adult critical care

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

"Boarding" or holding inpatient clients ED overcrowding has led to frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital. The ED nurse must be adept at providing safe and competent care to clients who are awaiting bed placement. The focus becomes one of ongoing care instead of one-time orders. Although a variety of clients spanning all age ranges, cultures and illnesses may present to the ED for treatment, this is not a direct result of overcrowding. Overcrowding has nothing to do with clients who may be uninsured or underinsured.

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

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

The elementary school nurse is teaching children how to prevent injuries from cold exposure in the winter. Which student statement demonstrates that the teaching has been effective? "Dressing in layers is important." "I will drink lots of water when I exercise." "Taking frequent breaks will help me rest." "Wearing three pairs of cotton socks is very important."

"Dressing in layers is important." Teaching has been effective when the student states that "Dressing in layers is important." Layering is very helpful in preventing cold injuries. The inner layer of clothing will provide insulation and the outer layers will help protect from wind and moisture. Lightweight and synthetic fabrics are preferable. Drinking lots of water and taking frequent breaks are more often associated with heat-related injuries. Although wearing layers is important, cotton socks are not the best choice as they will prevent evaporation of any moisture and can lead to hypothermia. Wearing three pairs of socks can decrease circulation to the toes increasing the risk of frostbite.

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

"Every bedroom should have a separate smoke detector." The school nurse states that every bedroom needs to have a separate smoke detector. All people should be taught to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home. Every room in the house does not need a smoke detector. There should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Each room that requires a smoke detector should also have a carbon monoxide detector. Carbon monoxide detectors are instrumental in picking up carbon monoxide gas emissions, such as from a defective heating unit.

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

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

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

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

A high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how to prevent a recurrence of this situation. Which student statement demonstrates that the nurse's teaching has been effective? "I should try to exercise between noon and 3 PM." "I will limit my fluids to drinking 'sports' drinks after I exercise." "Taking frequent rests is important when in a hot environment." "Wearing dark-colored clothing to deflect the sun away from me will help me stay cooler."

"Taking frequent rests is important when in a hot environment." The statement that demonstrates that the teaching about heat exhaustion is effective is the comment that stresses the importance of frequent rest periods when in a hot environment. Frequent rest periods will decrease the risk of heat exhaustion. Exercising during times of peak sun exposure (midday) will increase the risk of heat exhaustion. Fluids, particularly water, have to be consumed throughout the exercise period and not be limited to a certain type. Light colored clothing, not dark, reflects the sun away from the individual.

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

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

The nurse is teaching a class of park ranger trainees about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further teaching? "Do not allow the victim to ingest any alcohol or caffeine." "The extremity should be kept below the level of the heart." "The first priority is to call for EMS transport to a trauma center." "You should first place a tourniquet above the bite."

"You should first place a tourniquet above the bite." Placing a tourniquet above the bite could worsen local tissue necrosis by retaining venom in the tissues. If transportation and treatment are delayed, a constricting band may be applied proximal to an extremity wound to slow venom circulation via lymphatic flow. However, it would not be used as a tourniquet. Alcohol or stimulants such as caffeinated beverages must not be offered because they may speed up the absorption of venom. Affected extremities are kept below the level of the heart. The first priority is not to call for EMS transport although it will be important for the client to be evaluated and treated at an appropriate facility that is equipped to handle snakebites.

Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care? a. Avoiding manipulation of the client's limbs b. Asking a family member about any client drug allergies c. Cutting fabric that is stuck the client's skin with scissors d. Auscultating heart and lung sounds through the client's clothing

(cutting fabric ....) The nurse should remove all clothing to allow for a thorough assessment of the trauma client in order to accurately prioritize care. Cutting the fabric that is stuck to the client's skin with scissors is the appropriate action by the nurse. It is necessary to avoid manipulation of the client's limbs during the trauma assessment. While it is important to ask a family member about any client drug allergies, this is done after the initial assessment of the client. Clothing is always removed to allow for an accurate assessment.

