Exam 2 Practice Questions

Which parameter indicates to the nurse that the short-acting beta-adrenergic agonist the client used 5 minutes ago for an acute asthma attack is effective? A. SpO2 decreased from 85% to 78% B. Peak expiratory flow increase from 50% to 70% C. The obvious use of accessory muscles during inhalation D. Active bubbling in the humidifier chamber of the oxygen delivery system

Answer: B. Peak expiratory flow increase from 50% to 70% Rationale: Peak flow measures the effectiveness of expiratory efforts. An increased peak flow rate indicates less obstruction and greater movement of air with expiratory effort. Decreased SpO2 would indicate a worsening of the condition, not effectiveness of the therapy. The use of accessory muscles indicates that the work of breathing has increased. The active bubbling in the humidification chamber is not related to the client's respiratory effort or the drug therapy's effectiveness. Iggy p. 557, Safe and Effective Care Environment

What type of acid-base problem does the nurse expect in a client who is being insufficiently mechanically ventilated and whose most recent arterial blood gas results include a pH of 7.29? A. Metabolic acidosis with an acid excess B. Metabolic acidosis with a base deficit C. Respiratory acidosis with an acid excess D. Respiratory acidosis with a base deficit

Answer: C. Respiratory acidosis with an acid excess Rationale: The pH is lower than normal indicating acidosis. With insufficient ventilation the client is retaining carbon dioxide as a result of insufficient ventilation, making the acidosis respiratory in nature rather than metabolic. Carbon dioxide and hydrogen ion level are directly related. Thus, the retained carbon dioxide is causing an excess of acids. Iggy p. 183, Psychosocial Integrity

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has twitching muscle contractions in the lower extremities. B. The client's skin is cool and clammy. C. The urine specific gravity is increased. D. The hematocrit is 52%.

Answer: D) The hematocrit is 52%. Rationale: The serum sodium level is elevated, indicating hypernatremia. The elevation could be from an actual increase in sodium or from a loss of fluids only. A relative hypernatremia can occur as a result of dehydration (excessive fluid loss) without sodium loss. Such dehydration is usually accompanied by hemoconcentration. The higher than normal hematocrit suggests hemoconcentration. Iggy p. 163, Physiological Integrity

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours alerts the nurse to the possibility of oxygen toxicity? A. Oxygen saturation greater than 100% B. Decreased rate and depth of respiration C. Wheezing on inhalation and exhalation D. Discomfort or pain under the sternum

Answer: D. Discomfort or pain under the sternum Rationale: Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. Initial manifestations include dyspnea, nonproductive cough, chest pain beneath the sternum, and gastrointestinal upset. Oxygen saturation falls, not increases. Breathing becomes more rapid with the sensation of dyspnea. Wheezing represents airway obstruction, not damage to the alveolar membrane. Iggy p. 516, Physiological Integrity

The nurse caring for a client who is intubated and receiving mechanical ventilation notes that her oxygen saturation is 89%, her heart rate is 120 beats/min, and she is increasingly agitated and restless. On auscultation, the nurse finds the lung sounds are diminished on one side. Which action does the nurse perform first? A. Notify the provider and prepare for re-intubation or repositioning the tube. B. Document the findings and request sedation from the provider. C. Call respiratory therapy to obtain a set of arterial blood gasses. D. Reposition the tube, and call radiology for a stat chest x-ray.

Answer: A) Notify the provider and prepare for re-intubation or repositioning the tube. Rationale: With the decreased oxygen saturation and decreased breath sounds on one side, the endotracheal tube is incorrectly positioned into one bronchus. For effective gas exchange, the tube must be repositioned, which is a health care provider function, not a nursing function. Iggy p. 616, Safe and Effective Care Environment

Which question is most important for the nurse to ask the client who has a serum potassium level of 2.9 mEq/L? A. "Do you use sugar substitutes?" B. "Do you use diuretics or laxatives?" C. "Have you had any muscle twitches or cramps, especially at night? D. "Have you or any member of your family ever been diagnosed with lung disease?"

Answer: B. "Do you use diuretics or laxatives?" Rationale: The serum potassium level is low, and the client has hypokalemia. Misuse or overuse of diuretics, especially high -ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia among older adults and clients with eating disorders. Sugar substitutes do not change serum potassium levels. Muscle cramps and twitching may occur with hyperkalemia and hypocalcemia but not with hypokalemia. Lung disease is not associated with hypokalemia. Iggy p. 165, Physiological Integrity

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

Answer: B. Decreasing urine specific gravity Rationale: Urine output is the most sensitive noninvasive measure of fluid resuscitation adequacy. An increase in urine output is a positive sign; however, so is a decreasing urine specific gravity. As urine output increases, the concentration of the urine decreases, leading to a decreased urine specific gravity. A decreasing pulse pressure often indicates a fall in systolic pressure, which would not indicate fluid resuscitation adequacy. A decreasing core body temperature is related to changes in the inflammatory response or metabolism and not an indication of fluid resuscitation adequacy. An increasing respiratory rate could indicate pulmonary edema but not fluid resuscitation adequacy. The increased respiratory depth may indicate other positive changes but not adequacy of fluid resuscitation. Iggy p. 479, Safe and Effective Care Environment

A client receiving ciprofloxacin intravenously reports that the peripheral IV insertion site has become painful and reddened. In what order will the nurse perform the needed actions to manage this problem? A. Report the patient's problem to the health care provider. B. Document findings and actions in the electronic health record. C. Change the IV insertion site to a new location. D. Stop the infusion of the drug immediately.

