cells become edematous b. Intracellular potassium increases c. Vascular permeability occurs d. Thinning of the blood occurs e. Ice crystals form.

a. tissues and cells become edematous c. vascular permeability occurs e. ice crystals form

What should the nurse do with clients who arrive at the hospital on their own following a mass casualty disaster in the community? a. triage just like the clients coming by ambulance b. ask these clients to wait in the waiting room c. put these clients into a treatment room d. have the clients document their symptoms in writing.

a. triage just like the clients coming by ambulance Triage of clients following a disaster who walk into the facility should occur in the same way as for clients arriving by other modes of transportation, including an ambulance

After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question should the nursing supervisor ask at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all areas of the hospital have the supplies and personnel they need?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Does the Chief Medical Officer agree this disaster is under control?"

b. "do all areas of the hospital have the supplies and personnel they need?" Before "standing down," the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more "walking wounded" victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can "stand down."

A client who is having burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." What is the correct response? a. "Do I cause more pain than the other nurses?" b. "Tell me more about that." c. "Let me get you more pain medication." d. "You have the right to your judgments."

b. "tell me more about that"

After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention and those with less serious condition. 1. An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown. 2. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job. 3. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue. 4. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis. A. 4, 3, 2, 1 B. 1, 2, 4, 3 C. 1, 4, 2, 3 D. 4, 1, 3, 2

b. 1, 2, 4, 3

A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 46% B. 37% C. 36% D. 28%

b. 37% Back of right arm (4.5%), posterior trunk (18%), front of left leg (9%), anterior head and neck (4.5%) and perineum (1%) which equals 37%.

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

b. give a sedative before cardioversion is implemented When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor? A. Blood glucose B. C-reactive protein C. Serum and urine creatinine D. Platelet count

c. serum and urine creatinine A. 2 Topical gentamicin sulfate does not affect blood sugar. B. C-reactive protein is used as a marker of inflammation. C. Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment. D. Topical gentamicin sulfate does not alter platelet counts.

Select the patient below who is at MOST risk for complications following a burn: A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. C. A 36 year old male with full-thickness burns on the front of the left arm. D. A 10 year old with superficial burns on the right leg.

b. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. When thinking about which patient will have the MOST complications following a burn think about: percentage of the total body surface area that is burned (use the rule of nine to calculate), depth of the burn, age, location of the burn, and patient's medical history. The patient in option B has 40.5% TSBA burned (option A 27%, C: 4.5%, D: 9%). Remember that the higher the total of the body surface area that is burned the higher the risk of complications due to an increase in capillary permeability (swelling, hypovolemic shock etc.). In addition, the location of the burn is a major issue with the patient in option B. The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury. And with torso burns that are on the front and back, the patient is at risk for circumferential burns that can lead to further respiratory compromise. The other options have burns that are isolated.

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

b. active internal rewarming using warmed IV fluids

Twenty minutes later, assessment of the patient reveals loud wheezing on exhalation. What is the nurse's best action at this time? A. Check the pts. SaO2 with pulse oximetry B. Apply oxygen and call the Rapid Response Team C. Call a CODE and bring the crash cart to the room D. Call respiratory therapy for bronchodilator treatment

b. apply oxygen and call the rapid response team

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. What should the nurse do next? a. Request that the client's spouse sit in the waiting room b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

b. ask the spouse if he wishes to be present during the resuscitation If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply: A. Place cold compressions on the burn and place the right leg below the heart level B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level D. Place gauze securely around the leg to prevent infection

b. assess the distal pulses in the right extremity c. elevate the right leg above the heart level The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.

When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant? A. Help the family to collect belongings. B. Assisting with postmortem care. C. Facilitate meeting between the family and the organ donor specialist. D. Escorting the family to a place of privacy.

b. assisting with postmortem care

An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.

b. begin bag-valve-mask ventilation Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax.

A nurse is caring for a client on the telemetry unit and sees v-fib on the monitor. Which of the following is the priority action by the nurse? a. place an OPA or an NPA b. begin chest compressions c. request a 12-lead EKG d. call the healthcare provider

b. begin chest compressions Ventricular fibrillation is a terminal rhythm that indicates cardiac arrest. Immediate initiation of CPR, beginning with chest compressions, is associated with improved outcomes. Defib should be performed as soon as the defibrillator or AED is available. V-fib represents chaotic electrical activity in the heart with ineffective pumping and no CO.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

b. don PPE Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

As the nurse, you know that the following can cause rhythm disorders: (Select all that apply.) A. Exercise B. Electrolyte imbalances C. Myocardial hypertrophy D. Myocardial damage E. Eating red meat

