Sole Ch 21, Sole Ch 20, Sole Ch 16, Sole Ch 14

Which patient being cared for in the emergency department should the charge nurse evaluate first? a) A patient with a complete spinal cord injury at the C5 dermatome level b) A patient with a GCS score of 15 on a 3L nasal cannula c) An alert patient with a subdural bleed who is complaining of a headache d) An ischemic stroke patient with a blood pressure of 190/100 mmHg

A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise.

Acute kidney injury from postrenal etiology is caused by a) obstruction of the flow of urine b) conditions that interfere with renal perfusion c) hypovolemia or decreased cardiac output d) conditions that act directly on functioning kidney tissue

A Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive renal injury.

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? a) Frequent neurological assessment b) Side to side position changes c) ROM to extremities d) Frequent oropharyngeal suctioning

A Nurses complete neurological assessments based on prescribed frequency and the severity of the patient's condition. The newly admitted patient has an altered neurological status, so frequent neurological assessments are most important to include in the patient's plan of care.

The patient's potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction? a) Sodium polystyrene sulfonate b) Sodium polystyrene sulfonate w/ sorbitol c) Regular insulin d) Calcium gluconate

A Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate) actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction.

The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should a) assess that the blood tubing is warm to the touch. b) assess the hemofilter every 6 hours for clotting. c) cover the dialysis lines to protect them from light. d) use clean technique during vascular access dressing changes.

A The critical care nurse is responsible for monitoring the patient receiving CRRT. The hemofilter is assessed every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration without a change in the patient's hemodynamic status). The CRRT system is frequently assessed to ensure filter and lines are visible at all times, kinks are avoided, and the blood tubing is warm to the touch.

The most common cause of acute kidney injury in critically ill patients is a) sepsis b) fluid overload c) medications d) hemodynamic instability

A The etiology of AKI in critically ill patients is often multifactorial and develops from a combination of hypovolemia, sepsis, medications, and hemodynamic instability. Sepsis is the most common cause of AKI.

An autograft is used to optimally treat a partial- or full-thickness wound that (Select all that apply.) a) involves a joint b) involved the face, hands, or feet c) is infected d) requires more than 2 weeks for healing e) involved very large surface areas

A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization. Grafting is not done while a burn is infected. There may not be enough healthy skin to graft large areas.

The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.) a) bladder catheterization b) increasing fluid volume intake c) ureteral stenting d) placement of nephrostomy tubes e) increasing cardiac output

A, C, D The location of the obstruction in the urinary tract determines the method by which the obstruction is treated and may include bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes.

Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.) a) Protein b) Sodium c) Creatinine d) RBCs e) Uric acid

A, D Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane.

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a) Keep the neck in the hyperextended position b) Maintain proper head and neck alignment c) Prepare for immediate ET intubation d) Remove cervical collar upon arrival to the ED

B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury.

The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient's condition is a) prerenal b) postrenal c) intrarenal d) not renal related

B Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction.

The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is a) oliguria b) azotemia c) AKI d) prerenal disease

B Azotemia refers to increases in BUN and serum creatinine.

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for a) acute delirium b) PTSD c) suicidal intentions d) bipolar disorder

B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients who demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder.

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is a) altered nutrition, less than body requirements b) body image disturbance c) decreased CO d) fluid volume deficit

B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result.

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a) Maintain body temperature b) Monitor BP c) Pad all bony prominences d) Use proper hand washing

B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.

Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis a) is more frequently used for acute kidney injury. b) uses the patient's own semipermeable membrane (peritoneal membrane). c) is not useful in cases of drug overdose or electrolyte imbalance. d) is not indicated in cases of water intoxication.

B Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patient's own semipermeable membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity.

Silver is used as an ingredient in many burn dressings because it a) stimulates tissue granulation b) is effective against a wide spectrum of wound pathogens c) provide topical pain relief d) stimulates wound healing

B Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens.

The patient's serum creatinine level is 0.7 mg/dL. The expected BUN level should be a) 1-2 mg/dL b) 7-14 mg/dL c) 10-20 mg/dL d) 20-30 mg/dL

B The normal BUN/creatinine ratio is 10:1 to 20:1. Therefore, the expected range for this creatinine level would be 7 to 14 mg/dL.

The provider prescribes fosphenytoin, 1.5 g intravenous (IV) loading dose, for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a) Contact the admitting physician b) Administer the drug over 10 minutes c) Mix medication with 0.9% normal saline d) Administer via central line

B The nurse can administer the medication over 10 minutes as prescribed (100 to 150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose prescribed is appropriate for the patient's weight. Fosphenytoin does not have to be administered with normal saline or via a central line.

The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for "stat" administration of a) a blood transfusion b) fluid replacement w/ 0.45% saline c) infusion of an inotropic agent d) an antiemetic

B This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement. Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a hypotonic solution, such as 0.45% saline.

A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a) chemical burn b) electrical burn c) heat burn d) infection

B Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias.

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a) 2800 mL b) 7000 mL c) 14 L d) 28 L

C 154 pounds/2.2 = 70 kg 4 × 70 kg × 50 = 14,000 mL, or 14 liters.

In patients with extensive burns, edema occurs in both burned and unburned areas because of a) catecholamine-induced vasoconstriction b) decreased GFR c) increased capillary permeability d) loss of integument barrier

C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third-spacing).