Answer: D - Stop infusion A - Report to PCP C - Change IV site to new location B - Document findings and actions Rationale: The infusion must be stopped first to prevent further pain and redness from the IV solution. The health care provider needs to know because the client may need treatment for phlebitis. The findings are documented after the new site is started. p. 190, Safe and Effective Care Environment

A student nurse is working with a client in the ICU who is intubated and being mechanically ventilated. What action by the student causes the registered nurse to intervene? A. Repositioning the client every 2 hours B. Providing oral care with chlorhexidine rinse C. Checking tube placement at the client's incisor D. Turning off ventilator alarms while working in the room

Answer: D) Turning off ventilator alarms while working in the room Rationale: Ventilator alarms are critical to safety and indicating a need for early intervention when the client's gas exchange needs are not being met. Even when a nurse or other health care professional is present at the bedside, the alarms should never be turned off or set so inappropriately that they do not sound when parameters indicate a problem. Iggy p. 619, Safe and Effective Care Environment

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

Answer: D. Dry heat burn Rationale: Direct injury to the lung from contact with flames, scalding hot liquids, liquid chemicals, or electrical current rarely occurs. Rather, respiratory problems are caused by superheated air, steam, toxic fumes, or smoke. Although it is possible for an electric current to pass through the lungs, it seldom causes injury. Iggy p. 475, Physiological Integrity

Which assessment finding indicates to the nurse that fluid resuscitation therapy for the client with isotonic dehydration is effective? A. Respiratory rate has changed from 16 to 18 breaths/min. B. Urine specific gravity has increased from 1.040 to 1.050. C. Neck veins are flat when the client moves to a sitting position. D. Pulse pressure has changed from 22 mm Hg to 32 mm Hg.

Answer: D. Pulse pressure has changed from 22 mm Hg to 32 mm Hg. Rationale: Isotonic dehydration manifests as hypovolemia and shock. The increasing pulse pressure (difference between the diastolic and systolic blood pressures) is an indication that the fluid volume deficit is being corrected. Iggy p. 158, Safe and Effective Care Environment

The health care provider prescribes 1 L 5%D/0.9%NS to be infused over 10 hours. The nurse sets the rate at _______mL/hr of IV solution.

Answer: 100 Rationale: One liter of fluid is 1000 mL, which when divided by the total time of 10 hours would provide 100 mL/hr of solution.

The chest tube of a client 16 hours postoperative from a lobectomy is accidentally pulled out by a portable x-ray machine. What is the nurse's best first action? A. Clamp the tubing with padded clamps as close as possible to the insertion site. B. Reposition the client on the nonoperative side and support the tube(s) with pillows. C. Cover the insertion site with a sterile occlusive dressing and tape down on three sides. D. Don sterile gloves and attempt to reinsert the chest tube at the original insertion site.

Answer: C Rationale: Although the client had a pneumonectomy and sometimes chest tubes are not even used, the insertion site should be covered immediately to prevent infection. If this were a chest tube placed for any other reason, the action of covering the insertion site is still the best first action to prevent air from being sucked into the chest cavity. Clamping the tubing that has already fallen out of the chest does nothing to help the client or prevent a problem. Repositioning the client would cause neither harm nor benefit. Reinserting a contaminated chest tube is wrong and beyond the scope of nursing practice. p. 579, Safe and Effective Care Environment

A client with septic shock is to receive dopamine at 18 mcg/kg/min. The client's weight is 154 pounds. How many mcg/min does the nurse administer?

Correct Answer: 1260 First convert pounds to kilograms: 154 lb ÷ 2.2 = 70 kg. Then, 70 kg × 18 mcg/kg/min = 1260 mcg/min.

The client in shock has the following vital signs: T 99.8° F, P 132 beats/min, R 32 breaths/min, and BP 80/58 mm Hg. Calculate the pulse pressure.

Correct Answer: 22 mm Hg Pulse pressure is the difference between the systolic and diastolic pressures: 80 (systolic) - 58 (diastolic) = 22 (pulse pressure)

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? A) "Every bedroom should have a separate smoke detector." B) "Every room in the house should have a smoke detector." C) "If you have a smoke detector, you don't need a carbon monoxide detector." D) "The kitchen and the bedrooms are the only rooms that need smoke detectors."

Correct Answer: A) "Every bedroom should have a separate smoke detector." Teach all people to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom has a separate smoke detector, there should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Carbon monoxide detectors are instrumental in picking up other types of carbon monoxide gas, such as from a defective heating unit.

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. A) Ask family members to stay with the client. B) Call the health care provider. C) Increase IV and oxygen rates. D) Remain with the client. E) Reassure the client that everything is being done for him or her.

Correct Answer: A) Ask family members to stay with the client. D) Remain with the client. E) Reassure the client that everything is being done for him or her. Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.

A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation? A) Assessment B) Communication C) Priority setting D) Technical and procedural skills

Correct Answer: A) Assessment Similar to any nurse in practice, the foundation of the emergency nurse's skill base is assessment. The nurse must be able to discern normal from abnormal rapidly and accurately, and must interpret assessment findings according to acuity and age. Communication, priority setting, and technical and procedural skills are not the first competencies to be used in this situation.

A client with a gunshot wound is admitted to the emergency department (ED). Which minimum Standard Precaution activity does the nurse require for staff safety? A) Blood and body fluid precautions B) Metal detector screening of the client C) Placement of a security guard D) Use of a positive air-purifying respirator (PAPR)

Correct Answer: A) Blood and body fluid precautions The ED nurse uses Standard Precautions at all times when there is the potential for contamination by blood or other body fluids. Screening of the client with a metal detector, appointing a security guard, and use of a PAPR, although beneficial, are not minimum Standard Precautions.