A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. What is an appropriate treatment plan? a. Amiodarone bolus b. Intracardiac epinephrine c. Insertion of a pacemaker d. Cardiopulmonary resuscitation

A - Amiodarone suppresses ventricular activity; therefore, it is used for treatment of premature ventricular complexes (PVCs) and ventricular tachycardia. It works directly on the heart tissue and slows the nerve impulses in the heart. Epinephrine HCl is not used for ventricular tachycardia (VT) with a pulse; it is used for cardiac arrest and may even precipitate ventricular fibrillation. A pacemaker is used for symptomatic Bradycardia and heart blocks. The client has a pulse, CPR is not indicated.

During resuscitation of a 5-year-old child, the provider requests an intravenous dose of 1 mL of epinephrine to be given STAT. The nurse will perform which action? a. Ask the provider to clarify the dose and the concentration. b. Draw up the dose and give it as a rapid intravenous bolus. c. Give the dose as a slow intravenous bolus and monitor vital signs. d. Request an order to give the dose via endotracheal tube.

A - Epinephrine is available in two primary concentrations: 1:1,000 and 1:10,000 mL. The 1:10,000 concentration is used when giving a single IV dose of epinephrine. The 1:1,000 concentration is used for other routes. The nurse should clarify the dose and the concentration

A nurse administers topical gentamicin sulfate (Garamycin) to a patient's burn injury. Which laboratory value would the nurse monitor while the patient is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

A - Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any patient receiving gentamicin by any route would have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

Which client is at greatest risk for heat exhaustion? A 24-year-old construction worker A 34-year-old police officer A 42-year-old swimming instructor A 78-year-old gardener

A 78-year-old gardener Older adults are particularly at risk for heat-related illnesses because of decreased body fluid volume. Heat exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse as a result of the body overheating. It's one of three heat-related syndromes, with heat cramps being the mildest and heatstroke being the most severe. Older adults may also be at risk due to medications they are taking that lead to electrolyte imbalances for treatment of medical co-morbidities. The young construction worker is at risk, but is not the one at highest risk. These workers will typically have a "thirst" response and will keep hydrated as needed. The police officer is a young adult who is probably in an acceptable state of fitness. The swimming instructor may also be at risk but has the ability to cool off rapidly by getting into the water.

Clients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which client is most appropriate to assign to an LPN/LVN? A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) A client reporting right forearm swelling secondary to a "bug bite" with capillary refill in the right hand of greater than 3 seconds A client who was hiking and is now confused, and has crackles throughout all lung fields A client stung by an unknown insect who reports shortness of breath

A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) It is appropriate to assign an LPN/LVN to care for the stable, heat exhaustion client who is already receiving appropriate treatment.The data from the other three clients all support the need for ongoing assessment and intervention by an RN. The client who presents with vascular instability and compromise needs quick intervention. The client who has an unclear picture at present but has the potential to deteriorate rapidly and the client with the unknown insect bite also need assessment by the RN.

A nurse cares for a patient with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

A, B, C - Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the patient comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Provide education on the SBAR method of communication c. Create a template of suggested topics to include in report. d. Encourage staff to ask questions during hand-off. e. Give raises based on compliance with reporting.

A, B, C, D - The SBAR method of communication has been identified as an excellent method of communication between healthcare professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer patient errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria.

The nurse is coordinating care for a client who was bitten by a black widow spider. Which nursing action is assigned to the LPN/LVN? Administering tetanus toxoid vaccine intramuscularly Assessing the client for neurologic changes Monitoring for respiratory compromise in the client Providing discharge instructions to the client when the family arrives

Administering tetanus toxoid vaccine intramuscularly Administration of intramuscular medication is within the scope of practice and education level of an LPN/LVN. Physical assessment and ongoing monitoring for complications, as well as client education and planning for discharge, are all actions that require broader education and scope of practice and would be done by an RN.

The RN working at a long-term-care facility places priority on providing interventions for which resident? A 65-year-old paraplegic man who is demanding to see the health care provider about insurance benefits A 76-year-old woman with a total hip replacement who is showering for the first time since entering rehabilitation after surgery An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° C) An 82-year-old woman with dementia who is requesting "something" for a headache

An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° C) needs to be assisted back indoors with some alternatives provided for him to receive some "fresh air." This will help him meet his personal desires as well as maintain his safety and prevent potential heat-related illness. Although the 65-year-old paraplegic man has valid concerns, these concerns are not the nurse's highest priority in the group. The 76-year-old woman with a total hip replacement needs to be handled carefully and safely during a new activity, but she is not the nurse's greatest priority resident. Although the 82-year-old woman with dementia has a valid request, she is not the nurse's highest priority in this scenario.