b. electrolyte imbalances c. myocardial hypertrophy d. myocardial damage

A client treated with bumetanide (Bumex) has a prescription for magnesium after lab studies revealed Mg 0.8 mEq/L. The nurse knows that IV mag is used to treat which of the following rhythms? a. third-degree heart block b. torsades de pointes c. multifocal atrial tachycardia d. a-fib

b. torsades de pointes Normal Mg: 1.8 mEq/L

The nurse is reviewing the orders for a client admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider? a. Daily weights b. Hold omeprazole (Prilosec) c. Fentanyl (Actiq) 50 mcg IV every 4 hours PRN for pain d. Activity as tolerated

b. hold omeprazole (Prilosec) The nurse should question the order to hold omeprazole, a proton pump inhibitor agent. Clients with burn injury are at increased risk of developing an acute gastroduodenal ulcer (Curling's ulcer) within the first 24 hours after a severe burn injury because of reduced blood flow to the gastrointestinal tract and mucosal lining damage. Proton pump inhibitors and H2-histamine blocking agents along with early enteral feedings are important interventions to prevent this complication. Daily weights, IV opioid agents for pain management, and activity orders are appropriate for clients with burn injuries.

A nurse is caring for a client who has been resuscitated after cardiac arrest with pulseless electrical activity (PEA). When considering the causes for PEA, what are the "H's" associated with this rhythm? a. hypervolemia, hypoxia, hypothermia, hypokalemia, and hydrogen ion accumulation b. hypovolemia, hypoxia, hypothermia, hyperkalemia, hypokalemia, and hydrogen ion accumulation c. hypovolemia, hypoxia, hypothermia, hypercalcemia, hypokalemia, and hydrogen ion accumulation d. hypovolemia, hypoxia, hypothermia, hyperkalemia, hypokalemia, and hydrogen ion accumulation

b. hypovolemia, hypoxia, hypothermia, hyperkalemia, hypokalemia, and hydrogen ion accumulation

Which alteration observed in a client rescued from a fire indicates pulmonary injury? a. Exhaling through the mouth b. Inability to swallow fluids c. Reporting dizziness d. Coughing with sputum

b. inability to swallow fluids The client who has been rescued from a fire may have pulmonary injury due to inhalation of carbon monoxide. Pulmonary injury is characterized by difficulty in swallowing and a brassy cough. Exhaling through the mouth is not an indication of pulmonary injury. Even in deep breathing or in congestion, clients exhale through the mouth. The client may have dizziness due to an imbalance in body fluids and electrolytes. Carbonaceous sputum indicates pulmonary injury or airway obstruction. Cough with sputum can be seen with infections or chronic obstructive pulmonary disorder (COPD); it does not indicate pulmonary injury.

A nurse in the emergency department is caring for a client who has experienced an electrical burn. Which of the following nursing interventions is most appropriate in this situation? a. brush of dirt particles and debris b. monitor for cardiac arrhythmias c. cool the client with water d. lower the client's head

b. monitor the client for cardiac arrhythmias A client with an electrical burn may experience cardiac arrhythmia if the electrical current disrupts the cardiac electrical cycle. The nurse should monitor for signs of cardiac arrhythmias and provide CPR in the case of cardiac arrest.

Which method must be employed during hydrotherapy for the debridement of a wound in the client with acid burns? a. The wound must be cleaned three times a week. b. Nonviable tissue must be removed by forceps. c. The wounds are rinsed with cold water. d. Small blisters are opened with scissors.

b. nonviable tissue must be removed by forceps Nonviable tissue must not be touched with bare hands; it must be removed using scissors and forceps to avoid infection. The wound must be cleaned once or twice a day to avoid microbial infections. The wound must be rinsed with water at room temperature because it enhances the circulation of blood due to vasodilation. Small blisters must not be opened because they help in wound healing and act as covers and protective barriers.

A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? a. Give epinephrine (Adrenalin) IV. b. Perform immediate defibrillation. c. Prepare for endotracheal intubation. d. Ventilate with a bag-valve-mask device.

b. perform immediate defibrillation The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first.

A nurse is caring for a male client with extensive 2nd and 3rd degree burn injuries. Which of the following lab values should be reported immediately to the healthcare provider? a. glucose of 200 mg/dL b. potassium of 6.1 mEq/L c. Hgb of 19 g/dL d. Hct of 55%

b. potassium of 6.1 mEq/L Individuals with extensive burn injuries lose fluid and have increased metabolic demand. Fluid loss can result in electrolyte abnormalities. Fluid and electrolyte imbalances in clients with burns should be monitored closely by the nurse. A potassium level of 6.1 mEq/L represents moderate hyperkalemia, which can result in arrhythmias. If hyperkalemia is untreated, it may progress and result in death. This is the priority value to report.