A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? A) Broad-spectrum antibiotics B) Blood transfusion C) Cooling baths D) NPO status

Correct Answer: A) Broad-spectrum antibiotics Broad-spectrum antibiotics must be initiated within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell count or low hemoglobin and hematocrit; transfusion is not part of the sepsis resuscitation bundle. Cooling baths are not indicated because the client is hypothermic, nor is this part of the sepsis resuscitation bundle. NPO status is not indicated for this client, nor is it part of the sepsis resuscitation bundle.

What is the best method to prevent autocontamination for a client with burns? A) Change gloves when handling wounds on different areas of the body. B) Ensure that the client is in isolation therapy. C) Restrict visitors. D) Watch for early signs of infection.

Correct Answer: A) Change gloves when handling wounds on different areas of the body. Gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings. Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Watching for early signs of infection does not prevent contamination.

The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? A) Compare these vital signs with the last several readings. B) Request that the surgeon see the client. C) Increase the rate of intravenous fluids. D) Reassess vital signs using different equipment.

Correct Answer: A) Compare these vital signs with the last several readings. Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.

A 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

Correct Answer: A) Encouraging participation in wound care Encouraging participation in wound care will offer the client some sense of control. Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.

The client with which problem is at highest risk for hypovolemic shock? A) Esophageal varices B) Kidney failure C) Arthritis and daily acetaminophen use D) Kidney stone

Correct Answer: A) Esophageal varices Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen, not acetaminophen, predispose the client to gastrointestinal bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss or hypovolemia.

A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this client? A) Forensic nurse examiner B) Physician or health care provider C) Psychiatric crisis nurse D) Police officer

Correct Answer: A) Forensic nurse examiner The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. Although the physician or health care provider, the psychiatric crisis nurse, and the police officer may be involved at some point in the care of this particular client, they are not the best individuals to collaborate with at this time. It is important to remember that not all rapes are required to be reported to the police.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? A) Give oxygen per facemask. B) Infuse lactated Ringer's solution at 150 mL/hr. C) Give morphine sulfate 4 to 10 mg IV for pain control. D) Insert a 14 Fr retention catheter.

Correct Answer: A) Give oxygen per facemask. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

The nurse is reviewing the health history 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's history reveals which condition? A) Heart failure B) Diverticulitis C) Hypertension D) Emphysema

Correct Answer: A) Heart failure A client's health history, including any pre-existing illnesses, must be known for appropriate management. Obtain specific information about the client's history of cardiac or kidney problems, chronic alcoholism, substance abuse, and diabetes mellitus. Any of these problems can influence fluid resuscitation. The stress of a burn injury can make a mild disease process worsen. In older clients, especially those with cardiac disease, a complicating factor in fluid resuscitation may be heart failure or myocardial infarction. Diverticulitis, hypertension and emphysema are important to be aware of in guiding treatment options. However, heart failure is the main concern when attempting to optimize this older client's fluid resuscitation.

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

Correct Answer: A) In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development. 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. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

The client with which laboratory result is at risk for hemorrhagic shock? A) International normalized ratio (INR) 7.9 B) Partial thromboplastin time (PTT) 12.5 seconds C) Platelets 170,000/mm3 D) Hemoglobin 8.2 g/dL

Correct Answer: A) International normalized ratio (INR) 7.9 Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 seconds and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.

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 Glasgow Coma Scale 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

Correct Answer: A) Level I The American College of Surgeons defines a Level I trauma center as a regional resource facility capable of "providing leadership and total care for every aspect of injury, from prevention through rehabilitation." A Level II trauma center may not be able to meet the resource needs of clients who require very complex injury management, such as those in need of advanced surgical care. The primary focus of a Level III trauma center is injury stabilization and client transfer. In a Level IV trauma center, clients are stabilized to the best degree possible before transfer, with the use of available personnel. Resources, including the consistent availability of a physician, may be extremely limited.

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Physical Assessment Findings Diagnostic Findings Pulse 140 beats/min and thready ABG respiratory acidosis Blood pressure 60/40 mm Hg Lactate level 7 mOsm/L Respirations 40/min and shallow All of these provider prescriptions are given for the client. Which does the nurse carry out first? A) Notify anesthesia for endotracheal intubation. B) Give Plasmanate 1 unit now. C) Give normal saline solution 250 mL/hr. D) Type and crossmatch for 4 units of packed red blood cells (PRBCs).

Correct Answer: A) Notify anesthesia for endotracheal intubation. Establishing an airway is the priority in all emergency situations. Although administering Plasmanate and normal saline, and typing and crossmatching for 4 units of PRBCs are important actions, airway always takes priority.

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

Correct Answer: A) Painful red and white wounds A painful red and white wound bed characterizes deep partial-thickness burns; blisters are rare. Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

The nurse is caring for a client with a burn injury who is receiving silver 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

Correct Answer: A) Reduction of bacterial growth in the wound and prevention of systemic sepsis Topical antimicrobials such as silver sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? A) Temperature B) Pulse C) Respiration D) Blood pressure

Correct Answer: A) Temperature A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.

Which clients are at immediate risk for hypovolemic shock? Select all that apply. A) Unrestrained client in motor vehicle accident B) Construction worker C) Athlete D) Surgical intensive care client E) 85-year-old with gastrointestinal virus

Correct Answer: A) Unrestrained client in motor vehicle accident D) Surgical intensive care client E) 85-year-old with gastrointestinal virus The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.

As a direct result of overcrowding in emergency department (ED) environments, for whom must the emergency department nurse expect to provide care? A) A variety of age groups and cultures B) "Boarding" or holding inpatient clients C) Clients with a broad spectrum of issues, illnesses, and injuries D) Uninsured and underinsured clients

Correct Answer: B) "Boarding" or holding inpatient clients ED overcrowding has become a widespread problem, with frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital. The ED nurse must be adept at providing safe and competent care to clients who are awaiting bed placement. The focus then becomes one of ongoing care (scheduled medications, testing) instead of one-time orders. Although a variety of age groups and cultures; clients with a broad spectrum of illness, issues, and injuries; and uninsured/underinsured clients are seen in the ED, this is not a result of overcrowding.

