NRS 222: Trauma Emergencies

The nurse is working in the emergency department and is assessing a client who states, "I woke up with this nose bleed and it hasn't stopped bleeding for 3 hours. I take blood thinners and now I am feeling woozy." Which part of this statement is concerning and needs immediate attention? A) "I take blood thinners" B) "It hasn't stopped bleeding for 3 hours" C) "I woke up with this nose bleed" D) "I am feeling woozy"

"I am feeling woozy" Feeling woozy means the client is now symptomatic after blood loss. The client could potentially be shunting blood to vital organs. The nurse should ensure the client is laying down and get an EKG (ECG) to make sure the heart has a normal rhythm.

What are the types of shock?

-Hypovolemic -Cardiogenic -Septic -Neurogenic also... -Anaphylactic -Distributive -Obstructive

Which of the following fluids would be considered a type of crystalloid solution? A) Albumin B) 4% succinylated gelatin C) 6% hydroxyethyl starch D) 0.9% saline

0.9% saline Crystalloid solutions are clear fluids that can be administered intravenously to correct fluid balance. They are commonly used in cases of septic shock when there is a large loss of blood volume. Crystalloids are easily accessible and are usually cheaper when compared to colloid solutions. 0.9% saline is an example of a crystalloid solution.

A client is brought into the emergency department after suffering from third-degree burns in an explosion. The client has burns on approximately 40 percent of his body. The nurse weighs the client and notes that he weighs 170 lbs. Calculate the volume of IV fluid this client must receive in the first 24 hours using the Parkland formula. A) 16L B) 12L C) 8L D) 4L

12 L The Parkland formula is a method of calculating the amount of fluid needed for fluid resuscitation after a burn injury. To use the Parkland formula, the nurse must know the weight of the patient in kg and the approximate size of the burn. The Parkland formula is as follows: Fluid requirement (mL) = (4 mL of crystalloid) × (% TBSA burned) × body weight (kg). 170 lbs = 77 kg. Therefore, 4 x 40 x 77 = 12,320 mL fluid. So 12,000 mL = 12 L fluid needed in the first 24 hours. The first half of the result should be given in the first 8 hours, with the second half of the result given in the following 16 hours.

The nurse is working in the emergency department when a 2-year-old is brought in with burns from the bath tub to both legs. The nurse knows that this constitutes burns to what percentage of the body? A) 15% B) 30% C) 9.50% D) 19%

30% Both legs for a child are 15% for a total of 30%. The equation is as follows: Anterior leg on a 2 year old (use the 1 year old #'s until they reach 5 years old) = 3.25% thigh + 2.5% lower leg + 1.75% foot = 7.5%. The posterior leg is the same, so 7.5% x 2 = 15% for one leg, and 30% for two legs.

Living Donors vs Heart-beating donors

A person who donates an organ or tissue while alive. vs An organ that is taken from a body of someone that is brain dead.

A nurse is working with a client who has been wearing a fiberglass cast for an arm fracture for the past six weeks. Which intervention should the nurse perform after the cast has been removed? A) Perform the Weber-Rinne test with a tuning fork on the wrist B) Ask the client to push against a solid object C) Assess capillary refill and skin color in the distal extremity D) Obtain an x-ray of the arm

Assess capillary refill and skin color in the distal extremity When preparing to remove a client's cast, the provider may first order an x-ray to assess the fracture site. After the cast has been removed, the nurse should assess capillary refill in the area distal to the cast site and check the client's skin color to assess for good circulation. The newly exposed skin may itch, and the client should be instructed not to scratch it because this can cause damage to the skin.

A nurse is caring for a client who has experienced severe bleeding following surgery. Which of the following collections of vital signs would most likely indicate shock? A)HR 80 bpm, BP 100/70 mmHg, RR 12/min B) HR 100 bpm, BP 120/82 mmHg, RR 20/min C) HR 92 bpm, BP 138/98 mmHg, RR 16/min D) HR 130bpm, BP 88/50 mmHg, RR 28/min

HR 130bpm, BP 88/50 mmHg, RR 28/min Shock is a potentially life-threatening condition that occurs as the body tries to compensate for an injury or event. When signs of shock are present, the client can deteriorate quickly as the body begins to experience organ failure. Vital signs associated with shock include tachycardia, hypotension, and a rapid respiratory rate.

A 90-year-old client is admitted to the unit after being found on apartment floor. The client had been lying in the same position for three days and is diagnosed with rhabdomyolysis. Which of the following actions should the nurse take first? A) Infuse normal saline IV at 150ml/hr B) Ambulate the client TID C) Insert urinary catheter D) Administer furosemide 80 mg IV

Infuse normal saline IV at 150ml/hr Normal saline should be infused first to cleanse the kidney and body of toxins that were released from the muscle cells. This is the priority.

A client is being discharged from the hospital after recovering from septic shock. The nurse is providing discharge instructions about what to look for if post-sepsis syndrome develops. Which of the following is a symptom of post-sepsis syndrome? A) Nausea and vomiting B) Loss of self-esteem C) Racing thoughts and rapid speech D) Osteoporosis

Loss of self-esteem Post-sepsis syndrome (PSS) is a condition that develops in up to 50 percent of clients who have survived sepsis. It occurs as physical or psychological long-term effects after recovery. Because sepsis is a significant and life-threatening event, the client who survives and is discharged home may suffer from symptoms that can be debilitating, including multiple physical impairments, sleep disturbances, problems with concentration, fatigue, and loss of self-esteem.

Parkland Formula

Method of calculating fluid repletion in burn patients. ;4ml/ kg x TBSA%, and first half within the first 8 hours.