From an assessment of vital​ signs, the nurse learns that a client has a body temperature of​ 35.7°C (96.2°F). Which action should the nurse​ take? (Select all that​ apply.) a. Provide oral hygiene b. Provide warm oral fluids c. Cover with a warmed blanket d. Administer a tepid sponge bath e. Cover the head with a cap.

b. provide warm oral fluids c. cover with a warmed blanket e. cover the head with a cap

The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

b. red

The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

b. red

The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

b. red

The nurse is teaching a class about the clinical manifestations of hypothermia. Which information should the nurse​ include? (Select all that​ apply.) a. If frostbite is​ noted, the area should be rubbed vigorously b. The clinical presentation of the client should determine the severity of hypothermia c. Clients diagnosed with hypothermia should undergo a complete body survey d. A client diagnosed with hypothermia who is unresponsive and without a pulse should be declared dead e. Clients diagnosed with hypothermia should be encouraged to ambulate.

b. the clinical presentation of the client should determine the severity of hypothermia c. clients diagnosed with hypothermia should undergo a complete body survey

Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

b. young adult who suffered burn injuries in a closed space A. Clients typically have some type of respiratory distress. However, the client is talking without difficulty, which shows that the client has minimal respiratory distress. B. The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. C. Extensive burns to the hands and face, not the extremities, would be a greater risk. D. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

c. "in a disaster, extensive resources are not used for one person at the expense of many others." In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not "sacrificed." Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions. 1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant. 2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week. 3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days. 4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night. 5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour. A. 2,5,3,4,1 B. 3,1,4,5,2 C. 5,1,3,2,4 D. 2,5,1,4,3

c. 5, 1, 3, 2, 4

A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 40.5% B. 49.5% C. 58.5% D. 67.5%

c. 58.5% Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%.

The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102° F d. 50-year-old male with new-onset confusion and slurred speech

c. 75 y/o female with a cough and a temp of 102° F A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including O2 saturation.

c. Give supplemental O2 at 2-3 L/min via nasal cannula Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly.

The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first? A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating. B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade. C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown. D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.

c. a homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown

The nurse admits a client diagnosed with moderate hypothermia. Which finding should the nurse expect to observe during the physical​ assessment? a. Flushing b. Tachycardia c. Absence of shivering d. Tachypnea

c. absence of shivering shivering disappears at 86 degrees

A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is priority at this time? A. Impaired skin integrity B. Risk for fluid volume overload C. Risk for infection D. Ineffective coping

c. risk for infection The patient is now in the acute phase where fluid resuscitation was successful and ends with wound closure. Therefore, during this stage diuresis occurs (so fluid volume deficient could occur NOT overload) and INFECTION. The location of the burns increases the risk of infection because these areas naturally harbor bacteria. Therefore, this takes priority because during this phase wound healing is promoted.

A nurse in the emergency department is caring for a client who complains of "heart palpitations". After an ECG, the physician determines that the client is in atrial fibrillation. Which of the following nursing interventions is most appropriate with this diagnosis? a. prepare the client for unsynchronized cardioversion b. administer 100% oxygen and prepare to assist with endotracheal intubation c. administer anticoagulant therapy as ordered d. monitor intake and output for the next 24 hours

c. administer anticoagulant therapy as ordered Anticoagulant meds are commonly prescribed for a-fib to reduce the risk of stroke from thromboembolism due to pooling of blood in the atrium. If the client has a rapid ventricular response, then agents may be given to control rate and rhythm. a. synchronized cardioversion is usually performed after the client is anticoagulated, to avoid the risk of stroke b. the client may need O2 if he is experiencing SOB, but no indication is given for rapid intubation in this client

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: A. Prevent hypothermia B. Assess the blood pressure C. Assess the airway D. Prevent infection

c. assess the airway Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

Answer: C. Being aware of the agency's emergency response plan. In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents? A. Being aware of the signs and symptoms of potential agents of bioterrorism. B. Making ethical decisions regarding exposing self to potentially lethal substances. C. Being aware of the agency's emergency response plan. D. Being aware of what and how to report to the Centers for Disease Control and Prevention.

c. being aware of the agency's emergency response plan

Answer: C. Doing chest compressions. The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? A. Assisting with the intubation. B. Placing the defibrillator pads. C. Doing chest compressions. D. Initiating bag valve mask ventilation.

c. doing chest compressions

1. A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

c. encourage counseling upon deactivation of the emergency response plan To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each other's stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

Which dietary guideline must be followed for a client with a large burn area? a. The diet must be low-calorie and high-protein. b. The client must not be encouraged to have solid foods. c. Feeding can be started within 4 hours of fluid resuscitation. d. The nutritional value of the diet must be less than 5000 kcal/day.

c. feeding can be started within 4 hours of fluid resuscitation After starting fluid resuscitation feeding can begin for the client within 4 hours—this helps to provide stamina and energy to the client. The client requires a high amount of protein and calories for wound healing and tissue repair. The client must be encouraged to have solid food, to ingest as many calories as possible. A client who has a large burn area requires a diet with a nutritional value of more than 5000 kcal/day for effective body functioning.