The nurse is caring for a 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 now as in the beginning."

Correct Answer: B) "I don't know what I will do when people stare at me." The statement about not knowing what to do when people stare indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem. The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse doesn't stare at the scars as much all indicate that the client is coping effectively. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns.

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? A) Hourly urine output 10 to 12 mL/hr B) Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg C) Blood glucose 245 mg/dL D) Serum creatinine 3.6 mg/dL

Correct Answer: B) Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response in this case. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. Although a blood glucose of 245 mg/dL is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? A) Client receiving a blood transfusion B) Client with severe ascites C) Client with myocardial infarction D) Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

Correct Answer: B) Client with severe ascites Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take? A) Call the police. B) Consult with Social Services. C) Discharge the client as instructed. D) Instruct the client to go to a safe place.

Correct Answer: B) Consult with Social Services. If discharge home is not deemed safe, the client may be admitted to the hospital until resources can be organized to provide a safe environment. Social workers or case managers are consulted to investigate resource needs and plan accordingly. Calling the police is not an appropriate response. Letting the client go home could place the client in danger. The client may not have a safe place to go.

Which laboratory result is seen in late sepsis? A) Decreased serum lactate B) Decreased segmented neutrophil count C) Increased numbers of monocytes D) Increased platelet count

Correct Answer: B) Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease due to consumptive coagulopathy.

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? A) Administer the antibiotic immediately. B) Ensure that blood cultures were drawn. C) Obtain signature for informed consent. D) Take the client's vital signs.

Correct Answer: B) Ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours; timing is essential.

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

Correct Answer: B) Intravenous During the resuscitation 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. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? A) PaCO2 58 mm Hg B) Lactate 9.0 mmol/L C) Partial thromboplastin time 64 seconds D) Potassium 2.8 mEq/L

Correct Answer: B) Lactate 9.0 mmol/L Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid. Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis; this value is decreased and is not consistent with septic shock.

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? A) Localized erythema and edema B) Low-grade fever and mild hypotension C) Low oxygen saturation rate and decreased cognition D) Reduced urinary output and increased respiratory rate

Correct Answer: B) Low-grade fever and mild hypotension Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and increased respiratory rate indicate severe sepsis.

How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? A) Urine output 20 to 30 mL/hr for the last 4 hours B) Mean arterial pressure (MAP) 70 mm Hg C) Albumin 3.5 g/dL D) Hemoglobin 7.6 g/dL

Correct Answer: B) Mean arterial pressure (MAP) 70 mm Hg Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, which is a desired outcome in shock. Urine output should be 0.5 mL/kg/hr, or greater than 30 mL/hr. Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space; this does not improve an abnormal hemoglobin.

A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? A) Obtain vital signs every 15 minutes. B) Measure hourly urine output. C) Check oxygen saturation. D) Assess level of alertness.

Correct Answer: B) Measure hourly urine output. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

Several clients have been brought to the emergency department 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

Correct Answer: B) Young adult who suffered burn injuries in a closed space 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. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies? A) "Do you support each other?" B) "How do you plan to manage this situation?" C) "How have you handled similar situations before?" D) "Would you like to see a counselor?"

Correct Answer: C) "How have you handled similar situations before?" Asking how the client and family have handled similar situations in the past assesses whether the client's and the family's coping strategies may be effective. "Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage; asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A) "Do you want to pray about it?" B) "I know, and you will have to learn to adapt to a new body image." C) "Tell me more." D) "There must be a reason."

Correct Answer: C) "Tell me more." Asking the client to tell the nurse more encourages therapeutic grieving. Offering to pray with the client assumes that prayer is important to the client and does not allow for grieving; the nurse should never assume that the client is religious. The response, "I know, and you will have to learn to adapt to a new body image" only serves to add stress to the client's situation. The response, "There must be a reason" minimizes the grieving process by not allowing the client to express his or her concerns.

Emergency Medical Services 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.

Correct Answer: C) Clear the airway. Even minutes without an adequate oxygen supply in humans can lead to cerebral injury, and can progress to anoxic brain death. The airway should be cleared of any secretions or debris with a suction catheter or manually, if necessary. Applying pressure to wounds and placing a cervical collar are important, but neither is the priority. Commencing with artificial respiration is important, but the airway must be cleared first.

The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? A) Admission to rehabilitation hospital for ambulatory retraining B) Collaboration with home care agency for return to home C) Discussion with family and provider regarding palliative care D) Enrollment in a cardiac transplantation program

Correct Answer: C) Discussion with family and provider regarding palliative care In this irreversible phase, therapy is not effective in saving the client's life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal. A discussion on palliative care should be considered. Rehabilitation or returning home is unlikely. The client with sustained tissue hypoxia is not a candidate for organ transplantation.

A client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A) Range-of-motion exercises B) Emotional support C) Fluid resuscitation D) Sterile dressing changes

Correct Answer: C) Fluid resuscitation The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

Which problem places a client at highest risk for sepsis? A) Pernicious anemia B) Pericarditis C) Post kidney transplant D) Client owns an iguana

Correct Answer: C) Post kidney transplant The post-kidney transplant client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a very high risk for infection, sepsis, and death.

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

Correct Answer: C) Reduced self-image 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. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? A) Bowel sounds B) Muscle strength C) Signs of infection D) Urine output

Correct Answer: C) Signs of infection 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. Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

What typical sign/symptom indicates the early stage of septic shock? A) Pallor and cool skin B) Blood pressure 84/50 mm Hg C) Tachypnea and tachycardia D) Respiratory acidosis

Correct Answer: C) Tachypnea and tachycardia Signs of systemic inflammatory response syndrome, which precedes sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? A) Bowel sounds are absent. B) The pulse oximetry level is 91%. C) The serum potassium level is 6.1 mEq/L. D) Urine output since admission is 370 mL.