While on the school playground, a child is stung by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What does the nurse do first? Apply an ice pack to the stinger. Gently scrape out the stinger with a credit card. Inject the child with an epinephrine pen (EpiPen auto-injector). Remove the bee and save it for identification.

Apply an ice pack to the stinger. The nurse first needs to quickly remove the stinger by gently scraping or brushing it off with the edge of a knife blade, credit card, or needle. Once the stinger is removed, applying an ice pack to the area may decrease the pain in the area as well as venom distribution. Unless the child has had an allergic reaction in the past, an epinephrine pen would not be used. The bee does not need to be saved for identification.

The nurse is directing the care of a newly admitted client who is severely hypothermic. What does the nurse advise the rapid response team (RRT) to do first? Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity. Draw blood samples to rule out coagulation problems. Insert a nasogastric tube for rewarming purposes. Obtain intravenous (IV) access to provide fluids and administer drugs.

Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity. The nurse will advise the RRT to first place ECG leads on the client in order to monitor cardiac activity. People who are hypothermic are at risk for lethal cardiac dysrhythmias and need continual monitoring. Samples for laboratory testing and IV access would be implemented rapidly. Medications may not be effective until a client is normothermic, however warmed fluids may be administered to hasten the process. The same is true of inserting a nasogastric (NG) or orogastric (OG) tube as a means to rewarm the client.

A young client comes to the emergency department (ED) after being bitten by a scorpion on the playground at school. Which action does the nurse perform first? Administer a tetanus shot. Apply an ice pack to the sting site. Assess the client's vital signs. Call the poison control center.

Assess the client's vital signs. The first priority for the nurse to perform is vital sign assessment and continuous monitoring for several hours. This is done in the hospital ED or critical care unit to enable rapid intervention if symptoms progress. Although important, a tetanus shot and ice packs are not the immediate priority. Calling the poison control center is a secondary priority. This client may also benefit from transfer to a pediatric facility, if one is available.

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

Assessment The first core competency that is essential in this situation is assessment and is the foundation of the ED nurse's skill base to determine normal from abnormal client findings. Communication, priority setting, and technical and procedural skills are not the first competencies to be used in this situation. Until the client has been accurately assessed, care can begin.

Which medications are contraindicated with a scorpion sting? Acetaminophen (Tylenol) Barbiturates Benzodiazepines Opiates Tetanus toxoid

Barbiturates Benzodiazepines Opiates Medications contraindicated for a client with a scorpion sting include barbiturates, benzodiazepines, and opiates. These medications need to be avoided in clients with a scorpion sting because they can cause a loss of airway reflexes and can precipitate respiratory airway failure. It is safe to administer Tylenol to a client with a scorpion sting for fever and pain. Because the scorpion sting is a puncture wound, tetanus toxoid would be administered.

After receiving a change-of-shift report, the client with which condition would be assessed by the emergency department (ED) nurse first? Bee sting on the jawline with an inability to swallow Bite on the hand from a stray dog with minimal bleeding Severe muscle cramps after running Suspected spider bite with a red and swollen forearm

Bee sting on the jawline with an inability to swallow The nurse would first assess the client who was stung by a bee and is unable to swallow. This client is showing potential signs of respiratory compromise and needs immediate assessment and intervention. Neither the client with the spider bite nor the dog bite client have life-threatening injuries. The current tetanus immunization status would be checked for each client and administered if needed. The client bitten by the dog might also require rabies vaccination follow-up. The client with muscle cramping after running would need to be assessed thoroughly for the potential of heat-related injury although this does not appear to be a life threat at this time.