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mmHg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first? a) Blood cultures (2 specimens) for temperature >101°F b) Acetaminophen (Tylenol) 650 mg per rectum c) 500 mL albumin infusion intravenously d) Decadron 20 mg IVP every 4 hours

C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion.

In the trauma patient, symptoms of decreased cardiac output are most commonly caused by a) cardiac contusion b) cardiogenic shock c) hypovolemia d) percardial tamponade

C Hypovolemia is commonly associated with traumatic injury resulting from acute blood loss. Cardiac contusion may decrease cardiac output, but hypovolemia occurs more often. Cardiogenic shock is not typically associated with trauma. Pericardial tamponade would decrease cardiac output but is not as common as hypovolemia.

The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should a) reassess the patient in an hour b) raise the arm above the level of the patient's heart c) notify the provider immediately d) apply warm packs to the fistula site and reassess

C Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent. Loss of bruit and thrill indicate a loss of blood flow, most likely due to clotting. The patient will need to return to surgery as soon as possible for declotting.

The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas shows that the patient's pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to a) administer morphine to slow the respiratory rate b) prepare for intubation and mechanical ventilation c) administer IV sodium bicarbonate d) cancel tomorrow's dialysis session

C Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury. Treatment of metabolic acidosis depends on its severity. Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less than 7.20 are usually treated with IV sodium bicarbonate. The goal of treatment is to raise the pH to a value greater than 7.20.

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for a) AKI b) ARDS c) infection d) stress ulcers

C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection.

The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.) a) Whole blood b) Universal donor blood only c) RBCs d) Platelets e) Plasma

C, D, E The 1:1:1 transfusion protocol is an evidence-based practice consisting of transfusions of red blood cells, platelets, and plasma for optimal outcomes. Whole blood and universal donor blood exclusively are not included.

Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that a) a hemofilter is used to facilitate b) it provides faster removal of solute and water c) it does not allow diffusion to occur d) the process removes solutes and water slowly

D CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse. It is similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of ultrafiltration and diffusion. It differs in that CRRT provides a slow removal of solutes and water as compared to the rapid removal of water and solutes that occurs with intermittent hemodialysis.

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to a) hypervolemia from burn resuscitation b) increased incidence of ureteral stones c) nephrotoxic antibiotics for prevention of infection d) release of myoglobin from injured tissues

D Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury.

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a) ICP of 10 mmHg b) CPP of 70 mmHg c) GCS score of 5 d) CVP of 2 mmHg

D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum, indicates a slight improvement. A CVP of 2 mmHg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.

The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a) Arterial oxygen saturation b) Hourly urine output c) Mean arterial pressure d) Serum lactate levels

D Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by underperfusion (under-resuscitation).

Which of the following interventions is a strategy to prevent fat embolism syndrome? a) Administer lipid-lowering stain medications b) Intubate the patient early after the injury to provide mechanical ventilation c) Provide prophylaxis w/ low-molecular weight heparin d) Stabilize extremity fractures early

D Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the bone marrow must be accomplished as early as possible.

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a) Hyperoxygenate during ET suctioning b) Elevate the patient's HOB 30 degrees c) Apply bilateral heel protectors after repositioning d) Provide rest periods between nursing interventions

D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities.

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to a) remove the patient's clothes and flush the area with water b) apply saline compresses c) contact a poison control center for directions on neutralizing agents d) remove all jewelry

A As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patient's clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not applied as compresses.

An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a) Level I b) Level II c) Level III d) Level IV

A Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less severe injuries can be treated at lower-level trauma centers.

Continuous venovenous hemofiltration is used to a) remove fluids and solutes through the process of convection. b) remove plasma water in cases of volume overload. c) remove plasma water and solutes by adding dialysate. d) combine ultrafiltration, convection, and dialysis.

A Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection.

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a) Implement droplet precautions upon admission b) Wash hands thoroughly before leaving the room c) Scrub the hub of all central line ports before use d) Dispose of all bloody dressings in biohazard bags

A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection.

The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a) Ensure patency of IV line b) Mix drug with 0.9% normal saline c) Evaluate serum K+ level d) Obtain an IV infusion pump

A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis).

The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. The patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mmHg. The nurse should a) contact the provider and expect a prescription for a normal saline bolus. b) wait until the provider makes rounds to report the assessment findings. c) continue to evaluate urine output for 2 more hours. d) ignore the urine output, as this is most likely postrenal in origin.

A Most prerenal causes of AKI are related to intravascular volume depletion, decreased cardiac output, renal vasoconstriction, or pharmacological agents that impair autoregulation and GFR (Box 16-2). These conditions reduce the glomerular perfusion and the GFR, and the kidneys are hypoperfused. For example, major abdominal surgery can cause hypoperfusion of the kidney as a result of blood loss during surgery or as a result of excess vomiting or nasogastric suction during the postoperative period. The body attempts to normalize renal perfusion by reabsorbing sodium and water. If adequate blood flow is restored to the kidney, normal renal function resumes. Most forms of prerenal AKI can be reversed by treating the cause.

Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.) a) KUB x-ray b) Renal ultrasound c) MRI d) IVP e) Renal angiography

A, B, C Noninvasive diagnostic procedures that assess the renal system are radiography of the kidneys, ureters, and bladder (KUB); renal ultrasonography; and magnetic resonance imaging.

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a) Additional pain medication may be needed because of rapid body metabolism. b) Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c) Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d) The IM route is preferred for pain medication administration. e) Patients w/ a history of drug and alcohol abuse should not need as much pain medication as other patients.