Correct Answer: C) The serum potassium level is 6.1 mEq/L. An elevated serum potassium level can cause cardiac dysrhythmias and arrest, and so is of the most concern. Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

The nurse is evaluating the effectiveness of fluid resuscitation for a 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

Correct Answer: C) Urine output, 40 mL/hr Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL/hr or 0.5 mL/kg/hr. A BUN of 36 mg/dL is above normal, a creatinine of 2.8 mg/dL is above normal, and a urine specific gravity of 1.042 is above normal.

Which problem places a person at highest risk for septic shock? A) Kidney Failure B) Cirrhosis C) Lung Cancer D) 40% burn injury

Correct Answer: D) 40% burn injury The skin forms the first barrier to prevent entry of organisms into the body; this client is at very high risk for sepsis and death. Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.

A client with hypovolemic shock has these vital signs: temperature 97.9° F pulse 122 beats/min blood pressure 86/48 mm Hg Respirations 24 breaths/min urine output 20 mL for last 2 hours skin cool and clammy. Which medication order for this client does the nurse question? A) Dopamine (Intropin) 12 mcg/kg/min B) Dobutamine (Dobutrex) 5 mcg/kg/min C) Plasmanate 1 unit D) Bumetanide (Bumex) 1 mg IV

Correct Answer: D) Bumetanide (Bumex) 1 mg IV A diuretic such as bumetanide will decrease blood volume in a client who is already hypovolemic; this order should be questioned because this is not an appropriate action to expand the client's blood volume. The other orders are appropriate for improving blood pressure in shock, and do not need to be questioned.

When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? A) Obtain IV access and hang prescribed fluid infusions. B) Apply the automatic blood pressure cuff. C) Assess level of consciousness and pupil reaction to light. D) Check the airway and respiratory status.

Correct Answer: D) Check the airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? A) Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B) Recently admitted client with a high-voltage electrical burn C) A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D) Client receiving IV lactated Ringer's solution at 150 mL/hr

Correct Answer: D) Client receiving IV lactated Ringer's solution at 150 mL/hr An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr. The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

A client is admitted to the emergency department after being in a motor vehicle crash. The client was wearing a seat belt and the airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. The client's Glasgow Coma Scale score is 15. What does the nurse do next? A) Allows the client to go home B) Checks blood alcohol levels C) Prepares the client for surgery D) Monitors the client

Correct Answer: D) Monitors the client Blunt trauma results from impact forces. The energy transmitted from a blunt trauma mechanism, particularly the rapid acceleration-deceleration forces involved in high-speed crashes or falls from a great height, produce injury by tearing, shearing, and compressing anatomic structures. Injury may not be evident right away. A seat belt abrasion across the chest should alert the nurse to monitor closely for signs of potential internal injuries. Allowing the client to leave is not the best course of action because complications could still occur. No evidence in this scenario suggests that the client was drinking. There is no indication from the scenario that surgical intervention is required.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered 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

Correct Answer: D) Planning additions to the standard nutritional pattern 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. It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? A) Hypotension B) Bradypnea C) Heart blocks D) Tachycardia

Correct Answer: D) Tachycardia Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.

Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? A) The LPN/LVN who has 20 years of experience B) The new RN who recently finished orienting and is working independently with moderately complex clients C) The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago D) The RN with 2 years of experience in intensive care

Correct Answer: D) The RN with 2 years of experience in intensive care The RN with current intensive care experience who is not caring for a postoperative client would be an appropriate assignment. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. A client who is experiencing septic shock is too complex for the new RN. Although the RN who is also caring for the post-CABG client is experienced, this assignment will put the post-CABG client at risk for MRSA infection.

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 does 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.

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

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 a contusion on the head C) Teenager with a closed fracture of the leg D) Woman bleeding heavily

Correct Answer: D) Woman bleeding heavily The woman critically injured with trauma or an active hemorrhage is prioritized as emergent. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb and should be treated immediately. Although the child with an open fracture of the arm, the man with a contusion of the head, and the teenager with a closed fracture of the leg are urgent, they are not emergent and can wait for a short time.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A) "The last tetanus injection was less than 5 years ago." B) "Burn wound conditions promote the growth of Clostridium tetani." C) "The wood in the fire had many nails, which penetrated the skin." D) "The injection was prescribed to prevent infection from Pseudomonas."

Correct Answer: B) "Burn wound conditions promote the growth of Clostridium tetani." Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital. Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? A) Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B) Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C) An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D) Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

Correct Answer: B) Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" Smoke inhalation and facial burns are associated with airway inflammation and obstruction; the client with difficulty breathing needs immediate assessment and intervention. Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? A) Black-brown coloration B) Painful C) Moderate to severe edema D) Absence of blisters

Correct Answer: B) Painful Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters. A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

An older client with heat exhaustion is being cooled with cool water spray and fanning. What assessment indicates to the nurse that the client needs hospitalization? A) The client is alert and oriented. B) The client's mucous membranes are dry and sticky. C) The client reports weakness and nausea. D) The client continues to sweat while being cooled.

Correct Answer: B) The client's mucous membranes are dry and sticky. Rationale: Heat exhaustion is usually treatable with a cool water spray and fanning. However, if the client does not respond to these interventions, heat stroke can occur with severe dehydration. Dry and sticky membranes are present in clients with severe dehydration.

Which strategy does the nurse include when teaching a college student about fire prevention in the dormitory room? A) Use space heaters to reduce electrical costs. B) Check water temperature before bathing. C) Do not smoke in bed. D) Wear sunscreen.