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

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

A nurse uses the rule of nines to assess a patient with burn injuries to the entire back region and left arm. How would the nurse document the percentage of the patient's body that sustained burns? a. 9% b. 18% c. 27% d. 36%

C - According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the patient received burns to the back (18%) and one arm (9%), totaling 27% of the body

What is the best method to prevent autocontamination for a client with burns? Change gloves when handling wounds on different areas of the body. Ensure that the client is in isolation therapy. Restrict visitors. Use sterile gloves when changing dressings.

Change gloves when handling wounds on different areas of the body. Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Using sterile versus clean gloves is a matter of institutional preference and a topic of debate.

On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first? Administer two acetylsalicylic acid (aspirin) tablets orally. Check the client's airway and administer high-flow oxygen therapy. Monitor the client's vital signs. Place a cooling blanket on the client.

Check the client's airway and administer high-flow oxygen therapy. The first action made by the ED nurse is to check the client's airway and give high-flow oxygen therapy. Once in a clinical setting, the nurse monitors and supports the client's airway, breathing, and circulatory status. High-concentration oxygen therapy and IV lines with 0.9% saline solution are also indicated. This client is at risk for aspiration. Nothing would be given by mouth when a client is at risk for aspiration. Vital signs must be monitored, but they are not the immediate priority in this scenario. Use of a cooling blanket is important although not a top priority, especially if ice bags are already in place.

Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed? Carry out artificial respirations. Clear the airway. Place a cervical collar. Realign the leg and check for pulse.

Clear the airway. The airway should first be cleared of any secretions or debris with a suction catheter or manually, if necessary. The primary survey for a trauma client is based on the mnemonic "ABCDE", with "A" being airway. A cervical collar will need to be applied and respiration will need to be assisted with a bag-valve-mask (BVM) connected to 100% oxygen source. Although the leg does not have a pulse, life threats must be addressed before limb threats.

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

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

The nurse is providing reminders to a Red Cross class about safety procedures to prevent drowning. In which situation does this present the greatest risk? A couple going swimming together at a local lake Children swimming at the community pool College students going to a party at a boat house Families going to the quarry to swim

College students going to a party at a boat house The college party at the boat house is the situation that poses the greatest risk for drowning, due to the potential presence of alcohol or other mood-altering substances. The use of alcoholic beverages when swimming, boating, or near water increases the risk of water-related injuries and death. The couple swimming in the local lake is using the "buddy system." This situation does not present the greatest risk. Community pools frequently have life guards and safety equipment present. Because adults will be present at the quarry, this situation does not present the greatest risk.

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

Consult with Social Services. Consulting with social workers or case managers is the best course of action to investigate resource needs for this client and to plan accordingly. Contacting law enforcement, discharging the client, or telling the client to go to a safe place as instructed may not be in this client's best interest.

A client from a local care facility has sustained a cardiac arrest in the emergency department (ED), and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? Select ALL that apply Remove all lines and indwelling tubes. Cover the client with a sheet, leaving the face exposed. Call a chaplain or social worker to accompany the family. Tell the family that the client "is in a better place now." Dim the lights in the client's room.

Cover the client with a sheet, leaving the face exposed. Dim the lights in the client's room. Covering the client with a sheet, leaving the face exposed, and dimming the lights in the client's room are steps the ED nurse would take prior to the viewing. Sometimes by leaving the hands out from underneath the sheet it allows the family more "permission" to touch the client if they desire. The nurse's response needs to be one of empathy and dignity in all interactions. This death may be reportable as a medical examiner's case therefore, IV lines and tubes may need to be maintained. The nurse may ask the family if they want a chaplain or social worker. Statements to the effect that the client "is in a better place now" are inappropriate.

The nurse is caring for a patient experiencing an allergic reaction to a bee sting who has an order for diphenhydramine (BenaDRYL). The only medication in the patient's medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error? a. Communication b. Diagnostic c. Preventive d.Treatment

D - The nurse avoided a treatment error, giving the wrong medication. Benazepril is an ace inhibitor used to treat blood pressure. According to Leape, treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test. Communication errors refer to those that occur from a failure to communicate. Diagnostic errors are the result of a delay in diagnosis, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring or testing. Preventive errors occur when there is inadequate monitoring or failure to provide prophylactic treatment or follow-up of treatment

A patient who is experiencing chest pain and shortness of breath is brought to the emergency department. The nurse assesses a heart rate of 98 beats per minute, bilateral lung crackles, and an oxygen saturation of 93%. What drug will the nurse expect to administer initially to this patient? a. Albuterol b. Aspirin c. Nitroglycerin d. Oxygen

D - The patient has signs of pulmonary edema, which can cause chest pain, crackles, and shortness of breath along with compensatory tachycardia and low oxygen saturations. The initial drug of choice is oxygen, which can minimize chest pain and open up the alveoli. The other drugs are given for specific underlying causes and may be necessary after the patient is evaluated further.