A client arrives in the emergency room with rib fractures. The nurse and healthcare provider are reviewing the x-ray and would be most concerned about rib fractures in which of the following locations? A) Left side, ribs 4 & 5 B) Right side, ribs 1 & 2 C) Right side, ribs 8-11 D) Left side ribs 6 & 7

Right side, ribs 1 & 2 This location has the highest concern for the possibility of concurrent injuries. The significance of a first rib fracture is the association with cervical spine trauma, multiple rib fractures or life-threatening vascular injuries. Historically, fractures of ribs 1-3 have been associated with injuries of the brachial plexus and major vessels.

A client has a terminal illness and is near death. The nurse knows that this client is an organ donor. Which of the following tissues can be donated? - Skin - Aorta - Cornea - Tendons - Heart valves

Skin Tissues that can be donated include: Skin, bone, corneas, tendons, heart valves and saphenous veins. Cornea Tendons Heart valves Not the Aorta.

The nurse is caring for a client with a broken femur. The client is at higher risk for which of the following due to this specific bone fracture? Select all that apply. - Heart attack - Stroke - Pneumonia - Pulmonary embolism - Deep vein thrombosis

Stroke Long bone fractures such as the femur, tibia, and pelvis, put the client at risk for a fat embolism. This embolism can travel to the heart, lungs, or brain and cause obstructed blood flow to these areas. Heart attack A fat embolism is possible following a long bone fracture. If this particle of fat becomes lodged in the vessels of the heart, it can cause the client a heart attack. Pulmonary embolism The femur is a long bone. Fractures to long bones increase the risk of a fat embolism, which can travel to the lungs and cause a pulmonary embolism.

What are the common medications used for hypovolemic shock?

Vasopressors: - Dopamine - Norepinephrine - Phenylephrine Inotropes: - Dobutamine Enhancing Myocardial Perfusion: - Sodium nitroprusside

What are the listed abnormal lab findings for Fat Embolism Syndrome?

^ ESR ^ lipids v calcium v RBCs v platelets v PaO2

What are the listed nursing interventions/tx for Fat Embolism Syndrome?

bedrest oxygen IV fluids fracture immobilization possible steroid therapy

Which of the following is seen in a client with a flail chest? A) Hyperresonance on auscultation B) A sucking chest wound C) Affected side goes in with inspiration and out with expiration D) Rhonchi heard on auscultation

Affected side goes in with inspiration and out with expiration In a flail chest, the affected side goes in with inspiration and out with expiration, due to multiple breaks on a rib bone, causing a portion of the rib to 'float'. There is usually no sucking chest wound and there can be various lung sounds heard that are nonspecific for flail chest.

A 78-year-old client has been admitted to the hospital with sepsis. The nurse understands that older adults are at a higher risk of developing septic shock when compared to young adults. Which best describes the reason for this risk? A) An older adult is less likely to respond to antibiotic therapy B) An older adult secretes more melatonin that affects his ability to protect himself C) An older adult produces fewer plasma cells and is unable to fight off infectious pathogens D) An older adult has decreased immunity as a result of physical changes from aging

An older adult has decreased immunity as a result of physical changes from aging Older adults are at higher risk of developing complications when illness occurs because of the physical changes that have occurred as part of aging. Because of this, an older adult may have decreased immune function when compared to a young or middle-aged adult. For this reason, the healthcare provider must consider the unique needs of older adults and implement them into care to best prevent further complications from serious conditions like sepsis.

A client is admitted with rhabdomyolysis after joining a spinning class and overworking the legs. The client asks why the legs hurt so bad and the nurse knows that which of the following explanations about overworking the muscles would be best to give? A) Caused your bones to break down B) Caused muscle cell breakdown C) Caused damage to the veins D) Caused blood clotting

Caused muscle cell breakdown Overworking the muscles does lead to muscle breakdown resulting in rhabdomyolysis.

What are the listed S/Sx of Fat Embolism Syndrome?

Change in LOC Confusion- usually first sign v SaO2 dyspnea tachypnea chest pain tachycardia ^ temp crackles petechiae of chest-late sign (petechiae is only present in 50% of cases, but differentiates fat from blood emboli.)

Explain a CMS assessment.

Circulation- checking for distal pulses and cap refill. Motor Ability- can they move the extremity? Sensation- can they feel in the extremity?

A client on the unit is diagnosed with SIRS. The client has a history of congestive heart failure and chronic kidney disease. The client has received 2 liters of normal saline in the emergency department and is receiving normal saline at 150/hr. The nurse knows that which of the following orders should be questioned? Select all that apply. - Dialysis STAT for fluid removal - Insert urinary catheter to monitor output - Furosemide 80 mg IV BID - Potassium 50 mq PO BID with meals - Insert second IV access

Dialysis STAT for fluid removal Dialysis STAT is not an appropriate order for the client diagnosed with SIRS. The client needs fluid resuscitation. Diuretics may be given to avoid fluid overload.

A client with difficulty breathing gets a CT scan that shows multiple clots in the lungs as well as in the heart and kidneys. Which blood clotting condition does this client most likely have? A) Wiskott-Aldrich syndrome B) Disseminated intravascular coagulation C) Hemophilia D) Idiopathic thrombocytopenic purpura

Disseminated intravascular coagulation This occurs because the activation of the clotting cascade causes mini clots to form all throughout the vasculature of the body.

A nurse is caring for a comatose client and needs to test for brain stem function. Which test is used to test brain stem function? A) Cotton-tipped applicator scleral depression test B) Capillary refill C) Cardinal gaze test D) Doll's eye movement

Doll's eye movement The doll's eye movement test tells the nurse if the brain stem is working. With this test, the nurse will gently open the comatose client's eyelids and briskly move the head from side to side. If the eyes move in the opposite direction of the head, the client has a positive doll eyes reflex, which is normal. The reflex is absent if the eyes move in the same direction as the head or stay fixed at midline, which is ABNORMAL and indicates brain stem injury. X -Cotton-tipped applicator scleral depression test This test is for retinal detachment. X -Cardinal gaze test The cardinal gaze test is for cranial nerves 3, 4, and 6.