Correct Answer: C) Do not smoke in bed. Smoking in bed increases the risk for fire because the person could fall asleep. Use of space heaters may increase the risk for fire, especially if they are knocked over and left unattended. Checking water temperature does not prevent fires, but it should be checked if the client has reduced sensation in the hands or feet. Sunscreen is advised to prevent sunburn.

Which factors indicate that a client's burn wounds are becoming infected? A) Dry, Crusty Granulation Tissue B) Elevated Blood Pressure C) Hypoglycemia D) Edema of the skin around the wound E) Tachycardia

Correct Answers: A) Dry, Crusty Granulation Tissue D) Edema of the skin around the wound E) Tachycardia Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection. Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

A client from a local care facility has sustained a cardiac arrest in the emergency department (ED), and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? Select all that apply. 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 lights in the client's room

Correct Answers: B) Cover the client with a sheet, leaving the face exposed. E) Dim the lights in the client's room Not all clients presenting to the ED survive to discharge. The client's family has the right to view the body prior to removal to the morgue or funeral home. Dimming the lights in the room and covering the body with a sheet or blanket should be done prior to the family viewing. Leaving the head exposed allows the family to see the client and to comprehend that the death has occurred. IV lines and indwelling tubes may need to be left in place unless their removal has been authorized. The family should be escorted to the room by hospital personnel; however, this is not always exclusively done by a chaplain or social worker. The nurse must exhibit compassion and empathy; however, using terms such as "died" and "dead" create less confusion than "in a better place."

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? Select all that apply. A) Provides cushions and rugs for comfort B) Performs frequent handwashing C) Places plants in the client's room D) Performs gloved dressing changes E) Uses disposable dishes

Correct Answers: B) Performs frequent handwashing D) Performs gloved dressing changes E) Uses disposable dishes Handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible. Cushions and rugs are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

An occupational health nurse is teaching a safety class to city employees who work outdoors year round. What does the nurse teach are risk factors for developing frostbite? Select all that apply. A. Excessive fatigue B. Prior episodes of frostbite C. Diabetes or other peripheral vascular disease D. Dehydration E. Smoking F. Wearing polyester socks

Correct Answer: A. Excessive fatigue B. Prior episodes of frostbite C. Diabetes or other peripheral vascular disease D. Dehydration E. Smoking Rationale: All of these factors predispose a person to frostbite except for wearing polyester socks.

*50M tree trimmer touched powerline The patient is agitated and restless and continues to report increasing pain in both arms and hands and in the neck even though there is no area of burn on the neck. The exit wound is the right hand, including the fingers and thumb. The right arm is cyanotic and tense, and the wrist is acutely flexed and rigid in that position. There is an arc burn in the right axilla. The left arm is tense and cyanotic, and the wrist, hand, and fingers are charred* The patient has adequate IV access and is undergoing fluid resuscitation. While obtaining history from this patient, you find that he has not had a tetanus shot in the past 10 years. He continues to have pain in both arms and hands. On examination you note the burns are tan and dry and have no blisters or capillary refill. The radial pulses are no longer palpable. 1. Based on the information provided about the injury and the data gathered by examination, what degree of burn injury has this patient suffered? Provide a rationale for your choice. 2. What is the preferred route for analgesic administration? Provide a rationale for your choice. 3. What additional medications do you expect to be ordered for this patient given his history? 4. The patient requires escharotomies to both his upper extremities. What steps would you take to prepare the patient for this procedure? What post procedure care would you perform?

Suggested responses: 1. *Based on the information provided about the injury and the data gathered by examination, what degree of burn injury has this patient sustained? Provide a rationale for your choice.* Most, if not all, of his burns are full-thickness injuries. They meet the criteria of no bleeding, no blister formation, no evidence of vascular blood flow, dry, and without sensation. 2. *What is the preferred route for analgesic administration? Provide a rationale for your choice.* At this stage of burn injury, pain medication should be given by the IV route for several reasons. First, it will have a more rapid onset of action. Second, with fluid resuscitation, the patient will start third spacing and, if given by the intramuscular (IM) route, the drug could just remain in the tissues and not have any systemic effects at this time. Also, the gastrointestinal tract probably is experiencing shut-down with little or no motility or absorption. As a result, drugs given orally will be ineffective. The most important reason to give medications intravenously is that if given IM, when the fluid shift resolves, all of the drug doses administered will reenter the circulatory system at once, providing an acute overdose. 3. *What additional medications do you expect to be ordered for this patient given his history?* Almost all burns of this magnitude are at risk for tetanus infection, which can be fatal. Because his last tetanus booster was at least 10 years ago, he needs a tetanus booster now to protect him. 4. *The patient requires escharotomies to both his upper extremities. What steps would you take to prepare the patient for this procedure? What post procedure care would you perform?* First, explain what an escharotomy is and stress that it is done to prevent further damage to his arms. Assure him that he will be given a sedative and will feel no procedural pain. Begin the physical preparation by gently scrubbing the arms according to unit policy. After the procedure, minimal bleeding is expected, but the incisions represent an open wound. These should be cleaned and dressed according to agency policy. Assess the extremity distal to the escharotomy for adequacy of circulation (e.g., return of color, warmth, presence of pulses, and brisk capillary refill). A Doppler may be needed to assess blood flow. Iggy p. 481, Patient-Centered Care; Teamwork and Collaboration; Evidence-Based Practice

A 63-year-old obese, diabetic woman is transferred from the hospital to the skilled nursing facility (SNF) where you work as a charge nurse. The resident is being managed with IV cefoxitin 2 g IV piggyback (IVPB) every 8 hours for osteomyelitis resulting from an arterial foot ulcer. On review of her admission orders, you note that she has a newly inserted intermittent saline lock in her right forearm and is prescribed to receive the antibiotic for 4 more weeks. 1. The SNF policy for administration of drugs prescribed every 8 hours is a 6 pm-2 am-10 am schedule. Would you schedule her antibiotic at these times? Why or why not? 2. Two days later as you are planning to end your shift, the resident reports that her IV site seems red and swollen. What action will you take at this time? What will you document on the resident's electronic health record? 3. Is a peripheral vascular access device (VAD) the best choice for this resident? Why or why not? With whom will you or the oncoming nurse collaborate to make this decision? What does the evidence say about the type of VAD that would be best to meet this resident's needs? Where would you go to find the answer to this clinical question? 4. Using the SBAR technique, what will you report to the oncoming nurse about the resident's IV complications?