A, B, C The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given before the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route. A history of drug and/or alcohol abuse does not change the pain experience for this patient; they will need as much pain medication as other burn patients and in fact may need more due to increased tolerance to the effects of the medication.

Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.) a) Indwelling urinary catheters are a source of infection. b) Patients often develop infection and sepsis secondary to central line catheters. c) Pneumonia is often an adverse outcome of mechanical ventilation. d) Wounds require sterile dressings to prevent infection.

A, B, C Prevention of infection is essential in the care of trauma and postsurgical patients. Removing invasive devices when they are no longer needed for monitoring and ensuring aseptic care of devices are important nursing care considerations for management of indwelling urinary catheters, central lines, and airway adjuncts. Wounds, other than the immediate postoperative dressing, are not required to be sterile. Aseptic technique is used for wound care.

In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.) a) Doll's eyes absent indicate a disruption in normal brainstem processing. b) Doll's eyes present indicate brainstem activity. c) Eye movement in the opposite direction as the head when turned indicates an intact reflex. d) Eye movement in the same direction as the head when turned indicates an intact reflex. e) Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f) Presence of cervical injuries is a contraindication to the assessment of this reflex.

A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a) Prevention of hypothermia b) Administration of fresh frozen plasma as ordered c) Administration of potassium as ordered d) Administration of calcium as ordered e) Monitoring CBC and coagulation studies

A, B, D Ineffective coagulation is a serious complication for a trauma patient that can be prevented by maintaining normothermia, evaluating and treating for hypocalcemia, administering clotting factors found in fresh frozen plasma or platelets, and evaluating and treating metabolic acidosis. Evaluating and treating serum potassium levels is important for effective cardiac muscle function, not coagulation. Monitoring lab values does not prevent an event from occurring although it can allow the nurse to notice it sooner.

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a) Applying splints that maintain the extremity in an extended position b) Implementing passive or active ROM exercises c) Keeping the limbs as immobile as possible d) Wrapping fingers and toes individually with bandages e) Administering muscle relaxants around the clock

A, B, D It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splints to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility.

Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a) Establish a family spokesperson and communication system. b) Ask the family about their normal coping mechanisms. c) Limit visitation to set times throughout the day. d) Coordinate a family conference. e) Determine how the family perceives the event.

A, B, D, E The trauma team can assist the patient and family in crisis by helping them establish a consistent communication process between the health care team and family. Other interventions include exploring the family's perceptions of the event, support systems, and coping mechanisms. Family conferences early in the emergent phase and frequently during the critical care phase assist with communication and with understanding the patient's and family's expectations for care. Limiting visitation will not assist the patient or the family's ability to cope with the traumatic event.

Which complications may manifest after an electrical injury? (Select all that apply.) a) Long bone fractures b) Cardiac dysrhthmias c) Hypertension d) Compartment syndrome of extremities e) Dark brown urine f) Peptic ulcer disease g) Acute cataract formation h) Seizures

A, B, D, E, G, H Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries.

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) a) Make frequent neurological assessments b) Maintain CO2 level at 50 mmHg c) Maintain MAP less than 130 mmHg d) Prepare for thrombolytic administration e) Restrain affected limb to prevent injury

A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a) Chest wall ecchymosis b) Diminished or absent breath sounds c) Pink-tinged or blood secretions d) Signs of hypoxia on room air e) Paradoxical chest wall movement

A, C, D Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress.

The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.) a) evaluate morning laboratory results and report abnormal results. b) administer the patient's antihypertensive medications. c) assess the dialysis access site and report abnormalities. d) weigh the patient to monitor fluid status. e) give all medications except for antihypertensive medications.

A, C, D The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse. Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble) medications are not given until after treatment.

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a) Administer acetaminophen as ordered for the headache b) Assess for a kinked urinary catheter and assess for bowel impaction c) Encourage the patient to take slow, deep breaths d) Notify the provider of the patient's blood pressure

B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system, can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distension. Other causes that should be ruled out before pharmacological intervention include fecal impaction.

A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a) Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b) Crackles (rales) on auscultation of bilateral lung fields c) Responsive only to painful stimuli d) Irregular HR and rhythm

B Explosive blast energy generates shock waves that create changes in air pressure, causing tissue damage. Initially after an explosion, there is a rapid increase in positive pressure for a short period, followed by a longer period of negative pressure. The increase in positive pressure injures gas-containing organs. The tympanic membrane ruptures, and the lungs may show evidence of contusion, acute edema, or rupture. A low blood pressure and corresponding tachycardia are more suggestive of hypovolemia. Lack of response to stimuli suggests a neurological injury. An irregular heart rate and rhythm may be associated with blunt trauma to the heart (e.g., cardiac contusion).

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a) Carbon monoxide poisoning always occurs when soot is visible. b) Inhalation injury above the glottis may cause significant edema that obstructs the airway. c) The patient will have a copious amount of mucus that will need to be suctioned. d) The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway.

The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a) Administer over 2 minutes b) Administer over 20-30 minutes c) Mix medication with 0.9% normal saline d) Administer via central line

B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Phenytoin should be administered over 20 to 30 minutes.

The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best? a) Assess the patient's hearing b) Assess the patient's lungs c) Decrease IV fluids once the diuretic has been administered d) Give extra doses before giving radiologic contrast agents

B Mannitol, an osmotic diuretic often used in acute kidney injury caused by rhabdomyolysis, increases plasma volume. Patients may be at risk for the development of pulmonary edema due to the rapid expansion of intravascular volume triggered by mannitol.

