NU 214 EXAM 3 test questions

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on theinfusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting theinfusion pump, the nurse will set the infusion rate at how many milliliters per hour?

27

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?

27%

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to theburn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate(mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?

600mL

which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac (Toradol) b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

d. hydromorphone (Dilaudid)

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories

ABCD

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take(select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

ABDE

A patient with circumferential burns on both legs develops a decrease in dorsalis pedis pulses strength and numbness in the toes. Which action should the nurse take first? A. Monitor the pulses every hour B. Notify the health care provider C. Elevate both legs above heart level with pillows D. Encourgae the patient to flew and extend toes

B. Notify the health care provider

Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92kg (202.4 lbs). Which information would be a priority to communicate to the health care provider? A. Blood pressure is 95/48 per arterial line B. Urine output of 41ml over the past 2 hours C. Serous exudate is leaking from the burns D. Heart monitor shows sinus tachycardia of 108

B. Urine output of 41ml over the past 2 hours

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following inital laboratory results: HCT 58%, Hgb 18.2 mg/dL, (172 g/L), serum K+ 4.9 mEq/L (4.8mmol/L). Which of the following prescribed actions should be the nurses priority? A. Monitor the urine output every 4 hours B. Continue to monitor the laboratory results C. Increasing the rate of the ordered IV solution D. Typing and crossmatching for a blood transfusion

C. Increasing the rate of the ordered IV solution

Esomeprazole (Nexium) is prescribed for a patient who incurred extenssive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? A. Bowel sounds B. Stool frequency C. Stool Occult blood D. Abdominal distention

C. Stool Occult blood

In which order will the nurse take these actions when doing a dressing change for a partial thickness burn wound on a patients chest? (put a comma and a space between each) A. Apply sterile gauze dressing B. Document wound appearance C. Apply silver sulfadiazine cream D. Give IV fentanyl (Sublimaze) E. Clean wound with saline soaked gauze

D, E, C, A, B

A patient who has burns n the arms, legs, , and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? A. Stay at the bedside and reassure the patient B. Administer the ordered morphine sulphate IV C. Assess orientation and level of consciousness D. Use pulse oximetry to check oxygen saturation

D. Use pulse oximetry to check oxygen saturation

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Give vancomycin 1 g IV. b. Obtain blood and urine cultures c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation above 95%.

EDCBA

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venouspressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg

a. Administer furosemide (Lasix) 40 mg IV.

A patient arrives in the emergency department with facial and chest burns caused by a housefire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

a. Auscultate the patient's lung sounds.

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Give epinephrine. b. Administer diphenhydramine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count (CBC)

a. Give epinephrine.

The charge nurse observes the following actions being taken by a new nurse on the burn unit.Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F(35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider when a nondiabetic patient's serumglucose is elevated.

a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound.

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first? a. Remove nonadherent clothing and wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.

a. Remove nonadherent clothing and wristwatch.

Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who is scheduled for a dressing change d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

b. A patient with smoke inhalation who has wheezes and altered mental status

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories.

b. Continue to measure the urine output.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

b. Elevate the right arm and hand on pillows and extend the fingers.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

b. Full-thickness skin destruction

A patient with massive trauma and possible spinal cord injury is admitted to the emergencydepartment (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2°F (38.4°C)

b. Heart rate 45 beats/min

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure(PAWP). Which intervention ordered by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

b. Infuse normal saline at 250 mL/hr.

patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

b. Insert a feeding tube and initiate enteral feedings.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

b. Monitor breath sounds frequently.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

b. Notify the health care provider and prepare for endotracheal intubation.

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected uro-sepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

b. Patient with suspected uro-sepsis who has new orders for urine and blood cultures and antibiotics

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. b. Place on heart monitor. c. Check potassium level. d. Assess oral temperature.

b. Place on heart monitor.

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute.

b. The patient is complaining of chest pain.

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since being admitted.

b. The patient's central venous pressure is 3 mm Hg.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

b. Urine output is 65 mL over the past hour.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA),the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.

b. Urine output of 41 mL over past 2 hours.

While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination? a. Use sterile gloves when removing dressings. b. Wear gown, cap, mask, and gloves during care. c. Keep the room temperature at 70° F (20° C) at all times. d. Give IV antibiotics to prevent bacterial colonization of wounds.

b. Wear gown, cap, mask, and gloves during care.

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% albumin infusion b. furosemide (Lasix) IV c. epinephrine (Adrenalin) drip d. hydrocortisone (Solu-Cortef)

b. furosemide (Lasix) IV

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "Do you think dark beige makeup will cover this scar?" d. "I don't think my boyfriend will want to look at me now."

c. "Do you think dark beige makeup will cover this scar?"

A patient with severe burns has crystalloid fluid replacement ordered using the Parklandformula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. Theinitial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 219 mL/hr b. 625 mL/hr c. 938 mL/hr d. 1875 mL/hr

c. 938 mL/hr

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Check stools for occult blood. d. Palpate for abdominal tenderness.

c. Check stools for occult blood.

A patient has just arrived in the emergency department after an electrical burn from exposureto a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

c. Extremity movement

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion

c. Increase the rate for the sodium nitroprusside infusion.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Inspect the contact burns. b. Check the blood pressure. c. Stabilize the cervical spine. d. Assess alertness and orientation.

c. Stabilize the cervical spine.

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

c. The patient's IV infusion site is cool and pale.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase ofburn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel

c. Vanilla milkshake

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure of 92/40 mm Hg

c. Warm, pink, and dry skin

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. furosemide b. nitroglycerin c. norepinephrine d. sodium nitroprusside

c. norepinephrine

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

d. Apply water-based cream to burned areas frequently.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

d. Measure hourly urine output.

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

d. Oxygen saturation

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse takefirst? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

d. Use pulse oximetry to check oxygen saturation.

The emergency department (ED) nurse receives report that a seriously injured patient involvedin a motor vehicle crash is being transported to the facility with an estimated arrival in 5minutes. In preparation for the patient's arrival, the nurse will obtain a. a dopamine infusion. b. a hypothermia blanket. c. lactated Ringer's solution. d. two 16-gauge IV catheters.

d. two 16-gauge IV catheters.