Suggested responses: 1. *The SNF policy for administration of drugs prescribed every 8 hours is a 6 pm-2 am-10 am. Would you schedule her antibiotic at these times? Why or why not?* The 10 am dosing time would likely interfere with her morning activities of daily living and other activities. The 2 am dosing time would wake her up and the 6 pm time is at dinner time. Therefore, a different schedule might work better for the resident, such as 6 AM-2 pm-10 pm. That schedule would not interrupt the resident's sleep or morning ADLs. 2. *Two days later as you are planning to end your shift, the resident reports that her IV site seems red and swollen. What action will you take at this time? What will you document on the resident's electronic health record?* The saline lock needs to be removed immediately to prevent further tissue irritation. Perform a pain assessment and apply ice to decrease swelling followed by a warm compress on the area to promote blood flow and healing; place a sterile dressing over the affected area. Document when the lock was removed; your IV site assessment; and your actions, including the warm compress and dressing placement. Document when and where you restart a new saline lock. 3. *Is a peripheral vascular access device (VAD) the best choice for this resident? Why or why not? With whom will you or the oncoming nurse collaborate to make this decision? What does the evidence say about the type of VAD that would be best to meet this resident's needs? Where would you go to find the answer to this clinical question?* Given that the resident will be receiving long-term antibiotic treatment, a PICC line would be the better choice because it is less likely to cause phlebitis and become dislodged. You may collaborate with members of the health care team, including the patient, family, pharmacist, infusion therapy team (if available), and the primary health care provider to ensure that the patient receives the best possible infusion therapy care. Search the Internet for best practices, including those from the Infusion Nurses Society's Infusion Nursing Standards for Practice. 4. *Using the SBAR technique, what will you report to the oncoming nurse about the resident's IV complications?* S = Resident's saline lock is infiltrated which resulted in redness and swelling. B = Resident is in the facility for long-term (4-week) antibiotic therapy for osteomyelitis A = Resident needs a different type of VAD to prevent complications. R = Request that the health care provider be contacted to get an order for a PICC line insertion. Iggy p. 210, Patient-Centered Care; Teamwork and Collaboration; Informatics

The patient is a 21-year-old college student brought to the emergency department by his friends when he was found unconscious during a fraternity party. He was seen drinking heavily at the party and had not eaten for 2 days before the event. He takes no prescription drugs His current vital signs are: T = 97.8° F P = 48; slightly irregular and thready R = 28, deep and regular BP = 88/50. His current arterial blood gas results are: pH = 7.31 HCO3- = 25 mEq/L Paco2 = 28 mm Hg Pao2 = 99 mm Hg. 1. What specific type of acid-base problem does this patient have? Explain your choice. 2. What is the most probable origin of the acid-base imbalance? 3. Should oxygen be applied? Why or why not? 4. What nursing interventions for safety are most appropriate for this patient? 5. What additional laboratory and assessment data should be performed? Provide a rationale for your selections.

1. *What specific type of acid-base problem does this patient have? Explain your choice.* This patient appears to have metabolic acidosis. Although his pH is low, indicating acidosis, his arterial oxygen level is normal, and his bicarbonate is low. Therefore, this problem is not respiratory in origin. 2. *What is the most probable origin of the acid-base imbalance?* The most probable origin is acute alcohol intoxication leading to acidosis. The fact that he did not eat for about 2 days could contribute to the acidosis in terms of starvation causing an abnormal breakdown of fats for metabolism. 3. *Should oxygen be applied? Why or why not?* No, he is not hypoxic, as evidenced by his high Pao2. The acidosis is not related to a respiratory problem. 4. *What nursing interventions for safety are most appropriate for this patient?* Because he is unconscious and has consumed a large amount of alcohol, he is most at risk for vomiting and aspirating his vomitus. He should be positioned on his side and have suction equipment available and working at his bedside. In addition, he may have skeletal muscle weakness and is at risk for falling if he would attempt to get out of bed before he was fully awake. 5. *What additional laboratory and assessment data should be performed? Provide a rationale for your selections.* Because he has acidosis, his serum potassium level could be elevated as a result of cells exchanging potassium ions for hydrogen ions in an effort to reduce the blood hydrogen ion concentration. Muscle strength should be assessed but is not possible while he is unconscious. His deep tendon reflexes should be assessed and most likely would be depressed. Iggy p. 185, Patient-Centered Care, Safety

A new graduate nurse is being oriented to your medical-surgical nursing unit. Today he is assigned to care for three patients. One patient is an older adult with an infiltrated peripheral IV in her forearm. The second patient has a PICC line for antibiotic therapy, and the third patient has an arterial implanted port for chemotherapy. As his preceptor, you are responsible for teaching him how to assess patients with these devices and prevent and/or monitor for complications. Your unit has several memory checklists for IV care that you plan to review with him. 1. What best clinical practices will you teach the new nurse about how to care for patients who have a PICC line? 2. For what life-threatening complication is the patient with the implanted port most at risk? 3. You observe the new nurse as he prepares to restart the IV for the older adult patient. He chooses a vein in the dorsum of the hand. What is your best response about his IV site selection? 4. What is the value of memory checklists to ensure consistency among nurses caring for patients receiving IV therapy?