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a) Stop the infusion for 5 minutes b) Increase the dose by 2.5 mg/hr c) Notify the provider of the BP d) Begin weaning the infusion

B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient's blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse.

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? a) "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal." b) "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." c) "It is important to choose foods such as bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." d) "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing."

B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body.

During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent a) DIC b) multisystem organ dysfunction c) septic shock d) wound infection

B Patients with multisystem injuries are at high risk of developing myriad complications associated with the overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to prevent progression into multiple organ dysfunction syndrome.

When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a) High-speed motor vehicle crashes b) Poisonings from prescription or illegal drugs c) Violent or domestic traumatic altercations d) Work-related falls

B People age 35 to 54 years are at greater risk of experiencing poisonings from prescription and/or illegal drugs resulting in unintentional injury, followed by motor vehicle crashes (MVCs). MVCs and homicide are the leading causes of death for individuals age 16 to 24 years, and falls are responsible for traumatic injuries in those 65 years and older. Domestic violence is not well defined as an age-related trauma incident.

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent a) catheter-associated infection b) VTE c) fat embolism d) nosocomial pneumonia

B Prevention of venous thromboembolism is essential in the management of trauma patients. If not medically contraindicated, patients should receive pharmacological prophylaxis (e.g., heparin or heparin derivatives). Nurses should encourage ambulation, evaluate the patient's overall hydration, and ensure sequential compression devices are used properly.

The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should a) prepare to assist with a routine dialysis catheter change. b) evaluate the patient for signs and symptoms of infection. c) teach the patient that the catheter is designed for long-term use. d) use one of the three lumens for fluid administration.

B Routine replacement of hemodialysis catheters to prevent infection is not recommended. The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection.

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mmHg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which prescription by the provider should the nurse implement first? a) Obtain stat serum electrolytes b) Administer lorazepam c) Obtain stat portable chest x-ray d) Administer phenytoin

B The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticus. Phenytoin is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a) A fall from a 6-foot ladder onto the grass b) A shotgun wound to the abdomen c) A knife wound to the right chest d) An MVC in which the driver hits the steering wheel

B The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body.

Which of the following statements about mass casualty triage during a disaster is true? a) Priority treatments and interventions focus primarily on young victims. b) Disaster victims with the greatest chances for survival receive priority for treatment. c) Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims. d) Color-coded systems in which green indicates the patient of greatest need are used during disasters.

B Victims are triaged based on the severity of injury. Patients receive treatment based on the assessment of greatest chances for survival matched to resources available for medical intervention.

Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply) a) 5% Dextrose is recommended for rapid crystalloid infusion. b) IV fluids may need to be warmed to prevent hypothermia. c) Massive transfusions should be avoided to improve patient outcomes. d) Only fully crossmatched blood products are administered. e) Hypertonic saline solutions are often used during initial resuscitation.

B, C Lactated Ringer's and normal saline are the crystalloids of choice in trauma resuscitation. Because hypothermia is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Crossmatched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency. Isotonic solutions are used predominantly during fluid resuscitation.

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a) Burn injury less than 10% b) Bed rest c) Burns to lower extremities d) Electrical burn injury e) Delayed fluid resuscitation

B, C, E Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bed rest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA.

Which of the following patients is at the greatest risk of developing AKI? A patient who a) has been on aminoglycosides for the past 6 days b) has a history of controlled hypertension with a blood pressure of 138/88 mmHg c) was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks d) has a history of fluid overload as a result of heart failure

C Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug (more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after exposure. Because of this delay, the patient must be questioned about any recent medical therapy for which an aminoglycoside may have been prescribed.

The patient has just returned from having an arteriovenous fistula placed. The patient asks, "When will they be able to use this and take this other catheter out?" The nurse should reply, a) "It can be used immediately, so the catheter can come out anytime." b) "It will take 2 to 4 weeks to heal before it can be used." c) "The fistula will be usable in about 4 to 6 weeks." d) "The fistula was made using graft material, so it depends on the manufacturer."

C An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use.

A patient with a head injury has an intracranial pressure (ICP) of 18 mmHg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mmHg. What is the cerebral perfusion pressure (CPP)? a) 54 mmHg b) 72 mmHg c) 90 mmHg d) 126 mmhg

C CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a) Altered cerebral spinal fluid production and reabsorption b) Decreased cerebral blood volume due to vessel constriction c) Increased cerebral blood volume due to vessel dilation d) No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume.

Continuous venovenous hemodialysis is used to a) remove fluids and solutes through the process of convection. b) remove plasma water in cases of volume overload. c) remove plasma water and solutes by adding dialysate. d) combine ultrafiltration, convection and dialysis.

C Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion.

Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a) A patient who has a closed head injury with a decreased level of consciousness b) A patient who has a fractured femur and is currently in traction c) A patient who has received large volumes of fluid and/or blood replacement d) A patient who has underlying COPD

C During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third-spacing). As more IV fluids are given to support systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury, and MODS.

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? a) Have the patient blow the nose until clear b) Insert bilateral cotton nasal packing c) Place a nasal drip pad under the nose d) Suction the left nares until the drainage clears

C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment.

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for a) AKI b) ARDS c) intra-abdominal hypertension d) DIC disorder

C Intra-abdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function.