A nurse is caring for a client who has suffered an arm fracture and has a fiberglass cast applied. Which information should the nurse give to the client to help him reduce swelling in the extremity? A) Keep the fingers at rest to prevent increased circulation B) Check peripheral circulation by assessing capillary refill C) Apply heat to the fingertips, such as with a heating pad D) Elevate the cast and extremity

Elevate the cast and extremity The client with a cast in place may develop swelling in the affected extremity. Part of cast care is to teach the client how to prevent complications such as swelling and muscle atrophy. The nurse should encourage the client to keep the arm elevated and apply ice packs as needed. The client may check capillary refill, but this will not necessarily reduce swelling. Gentle exercise, such as range of motion activities, can also improve circulation and reduce swelling.

A client is recovering from an injury in which he was severely burned. The client is having difficulties coping with his appearance and he tells the nurse that he does not want to look at the burned area. Which response from the nurse is most appropriate? A) Tell the client about reconstructive surgery options B) Explain that the client's family or friends can be a support for him C) Encourage the client to get rid of all mirrors in the home D) Encourage the client to talk about their feelings of loss

Encourage the client to talk about their feelings of loss A client who has been disfigured after an injury commonly displays symptoms of post-traumatic stress disorder due to the traumatizing incident. This is especially true of the client who has been disfigured after a burn. This client needs ongoing emotional support from the nurse as well as from family and friends.

What are the listed nursing interventions/tx for a patient in hypovolemic shock?

Ensure airway & Breathing If bleeding-stop it. Ensure IV sites (ideally two and at least one 18g) oxygenation elevate feet & head flat or <30degrees IV fluids crystalloids (NS or LR) Meds Blood typing process Do not leave patient

The nurse is caring for a client that is suspected to have a flail chest injury. The nurse knows that it is best to position the client in which of the following positions? A) Flail side splinted with sand bags but keeping client dorso-recumbant B) High-fowler's position to prevent aspiration of hemoptysis C) Flail side upward to avoid hemo-pneumothorax from penetrating rib fractures D) Flail side downward to stabilize flail segments and improve ventilation

Flail side downward to stabilize flail segments and improve ventilation This will stabilize the chest and improve ventilation in the non-injured hemothorax.

The nurse is caring for a client whom the provider believes is suffering from sepsis. Which of the following orders would the nurse anticipate receiving for treatment for sepsis? Select all that apply. - Low molecular weight heparin - Fluid boluses - Procalcitonin level - Antihypertensives - Analgesics for pain relief

Fluid boluses This is an expected treatment component for the septic client. Procalcitonin level This is an expected treatment component for the septic client.

A 7-year-old child was brought into the emergency department with 2nd and 3rd degree burns over 36% of his body. What is the priority during this initial emergency department phase in caring for this client? A) Promote normothermia B) Pain control C) Debridement of the wounds D) Fluid resuscitation

Fluid resuscitation Clients with large surface area burns (especially anything over 20%) are at high risk of losing large amounts of interstitial fluid and going into hypovolemic shock. The top priority in the initial phase of care is to begin fluid resuscitation. Typically providers will use the Parkland Formula (4 x kg x %) as an initial guide, then titrate to urine output (0.5 mL/kg/hr).

A client presents to the emergency department who was moving a mirror that fell on the client and shattered. The client has a large laceration down the right arm. What is the priority concern for this client? A) Degloving B) Hemorrhage C) Infection D) Neuropathy

Hemorrhage The first priority for a client with a laceration is to control the bleeding.

What are the listed major complication to watch for with fractures?

Hemorrhage/Shock Venous Thromboembolism Acute Compartment Syndrome Fat Embolism Syndrome Crush Syndrome Infection (sepsis, osteomyelitis) Chronic Complications: - Complex Regional Pain Syndrome - Delayed Union - Ischemic Necrosis

The nurse is assigned to an older adult with a urinary tract infection. Which abnormal symptom would cause concern for sepsis? Select all that apply. - Hyperglycemia - Hypoglycemia - Hypertension - Hypotension - Bradycardia

Hypotension When a client goes into sepsis, hypotension is one of the main signs, as the body's system-wide response is to dilate the blood vessels. Hyperglycemia Septic clients often have elevated blood glucose, which is a response to stress and inflammation in the body.

A new nurse is having a difficult time knowing which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first? A) Hypotension, tachycardia, and lethargy B) Abdominal pain, hypertensive and constipated C) Febrile, tachycardia, and vomiting D) Dizziness with normal vital signs

Hypotension, tachycardia, and lethargy The hypotensive client with tachycardia is concerning for hypovolemia or shunting, especially with lethargy. This client is not stable. The lethargy indicates that blood flow and oxygenation are an issue.

What is the normal range for serum Lactic Acid?

Iggy: If we are using mg/dL: 3-7mg/dL If we are using mmol/L: 0.3-0.8mmol/L Most online sources: If we are using mg/dL: 5-20mg/dL If we are using mmol/L: 0.6-2.2mmol/L

The nurse is caring for a client noted to be at high risk for developing sepsis because of which of the following risk factors? Select all that apply. - Traveling outside the United States - Invasive devices - Being male - Infection - Older age

Infection Infection means a pathogen has already been introduced to the body, and has a potential to develop into sepsis. Invasive devices Infection means a pathogen has already been introduced to the body, and has a potential to develop into sepsis. Older age Extremes of age (very old and very young) are at risk for developing sepsis if they have an infection especially if they have a compromised immune system.