Suggested responses: 1. *What best clinical practices will you teach the new nurse about how to care for patients who have a PICC line?* PICC lines are ideal for any type of infusion because the tip is in the superior vena cava, where blood flow quickly dilutes the fluids being infused. They can also be used for long-term care and can be used for blood sampling. To keep the PICC line open, flush with 5 mL of heparin (10 units/mL) in a 10-mL syringe at least daily when using a nonvalved catheter and at least weekly with a valved catheter. Ten mL of sterile saline is used to flush before and after medication administration, and 20 mL of sterile saline is flushed after drawing blood. Always use 10-mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter. Observe for complications of PICC lines, which include phlebitis, deep vein thrombosis, and catheter-related bloodstream infections. Inspect the PICC site and observe for signs of infection, including fever and increased while blood cell count. 2. *For what life-threatening complication is the patient with the implanted port most at risk?* Many patients who have ports are immune compromised and therefore at risk for infection. The ports can also become clotted. 3. *You observe the new nurse as he prepares to restart the IV line for the older adult patient. He chooses a vein in the dorsum of the hand. What is your best response about his IV site selection?* Starting an IV line in the hand is very painful and may cause nerve damage. Using the forearm is a better choice. 4. *What is the value of memory checklists to ensure consistency among nurses caring for patients receiving IV therapy?* Memory checklists ensure that every patient receives the best possible practice from every nurse. Consistency ensures positive outcomes. Iggy p. 202, Evidence-Based Practice; Safety

During nasotracheal suctioning, the client's heart rate changes from 78 beats/min to 48 beats/min. What is the nurse's best first action? A. Immediately stop suctioning. B. Gently pinch the client's cheek. C. Administer oxygen by mask at 2 L/min. D. Document the change as the only action.

Answer: A. Immediately stop suctioning. Rationale: The change in heart rate is a serious response to suctioning. The client is experiencing vagal stimulation and bradycardia from the presence of the suction catheter in the tracheopharyngeal area. Such stimulation can lead to severe hypotension, heart block, and asystole. Administering oxygen would be a good second action but the first action is to stop the activity causing the problem. The client's response is not related to a lack of being alert. p. 527, Safe and Effective Care Environment

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? A) Pale, boggy, dry, or crusted granulation tissue B) Increasing wound drainage C) Scar tissue formation D) Sloughing of grafts

Correct Answer: C) Scar tissue formation Indicators of wound healing include the presence of granulation, re-epithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

A nurse is working at a day camp for church leaders when a sudden severe thunderstorm occurs. Several adults participating in outdoor activities appear to have been hit by lightning. The nurse arrives on scene and finds four injured people. One person appears to be unconscious, one has ferning marks and burns on his skin, and the other two are sitting up against the wall of a building and reporting severe weakness of their lower extremities. Which person should the nurse assess first and what is the priority of care of this patient?

The nurse should assess the unconscious patient first. The most lethal effect of lightning is on the cardiopulmonary system and can manifest as cardiopulmonary arrest. If needed, the nurse needs to provide cardiopulmonary resuscitation to this individual.

A 50-year-old tree trimmer has been brought to hospital after coming in contact with an 8000-volt power line while trimming trees with a pole trimmer. The emergency medical technicians (EMTs) report that they recovered this man from an insulated bucket in which he was working. According to bystanders, the metal pole-saw made contact with the power line. The patient was rendered unconscious only momentarily. The EMTs report that he had pain in both arms when they transported him to the hospital. He now has pain in the neck. The patient is agitated and restless and continues to report increasing pain in both arms and hands and in the neck even though there is no area of burn on the neck. The exit wound is the right hand, including the fingers and thumb. The right arm is cyanotic and tense, and the wrist is acutely flexed and rigid in that position. There is an arc burn in the right axilla. The left arm is tense and cyanotic, and the wrist, hand, and fingers are charred. 1. What initial consideration must be given in moving the patient from the stretcher to the bed? 2. Is the patient at risk for compartment syndrome? Provide a rationale for your response. If yes, what would you expect to find on assessment that would indicate compartment syndrome? 3. A Foley catheter has been placed in this patient, and it is documented the urine is wine pigmented. What is the etiology and potential complication if this symptom persists? 4. What interventions would you expect to be ordered to resolve myoglobinuria?

Suggested responses: 1. *What initial consideration must be given in moving the patient from the stretcher to the bed?* Do not pull on his arms. Lift rather than drag or pull him, taking care not to reposition him so that the circulation to his arms is compromised. 2. *Is the patient at risk for compartment syndrome? Provide a rationale for your response. If yes, what would you expect to find on assessment that would indicate compartment syndrome?* Yes, he is at risk for compartment syndrome, especially during fluid resuscitation. The burn is likely to include deep tissue and muscle, which will swell during fluid resuscitation, compressing blood vessels and nerves. Numbness, a tingling sensation, absence of pulses, a cool extremity, and decreased capillary refill would indicate compartment syndrome. 3. *A Foley catheter has been placed in this patient, and it is documented the urine is wine pigmented. What are the etiology and potential complications if this symptom persists?* Damage to muscles cause release of protein myoglobin, which enters the bloodstream and kidney circulation. When these large particles enter kidney tubules, they can precipitate and form a sludge that plugs the tubules and injures the kidney. This damage can lead to renal failure. 4. *What interventions would be ordered to resolve myoglobinuria?* Notify the provider. Increase intravenous (IV) fluids to maintain urine output of 75 to 100 mL/hr. Mannitol may be administered. Iggy p. 481, Patient-Centered Care; Safety; Evidence-Based Practice