The nurse is planning care for a client admitted with a diagnosis of moderate hypothermia. Which intervention is most appropriate to include in the plan of​ care? a. Perform diligent oral care b. Closely monitor for dehydration c. Handle the client gently to avoid cardiac stimulation d. Minimize heat exposure.

c. handle the client gently to avoid cardiac stimulation These patients are at risk for refractory v-fib so they need to be handled gently!!

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare to give IV amiodarone per agency dysrhythmia protocol. d. Perform synchronized cardioversion per agency dysrhythmia protocol.

c. prepare to give IV amiodarone per agency dysrhythmia protocol The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.

c. prioritize clients based on illness and severity ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the "head of the line."

A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route?A. The drug will be effective more quickly than if given IM or subcutaneously. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client has delayed gastric emptying.

c. the danger of an overdose during fluid remobilization is reduced Rationale: Although providing some pain relief is a high priority and giving the drug by the IV route instead of the IM, subcutaneous, or oral routes does increase the rate of effect, the most important reason is to prevent an overdose from the accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed while the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

c. use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10 This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer.

A nurse in an emergency department is admitting a client who is lethargic and unable to complete sentences. The client has a HR of 34 BPM and a BP of 83/48 mm Hg. The nurse applies electrodes to the client's chest and limbs and the ECG monitor shows a complete heart block. Which of the following actions should the nurse take first? a. transport the client to the cath lab b. prepare the client for insertion of a transvenous pacemaker c. activate the emergency response system and be prepared to perform CPR d. apply transcutaneous pacemaker pads

d. apply transcutaneous pacemaker pads The greatest risk to this client is injury or death from inadequate CO and tissue perfusion. Therefore, the first action the nurse should take is to apply transcutaneous pacemaker pads and begin external pacing of the heart until a temporary transvenous or permanent implanted pacemaker can be placed. Transcutaneous pacing is appropriate for emergency use, but is intended only for short periods of time because it causes the client significant discomfort.

The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

d. black

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned? A. Green B. Red C. Yellow D. Black

d. black The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Initiation of pulse oximetry. B. Complete set of vital signs. C. Client's allergy history. D. Brief neurologic assessment.

d. brief neuro assessment

The nurse caring for a client with hypothermia understands the compensatory mechanisms that are activated during this condition to decrease oxygen demands on the body. Which clinical manifestation should the nurse expect upon assessment for this​ client? (Select all that​ apply.) a. Increased respiratory rate b. Increased GI motility c. Increased heart rate d. Decreased respiratory rate e. Decreased heart rate

d. decreased RR e. decreased HR

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

d. direct medical-surgical and critical care nurses to assist with clients currently in the EF while emergency staff prepare to receive the mass casualty victims The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A. Bleeding around the lacerations. B. Withdrawal of the client in response to painful stimuli. C. Bruises and minimal edema of the eyelids. D. Drainage of a clear fluid from the client's nose.

d. drainage of a clear fluid from the client's nose

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

d. multiple fractured ribs and SOB Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent.

The client is in the acute phase of burn injury. In which situation will the nurse decide to coordinate with the dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

d. planning additions to the standard nutritional pattern A. It is fine for the client with a burn injury to have food brought in from the outside. B. The hospital kitchen can be consulted to see what other food options may be available to the client. C. It is not therapeutic for the client with burn injury to lose weight. D. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red. B. The client reports that the area hurts when touched. C. The area does not blanch when firm pressure is applied. D. Thrombosed blood vessels are visible beneath the skin surface.

d. thrombosed blood vessels are visible beneath the skin surface

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What will the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

d. titrate fluid replacement A. A common mistake in treatment is giving diuretics to increase urine output. Diuretics do not increase cardiac output. They actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. B. Fluid boluses are avoided because they increase capillary pressure and worsen edema. C. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital. D. The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).

The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people

d. underinsured people The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care.

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

elective cardioversion

Cardioversion

•Synchronized countershock •Used in emergencies for unstable ventricular/supraventricular tachydysrhythmias •Used electively for stable tachydysrhythmias resistant to medical therapies

Clinical signs of heat exhaustion

tachycardia dilated pupils mild confusion ashen color profuse diaphoresis hypotension temp: 99.6-104