Stages of Shock

Initial: 5-10mmHg < Baseline MAP, ^HR, some vasoconstriction, sympathetic stimulation. Non-progressive: 10-15mmHg < Baseline MAP, tachycardic, thready pulses, v urine o, polydipsia, RAAS increases vasoconstriction, mild hyperkalemia. Progressive: >20mmHg of Baseline MAP, Anaerobic metabolism, moderate acidosis & ischemia. Refractory: MODS, myocardial depressant released from pancreas, Death.

A nurse receives lab results on a client and knows that which of the following will alert the nurse that the client has sepsis? A)Wound culture positive for MRSA B) WBC 10,001 C) Nasal swab positive for influenza A D) Lactic acid 5.3mmol/L

Lactic acid 5.3 This shows that the client's organs and tissues are lacking oxygenation resulting in anaerobic metabolism with the byproduct of lactate. This nurse should be concerned about sepsis. Also, keep in mind the units of measure being used. If we are using mg/dL: 5-20mg/dL If we are using mmol/L: 0.6-2.2mmol/L

Family members of a client who is in a coma are concerned that the client is brain dead. The nurse responds by informing the family members that being in a coma is not the same thing as brain death. Which of the following could mimic brain death? Select all that apply. - Absence seizure - Fulminate Guillain-Barre Syndrome - Locked-in syndrome - CNS depressant overdose - Myocardial infarction

Locked-in syndrome There are multiple conditions that mimic brain death. These include locked-in syndrome, fulminate Guillain-Barre syndrome, severe hypothermia, post-cardiac arrest syndrome, massive baclofen/anticholinergic OD, CNS depressant overdose, snake envenomation, paralytic agents, and profound hypernatremia. Fulminate Guillain-Barre Syndrome This condition mimics brain death. CNS depressant overdose This condition mimics brain death.

What is the common medication used for DIC?

Low doses of Heparin

A pediatric nurse is caring for a 2-year-old child who suffered a femur fracture. The child has a cast on the leg and has been placed in Bryant's traction. Which of the following considerations must the nurse implement when working with a child who uses this traction? A) Provide the child with a liquid or mechanical soft diet B) Perform range-of-motion of the affected hip every 4 hours C) The knee must be maintained at a 90-degree angle D) Maintain the buttocks at a level just above the mattress of the bed

Maintain the buttocks at a level just above the mattress of the bed Bryant's traction is used for a fracture of the femur in some children. A child who uses Bryant's traction is typically less than 2 years old and weighs less than 30 pounds. While caring for this child, the nurse should ensure that the buttocks are at a level just above the mattress of the bed, as this form of traction pulls the legs and hips straight up off the bed.

A client comes into the emergency room with sepsis. Which of the following orders should the nurse implement first? A) Normal Saline 1000 mL bolus over 1 hour B) Urinary catheter placement C) IV azithromycin 250 mg q12h D) IV ceftriaxone 100 mg q8h

Normal Saline 1000 mL bolus over 1 hour The normal saline bolus should be started first because fluids are the priority with sepsis. The primary and most important treatment for sepsis is fluid resuscitation. The antibiotics may be started after the fluid bolus. Antibiotics should also wait until after a blood culture is obtained.

What are the 6 P's of compartment syndrome or of a neurovascular assessment?

Pain- 1st sign Pressure Pallor/Pink- usually pink Pulses- usually still present Paresthesia Paralysis- Worst/last sign

What are the listed S/Sx for Acute Compartment Syndrome?

Pain- early sign, unrelieved by meds. Pink (early) to Pallor (late). Paresthesia- tingling as nerves are impeded. Pressure- tight wood-like skin. Pulses- present but could be weak. Paralysis- late sign.

A client with a pericardial tamponade is being cared for in the hospital. The nurse is reviewing orders and knows that which if the following is an acceptable treatment for a pericardial tamponade? A) Pericardiocentesis B) Internal Cardiac Massage C) Defibrillation D) Thoracentesis

Pericardiocentesis This would alleviate the pressure from the blood in the pericardial sac. Pericardial tamponade is when fluid and blood collects around the heart, adding pressure to the heart.

The client admitted for rhabdomyolysis has received three fluid boluses and has normal saline infusing at 125/hr. The client begins to feel short of breath and the nurse listens to the lungs and hears crackles. The vitals are determined to be stable except for the pulse ox reading 86%. Which of the following is the nursing priority? A) Place 2 L NC oxygen on client B) Call the healthcare provider C) Increase the fluids D) Order furosemide to give stat

Place 2 L NC oxygen on client Breathing is the priority so the nurse should put oxygen on the client and the nurse can notify the healthcare provider after along with getting further orders.

A nurse receives report on the following clients and knows that the client with which of the following diagnosis is at the highest risk for developing SIRS? A) Pneumonia and sepsis B) Dehydration and UTI C) Cellulitis with MRSA D) Fevers of unknown source and altered mental status

Pneumonia and sepsis The client with sepsis is at a higher risk for developing SIRS.

A nurse is reviewing labs on an unconscious client who arrived to the emergency room. Which of the following abnormal lab values would make the nurse suspect a traumatic crush injury? A) PH 7.38 B) Potassium 7.2 mEq/L C) Calcium 9.0 mEq/L D) Sodium 140 mEq/L

Potassium 7.2 mEq/L Normal potassium is 3.5-5 mEq/L. 7.2mEq/L is elevated and it indicates hyperkalemia. This is a common result of severe crush injuries because the cells get crushed and push the potassium out of the cell into the bloodstream causing high potassium in the blood.

What establishes brain death?

Prerequisites: normal systolic BP 2 neuro exams established cause of coma normal body temp the neuro exam choices: coma pupillary response response to anoxious stimuli apnea test doll's eye test cornea reflex test gag-reflex test Imaging: EEG Cerebral Angiography

If you are suspecting that your patient may have acute compartment syndrome, you would respond by doing which of the following? Select all that apply. - Elevate the extremity above the heart level. - Ensure that the cast is tight and secure. - Remove all tight clothing, wraps, or confining materials - Ice the extremity. - Call a code blue. - Do a full CMS assessment - Call the doctor

Remove all confining materials from area. Do a full CMS assessment Call the doctor

What are the listed nursing interventions/tx for Acute Compartment Syndrome?