Which of the following best defines the term traumatic injury? a) All trauma patients can be successfully rehabilitated. b) Traumatic injuries cause more deaths than heart disease and cancer. c) Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d) Trauma mainly affects the older adult population.

C Many patients who sustain traumatic injury are under the influence of alcohol, drugs, or other substances. Rehabilitation potential depends on multiple factors, including severity of injury, patient age, and comorbidities. Heart disease and cancer claim more lives than trauma, but trauma claims lives of predominantly young individuals.

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a) pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b) pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c) pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d) pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35 to 45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.

The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient smells of alcohol and begins to vomit in the ED. Which of the following interventions is most appropriate? a) Insert an oral airway to prevent aspiration and to protect the airway. b) Offer the patient an emesis basin so that you can measure the amount of emesis. c) Prepare to suction the oropharynx while maintaining cervical spine immobilization. d) Send a specimen of the emesis to the laboratory for analysis of blood alcohol.

C Stabilization of the cervical spine, preventing aspiration, and maintaining a patent airway are essential elements of trauma management. An oral airway may increase the risk of aspiration related to the emesis, and offering an emesis basin would contradict spine precautions. Alcohol level is best determined by serum analysis.

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a) Both pressures are high b) Both pressures are low c) ICP is high; CPP is normal d) ICP is high; CPP is low

C The ICP is above the normal level of 0 to 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.

The patient asks the nurse if the placement of the autograft over his full thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be: a) "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b) "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c) "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d) "Unfortunately, autografts frequently do no adhere to burn wounds and a xenograft will be necessary to close the wound."

C The autograft is the only permanent method of grafting, and it uses the patient's own tissue to cover the burn wound.

The provider has opted to treat a patient with a complete spinal cord injury with Solumedrol. The provider orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hr for 23 hours. What is the total 24-hour dose for the 70-kg patient? a) 2478 mg b) 5000 mg c) 10,794 mg d) 12,750 mg

C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg × 70 kg) + (5.4 mg × 70 kg) × 23 hours = 10,794 mg.

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED a) includes a cervical spine x-ray study to determine the presence of a fracture. b) involves turning the patient from side to side to get a look at his back. c) is done quickly in the first few minutes to get a baseline assessment and establish priorities. d) is a methodical head-to-toe assessment identifying injuries and treatment priorities.

C The primary survey is a systematic rapid assessment of the patient's airway with cervical spine immobilization, breathing and ventilation, circulation with hemorrhage control, disability or neurological status, and exposure/environmental considerations. The secondary survey is more methodical and involves identifying injuries and specific treatment priorities.

The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should a) draw a trough level after the next dose of antibiotic. b) obtain an order to place the patient on fluid restriction. c) assess the patient's lungs. d) insert an indwelling catheter.

C The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for example, by auscultating the lung fields.

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a) The patient is exhibiting extension posturing b) The patient is exhibiting flexion posturing c) The patient is exhibiting purposeful movement d) The patient is withdrawing to stimulation

C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness.

Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a) 30 mL/hr b) 50 mL/hr c) 100 mL/hr d) 300 mL/hr

C Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the renal tubules. A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr. Urine volumes less than 100 mL/hr are insufficient and a urine volume greater than 200mL/hr will not harm the patient but may create too aggressive a diuresis.

The nurse is preparing to monitor intracranial pressure (ICP) with a fluidfilled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a) Use of a heparin flush solution b) Manually flushing the device "prn" c) Recording ICP as a "mean" value d) Use of a pressurized flush system e) Zero referencing the transducer system

C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Monro. Manually flushing the device may result in an increase in ICP.

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a) Assess for the presence of a headache b) Assess the patient's general orientation c) Determine the patient's drug allergies d) Determine the time of symptom onset

D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to IV administration because a) IM injections cause additional skin disruption b) burn pain is so severe it required relief by the fastest route available c) hypermetabolism limits effectiveness of medications administered IM d) tissue edema may interfere w/ drug absorption of injectable routes

D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly

In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible, a) it is not possible to determine the GFR b) the BUN may be used to determine renal function c) an elevated BUN/creatinine ratio can be used d) a standardized formula may be used to calculate GFR

D If a reliable 24-hour urine collection is not possible, the Cockcroft and Gault formula may be used to determine the creatinine clearance from a serum creatinine value.

The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient's urinalysis results. The nurse should become concerned when a) creatinine levels in the urine are similar to blood levels of creatinine. b) sodium and chloride are found in the urine. c) urine uric acid levels have the same values as serum levels. d) red blood cells and albumin are found in the urine.

D Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane. Their presence in urine may indicate glomerular damage.

The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action? a) Insert bilateral ear plugs b) Monitor airway patency c) Maintain neutral head position d) Apply a small nasal drip pad

D Patient assessment findings are indicative of a skull fracture. The presence of strawcolored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely.

The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day, when various treatments are scheduled. Which statement to the provider best indicates the nurse's knowledge of pain management for this patient? a) "Can we ask the music therapist to come by each morning to see if that will help the patient's pain?" b) "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." c) "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d) "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient.

Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a) Absence of pulse in affected extremity b) Pallor in the affected area c) Paresthesia in the affected area d) Severe, throbbing pain in the affected area

D Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the injury. Narcotic administration does not relieve the pain. The pain is localized to the involved compartment and increases with passive muscle stretching. The area affected is firm. Paresthesia distal to the compartment, pulselessness, pallor, and paralysis are late signs and must be reported immediately to prevent loss of the extremity.