The registered nurse assigns a patient who has an open burn wound to a licensed practical nurse (LPN). Which instruction would the nurse provide to the LPN when assigning this patient? a. "Administer the prescribed tetanus toxoid vaccine." b. "Assess the patient's wounds for signs of infection." c. "Encourage the patient to breathe deeply every hour." d. "Wash your hands on entering the patient's room."

D Infection can occur when microorganisms from another person or from the environment are transferred to the patient. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.

In addition to its benefit in reducing pain and anxiety in the patient with pulmonary edema, the nurse understands morphine produces which primary effect on the pathophysiology of pulmonary edema? Decreasing the conduction rate at the AV node Decreasing preload Increasing cerebral perfusion Increasing afterload

Decreasing preload Morphine sulfate is also indicated for acute pulmonary edema because it produces venous vasodilation that decreases cardiac preload, the amount of blood returning to the right ventricle. The net effect is a decrease in pulmonary venous congestion.

Which factors indicate that a client's burn wounds are becoming infected? select all that apply Dry, crusty granulation tissue Elevated blood pressure Hypoglycemia Edema of the skin around the wound Tachycardia

Dry, crusty granulation tissue Edema of the skin around the wound Tachycardia Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection.Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

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

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

In the case of cardiac arrest in a child, the nurse would prepare to administer intracardiac epinephrine IV or IO along which time frame? Every 30-60 sec Every 2-3 min Every 3-5 min Every 10 min

Every 3-5 min The pediatric dose of epinephrine is 0.01 mg/kg (1:10,000 solution) given every 3-5 min IV/IO for cardiac arrest. The ETT dose of 0.1 mg/kg should be given using the 1:1,000 solution every 3-5 min.

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

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

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

Fluid resuscitation During the first 24 hours after a burn injury, the nurse's first priority is to administer fluid resuscitation because fluid does not stay in the vessels after a burn injury. Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

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

Forensic nurse examiner The forensic nurse examiner is the best and most appropriate team member able to recognize evidence of abuse and to intervene on the client's behalf. Although the forensic nurse examiner is the best team member to provide care for this client, physicians or other health care providers or a psychiatric crisis nurse may also play a role in the client's care. Law enforcement may or may not be involved dependent on local laws.

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

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

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? Heart failure Diverticulitis Hypertension Emphysema

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

The nurse is caring for a client who was admitted after a diving accident in a lake. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? Assessing the client's lung sounds and neurologic status Drawing arterial blood gases (ABGs) and phoning results to the health care provider Helping to maintain cervical spine stability during transfer to a stretcher Notifying the flight team of a possible transfer

Helping to maintain cervical spine stability during transfer to a stretcher Transferring and positioning clients is included in a UAP's education and scope of practice. An experienced UAP would be able to help with maintenance of cervical spine stability while under the supervision of licensed nursing staff. Nursing activities such as making assessments, arranging for client transfers, and communicating laboratory results to the health care provider require broader education and scope of practice and must be done by an RN. The actual drawing of ABGs is usually done by a respiratory therapist.

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

Impaired self-image A priority problem of impaired self-image is expected during the rehabilitation phase. During this phase, the client is discharged and his or her life is not the same. A priority problem of impaired self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

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

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

The nurse is administering nitroglycerin at 10 mcg/min. The patient continues to complain of chest pain. What is the nurse's priority action? Perform an electrocardiogram (ECG). Stop the infusion. Increase the infusion by 5 mcg/min. Call the health care provider.