Remove compression (if external) Do a CMS assessment Make sure extremity is left at the level of the heart (not above). Notify provider immediately after - fasciotomy, then wound care (vac)

A client was in a motor vehicle accident in which he suffered a traumatic fracture in his lower leg. The nurse knows that the client is at risk for a fat embolism. What are signs and symptoms for the nurse to look for that indicate fat embolism syndrome (FES)? Select all that apply. - Respiratory distress - Tachycardia - Renal dysfunction - Upper body petechiae - Low body temperature

Respiratory distress A fat embolism occurs when a small piece of fat enters the bloodstream and lodges into a vein, potentially obstructing blood flow. A client who has had a traumatic fracture is at high risk of FES. Signs and symptoms of FES include respiratory distress, tachycardia, petechiae on the upper body, fever, renal dysfunction and jaundice. Nursing care for the client in FES includes IV fluid therapy, oxygen administration, DVT prophylaxis and supportive care. Tachycardia Tachycardia is one of the signs of a fat embolism. Renal dysfunction FES can cause renal dysfunction. Upper body petechiae Petechiae on the upper body is a sign of FES.

A client comes in with a large skin tear on the right arm and multiple lacerations on the legs immediately after a motor vehicle accident. Vitals are as follows: HR 140 Temperature 99.2F Blood pressure 140/54 Respirations 30 The clients white blood cell count is 22,000 uL. Which of the following syndromes should the nurse be concerned that may be occurring in the client? A) SIRS B) Sepsis C) Normal inflammatory response D) MODS

SIRS The nurse should be concerned that the client has SIRS due to the recent trauma, elevated heart rate, elevated white blood cells, and elevated respirations.

Differentiate "sprain" and "strain".

Sprain: stretch injury to ligaments. Strain: stretch injury to muscles (or tendon).

A nurse is caring for a client admitted for rhabdomyolysis after being found lying on the floor for three days. Which of the following orders should the nurse expect to implement? A) Fluid restriction B) NPO C) Keep legs elevated D) Strict intake and output

Strict intake and output The healthcare provider will likely order strict intake and output monitoring to keep track of the kidney function that is affected by rhabdomyolysis.

A nurse is caring for a 35-year-old client who has been diagnosed with hypovolemic shock as a result of severe hemorrhage. In which position should the nurse place this client to promote optimal circulation? A) Trendelenburg B) In the Sims' position C) Supine with the legs elevated D) Left side-lying with the head flat

Supine with the legs elevated The suggested position for the client in shock is supine with the legs elevated. This position is thought to promote venous return from the lower extremities so that blood can flow back to the heart and perfuse central organs, although research is scarce on this topic. The cardiovascular system does not have to work as hard and blood can be shunted to central organs until the client receives appropriate treatment.

A patient with a burn injury is brought in to the urgent care clinic and the nurse begins an initial assessment. Which signs or symptoms from the patient would the nurse attend to as highest priority? Select all that apply. -The client complains of pain in the right arm -The client has an oxygen saturation of 87 percent on room air -The client has retractions in the chest with breathing -The client has singed hairs around the mouth and nose -The client has a 3-inch bandaged laceration on the shoulder

The client has singed hairs around the mouth and nose the nurse would make assessing the client's airway, breathing, circulation, and cervical spine the highest priority over other minor injuries. The client has an oxygen saturation of 87 percent on room air A client in a critical situation requires assessment that is prioritized to the highest priorities being first. In this case, as with many other emergency situations, the nurse would make assessing the client's airway, breathing, circulation, and cervical spine the highest priority over other minor injuries. The client has retractions in the chest with breathing A client in a critical situation requires assessment that is prioritized to the highest priorities being first. In this case, as with many other emergency situations, the nurse would make assessing the client's airway, breathing, circulation, and cervical spine the highest priority over other minor injuries.

A triage nurse takes a call from a client who has been burned while trying to do some electrical wiring. The nurse asks the client for more information. Which data from the client would indicate that they have suffered a 2nd-degree burn? A) The skin is red and has blisters B) The skin is blackened with no pain C) The skin is white and appears charred D) The skin is red, painful and dry

The skin is red and has blisters A triage nurse must properly evaluate the extent of a client's injuries over the phone using all the information available. Burn wound management must be properly triaged to minimize the risk of improper care and subsequent poor outcomes for the client. A first-degree burn is red, painful and dry. An example of this is a sunburn. These minor burns can be cared for at home and are at little risk of infection or complications. However, if a client experiences a 2nd degree burn or worse, they should seek treatment at a healthcare center. A 2nd degree burn involves damage to the epidermis and part of the dermal layer of skin. It appears as skin that is reddened, painful, has blisters, and may be swollen.

As an ED nurse or first responder, how would we decide the TBSA for a burn patient?

To get a close estimated TBSA in a burn patient we use the Rule of 9's. This does not apply the same to pediatric pts, since their proportions are not the same.

A nurse is caring for a septic client with hypotension who is tachycardic and tachypneic. The nurse knows that the client is tachypneic for which of the following reasons? A) An anxiety attack B) To lower the blood PH C) To increase the blood PH D) Restricted bronchioles

To increase the blood PH The client with sepsis will have increased respirations (tachypnea) to blow off excess CO2 to battle the metabolic acidosis, and in turn, increase the PH of the blood.