After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? a) A patient with meningitis complaining of photophobia b) A mechanically ventilated patient with a GCS of 6 c) A patient with bacterial meningitis on droplet precautions d) A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F

D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104°F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis, and droplet precautions are appropriate for a patient with bacterial meningitis.

The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates a) administration of lactated Ringer's solution (1 L) wide open. b) chest x-ray study to determine the etiology of the symptoms. c) ET intubation and mechanical ventilation. d) needle thoracotomy and chest tube insertion.

D These are classic symptoms of a tension pneumothorax in a patient at high risk related to mechanism of injury. Emergent decompression by a needle thoracostomy followed by a chest tube insertion is needed.

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a) Stimulate the patient hourly b) Continue to monitor the patient c) Elevate the head of the bed d) Notify the provider immediately

D These are classic symptoms of epidural hematomas: injury, lucid period, and progressive deterioration. The provider must be notified of this neurological emergency so that appropriate interventions can be implemented.

Daily weights are being recorded for the patient with a urine output that has been less than the intravenous and oral intake. The weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n) a) fluid retention of 1.5 L b) fluid loss of 1.5 L c) equal I&O due to insensible losses d) fluid loss of 0.5 L

A A 1-kg gain in body weight is equal to a 1000-mL fluid gain. This patient has gained 1.5 kg, or 1.5 liters of fluid.

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a) Monitor the patient's airway patency b) Elevate the head of the patient's bed c) Increase supplemental oxygen delivery d) Support bony prominences with padding

A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient's airway.

A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to a) assign the nurse administrative duties, such as obtaining patient demographic information. b) assign the nurse to a triage room with another nurse from the emergency department. c) thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. d) have the nurse assist with transport of patients to procedural areas.

A A nurse in the medical records department is a knowledgeable health care provider who can help in a disaster by obtaining essential patient information. Assigning the nurse to provide direct care to patients, such as assisting in the triage room or transporting patients, may not be appropriate, as the direct care skills are not known. Asking the nurse to return to the medical records department also may not be appropriate because the nurse offers a skill set that can be used during the disaster.

The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a) Placement of an IO catheter b) Placement of a central line c) Insertion of a femoral catheter by a trauma surgeon d) Rapid transfer to the OR

A Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to obtain intravenous access for fluid resuscitation.

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a) CNS deficits b) Contractures c) Infection d) Stress ulcers

A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits.

Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? a) Insertion of a nasotracheal tube b) Insertion of an indwelling urinary cathteter c) ET intubation d) Placement of an oral airway

A Nasotracheal tubes are contraindicated in basilar skull fractures because insertion may result in penetration of the meninges. An indwelling urinary catheter may be necessary to monitor fluid balance. Protection of the airway to include placement of an oral airway or endotracheal tube may be indicated.

A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends a) a diet of 2500 to 3500 kcal/day b) protein intake of less than 50g per day c) potassium intake of 10 mEq per day d) fluid intake of less than 500 mL

A Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per day (2500 to 3500 kcal) and protein intake of no less than 0.8 g/kg body weight.

A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non-burn-injured skin disorder? a) Toxic epidermal necrolysis b) Staphylococcal scalded skin syndrome c) Necrotizing soft tissue infection d) Graft vs. host disease

A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute-onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours; skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury.

The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient's temperature is elevated. The nurse should a) assess peritoneal dialysate return b) check the patient's blood sugar c) evaluate the patient's neurological status d) inform the provider of probable visceral perforation

A Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by contamination in the system. Peritonitis is manifested by abdominal pain, cloudy peritoneal fluid, fever and chills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity.

Renin plays a role in blood pressure regulation by a) activating the renin- angiotensin-aldosterone cascade. b) suppressing angiotensin production. c) decreasing sodium reabsorption. d) inhibiting aldosterone release.

A Renin activates the renin-angiotensin-aldosterone cascade, which ultimately results in angiotensin II production. Angiotensin II causes vasoconstriction and release of aldosterone from the adrenal glands, thereby raising blood pressure and flow and increasing sodium and water reabsorption in the distal tubule and collecting ducts.

Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to a) remove plasma water in cases of volume overload b) remove fluids and solutes through the process of convection c) remove plasma water and solutes by adding dialysate d) combine ultrafiltration, convection, and dialysis

A Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload.

The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of a) a percutaneous catheter at the bedside b) a percutaneous tunneled catheter at the bedside c) an AV fistula d) an AV graft

A Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be used immediately.

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first? a) Mannitol 1g IV b) Portable chest x-ray c) Seizure precautions d) Ancef 1g IV

A The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure.

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a) Assist the patient to the floor and provide soft head support b) Insert a nasogastric tube and connect to continuous wall suction c) Open the patient's mouth and insert a padded tongue blade d) Restrain the patient's extremities until the seizure subsides

A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported.

Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.) a) Hypotension b) Dysrhythmias c) Muscle cramps d) Hemolysis e) Air embolism

A, B Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution.

The trauma nurse understands which information related to the older trauma patient? (Select all that apply.) a) Falls are the leading cause of death in the older population. b) Physiologic capacity is an important predictor of outcome. c) Hypotension in the elderly can appear as normotension. d) Chronic diseases don't have much effect on the older trauma patient. e) Fractures to bones other than hips are uncommon from trauma.