Increase the infusion by 5 mcg/min. A continuous infusion is started for the patient with chest pain at a rate of 10-20 mcg/min and increased by 5-10 mcg/min based on the patient's symptoms. The patient would have had an ECG at the beginning of the episode. Another ECG is not needed. The infusion should not be stopped. The health care provider does not need to be called because there are interventions that the nurse can do.

A 2-year-old child falls into the community swimming pool and does not resurface. A lifeguard dives in to save the child. What does the lifeguard do first after the rescue? Initiates rescue breathing on the child Rapidly rewarms the child Removes water from the child's lungs Stabilizes the child's spine

Initiates rescue breathing on the child Airway clearance and ventilatory support measures must be started as soon as possible. There is no indication this child was exposed to cold water, however any water exposure can pose the risk of hypothermia in a small child. No attempt would be made to remove water from the lungs. Spinal cord injury would always be considered in a water-related emergency. However, it is not likely in this scenario.

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

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

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

Level I A Level I Trauma Center would be most appropriate to handle the complex level of care required by this client with a potential traumatic brain injury and apparent partial amputation of both hands. A Level I Trauma Center is a regional resource facility that provides leadership and collaborative care for every type of injury. Since the airway is secure and the vital signs are stable, there is no need to stop at a Level II, II or IV Trauma Center for stabilization. This client would require initial transfer to a Level I facility for likely surgery and rehabilitation in this situation.

A group of clients who sustained severe injuries in an earthquake received a full continuum of trauma services. Which level of trauma center provided these services to the clients? a. Level I b. Level II c. Level III d. Level IV

Level I. Level I trauma centers are usually located in large teaching hospital systems in densely populated areas and they provide a full continuum of trauma services for all clients. Level III trauma centers are typically located in community hospitals and are able to provide care for clients with major injuries up to stabilization before transporting them to higher-level centers if the require more resources for treatment. Level II trauma centers are community based trauma centers that provide care to most injured clients. However, if needs exceed resource capabilities, these centers transport the clients to high level trauma centers. Level IV trauma centers provide basic trauma client stabilization and advanced life support within resource capabilities.

A client presents to a clinic stating, "I got bit by something cleaning out the shed." On assessment, the nurse notices a bite mark with a bluish-purple center on the client's posterior calf. What treatment would the nurse anticipate as first line care? Application of ice to bite Elevation of affected extremity Initiation of transfer to trauma center Localized wound care

Localized wound care The nurse would anticipate localized wound care as first line care for this client. A brown recluse spider bite is characterized by a wound that develops a bluish-purple center. Since the bite has already developed a dark center, this type of wound care needs to be initiated as soon as possible. Although cold compresses are beneficial initially, applying ice directly to a wound would potentially cause more tissue damage. Elevation of the extremity is more beneficial in the early stages immediately after the bite. This client does not require transfer to a trauma center for surgical intervention at this time, although the bite must be monitored for further tissue destruction and the need for debridement.

A hiker begins to feel ill within 48 hours after arriving at a resort in Colorado. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment provides the most effective relief for this hiker? Acetazolamide sodium (Diamox) Dexamethasone (Decadron) Lower altitude Oxygen therapy

Lower altitude The most effective intervention to manage serious altitude-related illness is gradual descent to a lower altitude. Diamox needs to be taken before and during the trip for prevention, but will not help after symptoms of altitude-related illness have begun. Decadron can be administered during descent to help with symptoms, but is not the most effective treatment at this time. Oxygen is not the most effective treatment.

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

Monitors the client Blunt force injuries are from acceleration/deceleration forces, and can cause trauma to bones, blood vessels, and soft tissue. An injury may not be evident right away. A seat belt abrasion across the chest would alert the nurse to monitor closely for signs of potential internal injuries. While the nurse is monitoring the client, routine labs, including blood alcohol levels, may be obtained as well as computerized tomography (CT) scans. Based on these results, a decision regarding disposition will be made. Allowing the client to go home or preparing for surgery are not appropriate actions in this situation.

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. After ensuring the ABC's are intact, what does the team nurse do first? Give salt tablets. Move the player to the shade. Place ice packs under the arms. Provide a cool electrolyte fluid drink.