A nurse must give an intramuscular injection of pain medication to a client who has suffered a left arm fracture. Which of the following situations would be a contraindication to administering medication in this manner? Select all that apply. - The drug follows thrombolytic therapy - The dose of the drug is over 2 mL - A known reaction to the medication - A birthmark is at the site of injection - The client is uncooperative

X -The dose of the drug is over 2 mL IM injections, depending on the injection site, can be given up to 5 ml. The client is uncooperative The nurse should not give pain medication to a client who does not want it. A known reaction to the medication Any time the patient has a known reaction to a medication, the medication should be avoided. The drug follows thrombolytic therapy If the patient has received thrombolytic therapy, an IM injection is contraindicated because of the increased bleeding potential. A birthmark is at the site of injection Other situations in which the nurse should not give an IM injection include if there is redness, inflammation, bleeding, or a birthmark over the injection site.

The nurse is checking the client's chart for proper paperwork before cardiac surgery. Which of the following is a legally required part of an advance directive? Select all that apply. - The durable power of attorney is named - A list of client wishes in certain medical situations is included - Organ donation directives are included in the durable power of attorney - A list of the client's beneficiaries is included if the document is a living will - The directive is signed by the client

The durable power of attorney is named The advance directive usually contains a list of the client's wishes in certain medical situations as well as naming the durable power of attorney when it comes to making medical decisions. The directive is signed by the client, and a durable power of attorney is signed by a witness, while a living will may or may not be signed by a witness. A list of client wishes in certain medical situations is included The advance directive usually contains a list of the client's wishes in certain medical situations as well as naming the durable power of attorney when it comes to making medical decisions. The directive is signed by the client, and a durable power of attorney is signed by a witness, while a living will may or may not be signed by a witness. X -A list of the client's beneficiaries is included if the document is a living will Beneficiaries are not a part of a living will. X -Organ donation directives are included in the durable power of attorney Organ donation directives can be included in advance directives, but are an add on. They are not required. The directive is signed by the client The advance directive usually contains a list of the client's wishes in certain medical situations as well as naming the durable power of attorney when it comes to making medical decisions. The directive is signed by the client, and a durable power of attorney is signed by a witness, while a living will may or may not be signed by a witness.

The nurse is receiving report on a client with chemical burns over 70% of the body. The outgoing nurse states that the client's pain is a 7/10. The client has been averaging 80 ml/hr out of urine output and receiving 125 ml/hr 0.9% normal saline into a central venous catheter. The serum sodium is 133, K is 3.4, and Mag is 1.9. Vital signs are stable. The client is receiving antibiotics and is on a regular diet. What is the nurse's primary concern? A) Pain level B) Urinary output C) Diet order D) Magnesium level

Urinary output These client have a risk for dehydration, fluid volume overload, and third spacing, so optimizing fluid volume status is essential. Optimal fluid resuscitation is shown when the urinary output remains between 30-50 ml/hr. This client is putting out too much urine, and therefore receiving too much IV fluid. The IV rate should be adjusted. X -Pain level While the client's pain needs to be addressed, it is not the primary concern, The client WILL have pain. The more pressing concern is the fluid volume status. The IV fluid rate is the underlying problem that can be adjusted to help stabilize the fluid volume status. X -Magnesium level This is a normal magnesium level. X -Diet order The client's regular diet is appropriate. Calories should not be restricted in a client with burns, because calories and protein are necessary for healing.

Which of the following sign and symptoms indicate that a client is having a systemic inflammatory response? Select all that apply. - Respiratory rate 24 - White blood cell count >12000 - Decreased urine output - Increased urine output - White blood cell count

White blood cell count >12000 Systemic Inflammatory Response Syndrome (SIRS) criteria include temperature above 100.5 degrees Fahrenheit, heart rate >90 bpm, respiratory rate >20, and increased WBC OR decreased WBC with greater than 10% bands (immature neutrophils). A client needs to only meet two of these criteria to be considered a SIRS client. White blood cell count This is included in criteria for SIRS. Respiratory rate 24 A respiratory rate >20 is criteria for SIRS.

The nurse is working a shift on the medical surgical floor. The nurse knows that which of the following clients is at the highest risk for hypovolemic shock? Select all that apply. - A 53-year-old with a blistered burn to their thumb - A 52-year-old receiving heparin for a myocardial infarction - A 55-year-old with pancreatitis receiving Ringer's lactate at 100 mL/hr - A 51-year-old just returning from surgery for gallbladder removal - A 54-year-old alcoholic who is sleeping

A 51-year-old just returning from surgery for gallbladder removal Surgery causes an increased risk for hypovolemic shock due to the risk of hemorrhage. A 52-year-old receiving heparin for a myocardial infarction Anticoagulant therapy carries an increased risk for hypovolemic shock. Factors leading to hypovolemic shock include body fluid depletion, hemorrhage due to trauma, surgery, GI ulcer, or increased clotting, dehydration from nausea, vomiting and diarrhea, hyperglycemia, and diuretic therapy.

A 34-year-old client has suffered a femur fracture and is using skeletal traction while in bed. Which nursing diagnoses would be most applicable in this situation? Select all that apply. - Risk for Impaired Gas Exchange - Risk for Bowel Incontinence - Acute Pain - Fluid Volume Excess - Risk for Peripheral Vascular Dysfunction

Acute Pain The femur is such a large bone, a femur fracture has the potential to cause several complications for the affected client. The client may have activity intolerance and would be at risk of several issues, including impaired gas exchange due to immobility, and poor tissue perfusion due to potential swelling and circulatory compromise in the affected leg. The nurse will need to be vigilant with pain control for this client as well. Risk for Peripheral Vascular Dysfunction The femur is such a large bone, a femur fracture has the potential to cause several complications for the affected client. The client may have activity intolerance and would be at risk of several issues, including impaired gas exchange due to immobility, and poor tissue perfusion due to potential swelling and circulatory compromise in the affected leg. The nurse will need to be vigilant with pain control for this client as well. Risk for Impaired Gas Exchange The femur is such a large bone, a femur fracture has the potential to cause several complications for the affected client. The client may have activity intolerance and would be at risk of several issues, including impaired gas exchange due to immobility, and poor tissue perfusion due to potential swelling and circulatory compromise in the affected leg. The nurse will need to be vigilant with pain control for this client as well.