A, B, C Falls are the leading cause of death in the elderly and frequently result in fractures to many different bones, not just hips. Decreased physiologic reserve leads to poorer outcomes. Hypertension can mask hypotension by the blood pressure appearing to be normal. That is just one example of how chronic disease can complicate the picture of an older trauma patient.

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a) Crush injury to right arm b) Gunshot wound to the abdomen c) Lightening strike of the left arm and chest d) Pulmonary contusion and rib fracture e) Penetrating wound to both legs

A, C Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being struck by lightning.

Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.) a) MAP 48 mmHg b) Elevated serum blood alcohol level c) Nonreactive pupils d) RR of 10 breaths/min e) Open skull fracture

A, C, D, E Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral perfusion; nonreactive pupils are an abnormal finding and require immediate attention to evaluate the cause. Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of 10 requires further evaluation. An open skull fracture leaves the patient extremely vulnerable to infection in the brain. An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention.

The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.) a) Acidosis b) Hypokalemia c) Volume overload d) Hyperkalemia e) Uremia

A, C, D, E The most common reasons for initiating dialysis in acute kidney injury include acidosis, hyperkalemia, volume overload, and uremia.

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a) Apply topical antibacterial wound ointments/dressings b) Change indwelling urinary catheter every 7 days c) Daily assess the need for central IV catheters d) Restrict family visitation e) Maintain strict aseptic technique during burn wound management

A, C, E Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention.

The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate a) increased nitrogen intake b) AKI, such as ATN c) hypovolemia d) fluid resuscitation

B A normal BUN/creatinine ratio is present in ATN. In ATN, there is actual injury to the renal tubules and a rapid decline in the GFR; hence, BUN and creatinine levels both rise proportionally as a result of increased reabsorption and decreased clearance.

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a) Arm b) Face c) Leg d) Chest

B A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest).

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to a) excessive alcohol use b) methamphetamine use c) PTSD d) subacute delirium

B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.

A normal GFR is a) less than 80 mL/min b) 80-125 mL/min c) 125-180 mL/min d) more than 189 mL/min

B At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate.

The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should a) not be concerned unless urine output decreases b) evaluate the patient's serum creatinine for up to 72 hours after procedure c) obtain an order for a renal ultrasound d) evaluate the patient's postvoid residual volume to detect intrarenal injury

B Contrast- induced kidney injury is diagnosed by an increase in serum creatinine of 25%, or 0.5 mg/dL, within 48 to 72 hours following the administration of contrast. Urine output usually remains normal. The renal ultrasound and postvoid residual assessment are not warranted.

An elderly individual from an assisted-living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a) Ask the caregiver at what temperature the water heater is set in the home. b) Ask the caregiver to step out while examining the patient's burn injury. c) Immediately contact the police to report the suspected elder abuse. d) Ask the caregiver to describe exactly how the injury occurred.

B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver.

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a) Maintain a closed wound system to decrease the risk of infection b) Remove excessive wound fluid and promote moist wound healing c) Increase patient mobility w/ large burn wounds d) Quantify wound drainage amount for more accurate output assessment

B Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment.

What is a minimally acceptable urine output for a patient weighing 75 kg? a) Less than 30mL/hr b) 37 mL.hr c) 80 mL/hr d) 150 mL/hr

B Normal urine output is 0.5 to 1 mL/kg of body weight each hour.

The nurse is caring for an elderly patient who was admitted with renal insufficiency. An expected laboratory finding for this patient may be a) an increased GFR b) a normal serum creatinine level c) increased ability to excrete drugs d) hypokalemia

B Serum creatinine levels may remain the same in the elderly patient, even with a declining GFR, because of decreased muscle mass and hence decreased creatinine production.

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is a) to keep the extremity in a dependent position b) active or passive ROM exercises every hour c) to prepare for a escharotomy as a prophylactic measure d) to splint the forearm

B Special attention is given to circumferential (completely surrounding a body part) full-thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema.

The critical care nurse knows that in critical ill patients, renal dysfunction: a) is a very rare problem b) affects nearly two thirds of patients c) has a low mortality rate once renal replacement therapy has been initiated d) has little effect on morbidity, mortality, or quality of life

B The kidney is the primary regulator of the body's internal environment. With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. Renal dysfunction is a common problem in critically ill patients, with nearly two thirds of patients experiencing some degree of renal dysfunction. The most severe cases, requiring renal replacement therapy, have a reported mortality rate of 50% to 60%. Acute kidney injury that progresses to chronic renal failure is associated with increased morbidity, mortality, and reduced quality of life.

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the provider prescriptions, which order is of the highest priority? a) Lasix 20mg IVP as needed b) 500 mL albumin IV infusion c) Decadron 10mg IVP d) Dilantin 50 mg IVP

B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mmHg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate.

It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a) ARDS b) Coagulopathies c) Dysrhythmias d) Myocardial dysfunction e) Fat embolism

B, C, D Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation).

The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient's urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has: a) AKI from a prerenal condition b) AKI from postrenal obstruction c) intrarenal disease, probably ATN d) a UTI

C Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Coarse, muddy brown granular casts are classic findings in ATN. Microscopic hematuria and a small amount of protein also may be seen.

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5°F. What is the priority nursing action? a) Elevate the HOB 30 degrees b) Keep lights dim at all times c) Implement seizure precautions d) Maintain bed rest at all times

C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation, such as photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury.