Move the player to the shade. After ensuring the ABC's are intact, the nurse would first move the player into the shade. After the player is in the shade, the nurse would place ice packs under the arms as well as in the groin to cool the client. Due to a diminished level of consciousness, nothing would be given by mouth to prevent aspiration. Salt tablets are not given.

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

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

A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially? Apply a dressing over the skin burn where the lightning entered. Instruct everyone to not to touch the victim to avoid being hurt. Immediately begin cardiopulmonary resuscitation. Palpate to check for the presence of a pulse.

Palpate to check for the presence of a pulse. Initially, the nurse would palpate to check for the presence of a pulse. The most lethal initial effect of the massive current discharge of lightning on the cardiopulmonary system is cardiac arrest. If the client does not have a pulse, CPR will be started utilizing BLS protocols. The golfer is not electrically charged so he/she is not a danger to anyone else. The skin burn can be dressed when everyone is in a safe location from further lightning strikes.

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? select ALL that apply Provides cushions for comfort Performs frequent handwashing Places plants in the client's room Performs gloved dressing changes Uses disposable dishes

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

A patient has been prescribed nitroprusside for treatment of a hypertensive emergency. Which interventions will the nurse include when administering nitroprusside? select all that apply Vigorously shake the mixture before administration. Place the bottle in an opaque bag. Closely monitor the patient's blood pressure. Monitor the patient's thiocyanate levels. Administer the solution slow IV push. Do not mix nitroprusside with other drugs.

Place the bottle in an opaque bag. Closely monitor the patient's blood pressure. Monitor the patient's thiocyanate levels. Do not mix nitroprusside with other drugs. Nitroprusside will lower the patient's blood pressure owing to vasodilation. Thiocyanate toxicity is an adverse reaction, and levels should be monitored. To prevent drug interactions, nitroprusside should not be mixed with other drugs. The mixture should not be vigorously shaken. Nitroprusside sodium is rapidly inactivated by light; the IV bottle or bag must be wrapped with aluminum foil or another opaque material to protect the solution from degradation. The medication should not be administered IV push.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? Discouraging having food brought in from the client's favorite restaurant Providing more palatable choices for the client Helping the client maintain a desirable weight Planning additions to the standard nutritional pattern

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

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? Red and white wounds with mild pain to palpation Painless, brownish yellow eschar Painful reddened blisters Black skin with eschar and no pain

Red and white wounds with mild pain to palpation A red and white wound bed characterizes deep partial-thickness burns. Blisters are rare. Pain is less than with other types of burns because nerve endings are affected. Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

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

Reduction of bacterial growth in the wound and prevention of systemic sepsis The best description of the goal of topical antimicrobials such as silver sulfadiazine is that they help prevent infection in burn wounds. Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

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

Scar tissue formation Indicators of wound healing include the presence of granulation, reepithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

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

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

A patient is receiving mannitol for treatment of cerebral edema. The nurse assesses a heart rate of 110 beats/min and rhonchi throughout the lung fields, and the patient complains of blurred vision. What will the nurse do? Continue to assess the patient. Encourage the patient to cough and deep breathe. Tell the patient to close her eyes and relax. Stop the infusion and call the health care provider.

Stop the infusion and call the health care provider. Pulmonary congestion, tachycardia, and blurred vision are symptoms of adverse effects of mannitol. The nurse should stop the infusion. Coughing and deep breathing will not assist the patient.

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

The serum potassium level is 6.1 mEq/L (6.1 mmol/L). The greatest concern for the nurse is to notice an elevated serum potassium level that can cause cardiac dysrhythmias and arrest. Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

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

Titrate fluid replacement. The nurse first needs to adjust and titrate the intravenous fluid rate on the basis of urine output plus serum electrolyte values. A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) Creatinine, 2.8 mg/dL (248 mcmol/L) Urine output, 40 mL/hr Urine specific gravity, 1.042

Urine output, 40 mL/hr Clinical improvement based on fluid resuscitation for a burn client correlates with a urine output of between 30 and 50 mL/hr or 0.5 mL/kg/hr.A BUN of 36 mg/dL (12.9 mmol/L) is above normal, a creatinine of 2.8 mg/dL (248 mcmol/L) is above normal, and a urine specific gravity of 1.042 is above normal.