The nurse is caring for a client who is demonstrating signs of sepsis. What is the priority for septic clients? Select all that apply. - Breathing treatment - Blood cultures - ECG - Fluids - Antibiotics

Blood cultures A client who is septic needs blood cultures FIRST, in order to determine what type of pathogen is present. Antibiotics A client who is septic needs antibiotics as soon as blood cultures have been obtained. The sooner antibiotics are started, the better the outcome for the client. Fluids After the initiation of antibiotics, the nurse will need to start IV fluids on the septic client. These clients usually require massive fluid resuscitation.

A nurse is caring for a client who is admitted for pneumonia and sepsis. The nurse is reviewing orders and knows to implement which of the following prior to hanging antibiotics? A) Vancomycin trough B) Midodrine PO TID C) Blood culture D) IV hydralazine 40 mg OT

Blood culture The nurse should ensure that the blood cultures are drawn before the antibiotics are first given to ensure that the antibiotics don't affect the results of the blood culture.

A client is brought into the hospital after suffering a mid-shaft femur fracture in a motorcycle accident. After surgery to nail the broken femur, the client is stabilized and brought to the hospital room. The client begins to complain of severe pain in the femur, and numbness and tingling in the lower extremity of the affected leg. The nurse gives pain medication but the pain continues to increase. Which of the following actions should the nurse take? A) Find out when the client last had a bowel movement, and offer a stool softener or laxative B) Ask the client to contact the nurse if the pain medication does not begin to work in thirty minutes C) Contact the surgeon immediately and prepare the client for surgery D) Utilize non-pharmacological measures, such as ice packs and guided imagery

Contact the surgeon immediately and prepare the client for surgery A femur fracture is a significant injury that often occurs as a result of severe trauma. Because of its large size, a broken femur can also lead to extensive complications, including compartment syndrome. Signs and symptoms of compartment syndrome include numbness and tingling on the affected leg, severe pain that is unrelieved by pain medication, pallor, and an inability to move the leg. If the nurse sees these signs, it is a medical emergency, and the client will need surgery as soon as possible.

A client with the diagnosis for rhabdomyolysis has orders for lab work to be done. The nurse is reviewing the lab orders and knows that which of the following lab value help diagnose the client with rhabdomyolysis? A) Lactic acid B) Creatinine kinase (CK) C) Hemoglobin D) Magnesium

Creatinine kinase (CK) CK level will help to diagnose rhabdomyolysis. The breakdown of muscle cells releases CK into the bloodstream.

A nurse is caring for a client who is suffering from an acute hemorrhage after a traumatic injury. The nurse has secured the client's airway, breathing, and circulation and has started a large-bore IV. Which of the following solutions should the nurse administer first? A) O neg whole blood B) Sodium bicarbonate C) Plasma D) Crystalloid IV solution

Crystalloid IV solution A client who is suffering from a severe hemorrhage should have volume replacement in the circulatory system to prevent further complications of hypoperfusion. The first line of treatment is administration of a crystalloid IV solution, such as 0.9% Normal Saline, to restore fluid volume in the cardiovascular system. Crystalloids are widely available, inexpensive, and can be immediately administered without any client testing. After initial resuscitation, the nurse can expect to administer other products, such as plasma, whole blood or packed red blood cells, as ordered.

The nurse is caring for a client who is 32 weeks pregnant and diagnosed with disseminated intravascular coagulation. Which of the following lab values is NOT consistent with this client's condition? A) Decreased PTT B) Increased clotting time C) Decreased platelets D) Decreased hematocrit

Decreased PTT DIC would reflect an increased PTT, because in this condition, the client's clotting time increases due to the depletion of coagulation factors.

A 46-year-old client was involved in a motorcycle accident and comes in to the emergency department with rib fractures and a flail chest. The provider orders to set up for treatment utilizing pneumatic stabilization. Which actions would be included as part of this treatment? Select all that apply. - Administration of epinephrine - Endotracheal intubation - Use of PEEP with ventilation - Oro- and nasogastric suctioning - Mechanical ventilation

Endotracheal intubation A flail chest occurs with rib fractures when three or more portions of the rib are broken, causing floating pieces of ribs in the chest cavity. Pneumatic stabilization involves stabilizing the internal lung tissue to support ventilation. This includes endotracheal intubation and mechanical ventilation with PEEP. Mechanical ventilation Mechanical ventilation would be used in this scenario. Use of PEEP with ventilation Positive end expiratory pressure is used in a client with flail chest to decrease the chance of alveoli collapsing.

A nurse is caring for a client who has suffered a fracture to the humerus after falling on their outstretched arm. The ends of the bone were driven into each other during the fall. This type of fracture is best described as which of the following? A) Oblique fracture B) Comminuted fracture C) Greenstick fracture D) Impacted fracture

Impacted fracture An impacted fracture is one in which the ends of the bone in a fracture are driven into each other. This type of fracture is most likely the result of a fall, such as onto an outstretched arm. It may also occur when the bone breaks from collapse of the structure, which is known as a buckle fracture.

A client who has been severely burned in an accident is brought to the emergency department. The physician orders a regimen to begin fluid resuscitation. Which type of fluid would the nurse most likely use as part of fluid resuscitation following a burn injury? A) 0.9% Normal saline B) D10W C) Lactated Ringer's solution D) D5 ½ NS with KCl

Lactated Ringer's solution When a client is severely burned, they require a significant amount of fluid replacement in the first 24 hours, known as fluid resuscitation. Lactated Ringer's solution is typically the fluid of choice because it is widely available and closely resembles the fluid lost in a burn injury. Lactated Ringer's is an isotonic, crystalloid solution that contains a small amount of electrolytes. X -0.9% Normal saline It is not typically used in initial burn fluid resuscitation. X -D10W This solution is used for clients who are severely hypoglycemic, not for burn patient fluid resuscitation. X -D5 ½ NS with KCl This is used as a post-operative fluid replacement solution, not as a first line fluid for burn resuscitation.