The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of a) dialyzer membrane incompatibility b) a shift in potassium levels c) dialysis in disequilibrium syndrome d) hypothermia

C Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had sudden, large decreases in BUN and creatinine levels as a result of the hemodialysis. Because of the blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid. The extra fluid in the brain tissue creates a state of cerebral edema for the patient, which results in severe headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures.

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is a) BUN b) daily weight c) hourly intake and urine output d) serum potassium

C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone.

In calculating the glomerular filtration rate (GFR) results for women, the creatinine clearance is usually: a) the same for men b) greater than that for men c) multiplied by 0.85 d) multiplied by 1.15

C For women, the calculated result is multiplied by 0.85 to account for the smaller muscle mass as compared to men.

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a) "Do you live alone?" b) "Do you have any drug or food allergies?" c) "Do you have a heart condition or heart failure?" d) "Have you had any surgeries?"

C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutritional status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patient's cardiovascular status, including heart failure.

The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should a) apply a sterile gauze dressing to maintain sterility b) replace the transparent dressing every 10 days to prevent manipulation c) assess the catheter site for redness and/or swelling d) use the catheter for drawing blood samples to reduce patient discomfort

C Tenderness at the insertion site, swelling, erythema, or drainage should be reported to the physician.

Conditions that produce AKI by directly acting on functioning kidney tissue are classified as intrarenal. The most common intrarenal condition is: a) prolonged ischemia b) exposure to nephrotoxic susbtances c) acute tubular necrosis d) hypotension for several hours

C The most common intrarenal condition is ATN. This condition may occur after prolonged ischemia (prerenal), exposure to nephrotoxic substances, or a combination of these. Some patients have ATN after only several minutes of hypotension or hypovolemia, whereas others can tolerate hours of renal ischemia without having any apparent tubular damage.

The nurse is preparing to administer a routine dose of phenytoin. The provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? a) Administer over 2 minutes b) Administer w/ 0.9% normal saline c) Contact the provider d) Assess cardiac rhythm

C The ordered dose is an inappropriate maintenance dose. The nurse should contact the provider. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority? a) Place the patient on a cardiac monitor b) Prepare for rapid intubation c) Seal the wound w/ occlusive dressings d) Start 2 large bore IVs

D A patient with a hemothorax will need blood transfusions and a chest tube placement for treatment. The nurse should start 2 large bore IVs with crystalloid solution. A cardiac monitor is also necessary, but active measures to treat the patient should be done first. The patient may or may not need intubation and mechanical ventilation. An occlusive dressing is not necessary.

An advantage of peritoneal dialysis is that a) peritoneal dialysis is time intensive b) a decreased risk of peritonitis exists c) biochemical disturbances are corrected rapidly d) the danger of hemorrhage is minimal

D Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate solutions can be individualized.

The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should a) draw blood from the left arm b) take blood pressures from the left arm c) start a new IV line in the left lower arm d) auscultate the left arm for a bruit and palpate for a thrill

D An arteriovenous fistula should be auscultated for a bruit and palpated for the presence of a thrill or buzz every 8 hours. The extremity that has a fistula or graft must never be used for drawing blood specimens, obtaining blood pressure measurements, administering intravenous therapy, or giving intramuscular injections. Such activities produce pressure changes within the altered vessels that could result in clotting or rupture.

A normal urine output is considered to be a) 80-125 mL/min b) 180 L/day c) 80 mL/min d) 1-2 L/day

D At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate. As the filtrate passes through the various components of the nephrons' tubules, 99% is reabsorbed into the peritubular capillaries or vasa recta. Eventually, the remaining filtrate (1% of the original 180 L/day) is excreted as urine, for an average urine output of 1 to 2 L/day.

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a) Ensure adequate periods of rest between nursing interventions. b) Insert an oral airway and monitor respiratory rate and depth. c) Maintain neutral head alignment and avoid extreme hip flexion. d) Reduce ambient room temperature and administer antipyretics.

D In this scenario, the patient's temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response? a) "Unfortunately, kidney injury is not reversible; it is permanent." b) "Kidney function usually returns within 2 weeks." c) "You will know for sure if you start urinating a lot all at once." d) "Recovery is possible, but it make take several months."

D Renal dysfunction is potentially reversible during the initiation phase. This phase spans several hours to 2 days, during which time the normal renal processes begin to deteriorate, but actual intrinsic renal damage has not yet occurred. During the maintenance phase, intrinsic renal damage is established, and the GFR stabilizes at approximately 5 to 10 mL/min. This phase usually lasts 8 to 14 days, but it may last up to 11 months. The longer a patient remains in this stage, the slower the recovery and the greater the chance of permanent renal damage will be. The recovery phase is the period during which the renal tissue recovers and repairs itself. A gradual increase in urine output and an improvement in laboratory values occur. Recovery may take as long as 4 to 6 months.

The removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient is known as a) dialysis b) diffusion c) clearance d) ultrafiltration

D Ultrafiltration is the removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient. Ultrafiltration is primarily aimed at controlling fluid volume, whereas dialysis is aimed at decreasing waste products and treating fluid and electrolyte imbalances. Diffusion (or clearance) is the movement of solutes such as urea from the patient's blood to the dialysate cleansing fluid, across a semipermeable membrane (the hemofilter).

The correct priority order of actions in prehospital primary survey for burn injuries is: a) assess ABCs and cervical spine b) provide oxygen therapy if smoke inhalation is suspected c) make rapid head-to-toe assessment to rule out additional trauma d) stop the burning process and prevent further injury

D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.