The client has suffered from a chest injury. What are some nursing interventions appropriate to this situation? Select all that apply. - Provide humidified O2 - Monitor for shock - Strict intake and output measurements - Administer laxatives to prevent constipation - Monitor ABGs

Monitor for shock A client with a chest injury is at high risk for hypovolemic shock and must be monitored appropriately. Provide humidified O2 This client is at risk for impaired oxygenation and the nurse will plan to support with supplemental humidified oxygen as needed. Monitor ABGs Due to the risk for impaired oxygenation and gas exchange, ABGs will need to be monitored in order to recognize potential decompensation.

A client is being seen for follow-up care after surgery for a fracture in which an external fixation device was placed. What is the most important part of the assessment? A) Monitor the pin sites for signs of infection B) Ensure that nothing touches the outside of the fixation device C) Clean and thoroughly dry the skin under the traction D) Assure that the traction weights hang freely

Monitor the pin sites for signs of infection An external fixation device is applied to correct a fracture. The device is secured to the client by screws or pins that go through the skin into the underlying bone. If the client develops an infection it could quickly develop into sepsis. The MOST important action by the nurse is to monitor the pin sites and keep them clean to prevent infection.

A nurse is caring for a client who is recovering from a severe burn injury. The nurse keeps track of the client's intake and output each day throughout the shift. Which choice best describes the purpose of monitoring intake and output for a burn client? A) Checking whether a drug should be administered on time B) Determining whether the client's blood pressure is normal C) Identifying the client's appropriate weight D) Monitoring for electrolyte imbalances

Monitoring for electrolyte imbalances Skin, the largest organ in the body, protects against fluid and electrolyte loss. When a client suffers a burn, the ability to protect against fluid loss is compromised. The client is at risk for major shifts in fluid and electrolytes, so the nurse should monitor intake and output with each shift. This process helps the nurse to know how much fluid the client receives through oral intake and intravenous infusion, and how much the client excretes through urine, gastric and wound output. X -Identifying the client's appropriate weight Intake and output monitoring is not necessary to identify the client's accurate weight. Rather, the client should be weighed in real time using a standing scale if the client is able, or a bed scale if the client is unable to get out of bed.

The nurse received a client into the trauma bay after a suspected suicide attempt. Witnesses state the client jumped from a 35 foot ledge landing on his/her back. The nurse stabilized the client and inserted a urinary catheter. A scant amount of dark, tea colored urine is noted in the collection bag. The nurse should obtain orders for which of the following first? A) Discontinue urinary catheter B) 40mg Lasix IV C) Normal saline D) 1 amp of sodium bicarbonate now

Normal saline This is one of the first-line treatments for suspected rhabdomyolysis. The administration of IV fluids will help flush the toxins from the body.

Twelve hours after abdominal surgery, the nurse assesses the client and notes restlessness and complaints of thirst. The nurse notes that the client has cool, pale extremities, tachycardia and has become diaphoretic. The nurse notes that the dressing to the surgical site is soaked with blood. Which of the following is the next action the nurse should take? A) Implement safety precautions B) Turn the client on the left side C) Provide pressure to the surgical site D) Call for a code blue

Provide pressure to the surgical site This client is experiencing post-op hemorrhage and is at high risk of shock from excessive blood loss. The nurse must apply pressure to the site of bleeding, whether internal or external. The nurse then contacts the provider, provides oxygen if needed, and administers IV fluids and/or blood as ordered. The client may need to be prepared for surgery based on the provider's orders as well.

An emergency department nurse is caring for a client with 2nd and 3rd degree burns on 40 percent of his body. The nurse knows that the effects of the burn on the cardiovascular system include which of the following? Select all that apply. - Increased pulse rate - Hypovolemic shock - Decreased cardiac output - Increased mean arterial pressure - Fluid volume deficit

X -Increased mean arterial pressure In hypovolemia the blood pressure decreases, which would lead to a decrease in mean arterial pressure instead of an increase. Fluid volume deficit A severe burn such as the 40% body surface burn of the above client will impact all body systems. The cardiovascular system is affected due to a large fluid shift that occurs. The injured tissue releases vasoactive substances that increase capillary permeability, which causes fluids to leak into surrounding tissue. The client experiences a fluid volume deficit, cardiac output is decreased and hypovolemic shock can occur. The pulse rate increases in the client with a fluid volume deficit as well. Increased pulse rate This is consistent with a fluid shift into the intravascular space. Hypovolemic shock Hypovolemic shock can occur when fluid shifts out of the vasculature and into the surrounding tissue. Decreased cardiac output With a decreased circulating blood volume, decreased cardiac output follows.

The nurse is caring for a client in shock. Which of the following would be included in the nursing care plan? Select all that apply. - Maintain a patent airway - Treat acidosis - Maintain systolic BP above 130 - Maintain adequate tissue oxygenation - Assess electrolytes

X -Maintain systolic BP above 130 The nurse needs to maximize circulation and maintain a systolic BP, but 130 is much too high. A systolic blood pressure above 90 is ideal. Maintain adequate tissue oxygenation In managing the care of a client with shock, BP should be maintained at above 90 systolic, adequate tissue oxygenation should be maintained, acidosis should be treated and a patent airway maintained. The client should be kept warm. Treat acidosis Acidosis occurs due to the lack of CO2 being blown off, so this must be treated. Maintain a patent airway The client must have a patent airway. X -Assess electrolytes Electrolyte levels are not specific to shock