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

Woman bleeding heavily The critically injured woman with active hemorrhage is the emergent priority in this situation. This condition is potentially life threatening. The child with an open fracture of the arm, the man with a contusion of the head, and the teenager with a closed fracture of the leg are urgent and treatment can wait.A client with a gunshot wound is admitted to the emergency department (ED). Which minimum Standard Precaution activity does the nurse require for staff safety?

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

Young adult who suffered burn injuries in a closed space The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack? a. Atropine b. Dopamine c. Epinephrine d. Norepinephrine

a (atropine) - Atropine should be listed as the antidote for nerve agent poisoning in the disaster plan for a terrorist attack. Nerve gasses cause the client's system to be flooded with acetylcholine, with results in an overstimulation of the nerve cell. Atropine works by blocking the acetylcholine receptors. Therefore the receptors will not pick up the acetylcholine. Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve agent poisoning.

A client with burns over 35% of the body reports chilling. Which action will the nurse take to promote client comfort? a. Limit room drafts b. Place a sterile top sheet over the client c. Decrease the room humidity below 10% d. Maintain an 80F room temperature

a (limit room drafts) - Limiting drafts minimizes body heat lost by convection; the loss of body heat increases when moisten skin is exposed to slightly moving air. Maintaining humidity in the sir holds in heat; decreasing the humidity will cool the room and increase chilling. The room temperature should be kept at approximately 85F, because heat is lost from burned areas. A sterile sheet is not necessary; some client may be treated by the open method and have burns exposed.

Which is essential for ensuring disaster readiness in a community? a. Trauma system b. State government c. Federal government d. Emergency response system

a (trauma system) - A well-functioning trauma system is essential to general public health and safety. It provides the structure necessary for disaster readiness and community preparedness. Although most states now have at least some basic elements of a trauma system in place, significant gaps still exist in many regions. The federal government may provide oversight for disaster readiness; however, it does provide the fundamental structure. The emergency response system is one aspect of disaster readiness; however, it does not provide the structure

The registered is teaching a student nurse about priority of care while caring for clients with different conditions in an emergency department. Which clients if selected by the student nurse as lowest priorities of care would indicate effective learning? Select all that apply. a. Clients with cystitis b. Clients with cold symptoms c. Client with a closed fracture d. Client with intubation trauma e. Client with moderate abdominal pain

a, b (cystitis & cold symptoms) Care for clients with cystitis and cold symptoms can be delayed because these conditions may be stable when compared to other clients and these are not life-threatening conditions. Clients with closed fractures can be cared for within an hour. The client with intubation trauma should be given immediate care because the client's condition with trauma may not be stable. The client with moderate abdominal pain can wait for some time to receive care.

The registered nurse is caring for a client in the emergency department. Which conditions of the client made the nurse stabilize the cervical spine as the primary nursing intervention: Select all that apply. a. Flail chest b. Head injuries c. Facial chemical burns d. Renal colic pain e. Blunt abdominal pain

a, b, c - Immediate care for a client with head injury and facial burn chemical burns is stabilization of the cervical spine because the client may suffer severe respiratory distress. Cervical spine trauma should be suspected in any client with face, head, or neck trauma and significant upper chest injuries, such as flail chest. The nurse should stabilize the cervical spine and or immobilize during assessment of the airway. Stabilization of the cervical spine may not be required in a client with renal colic pain or with blunt abdominal pain because the clients may not experience respiratory distress.

The nurse is teaching a burns safety class. Which examples should the nurse use to describe the usual occupational hazards for burn injuries? Select all that apply. a. Road tar b. Power lines c. Fertilizers d. Cooking grills e. Microwave ovens

a, b, c, d - Tar applied for road maintenance, electrical power lines, restaurant cooking grills, and agricultural fertilizers are common occupational hazards for burn injuries. Microwave ovens are considered a general household source of burn injuries that can occur when accessing food too soon after cooking it.

The client is admitted with paroxysmal supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and the client is asymptomatic except for a "fluttering feeling" in the chest. Which treatments should the nurse be prepared to administer? Select all that apply. a. Intravenous adenosine b. Intravenous beta blockers c. Intravenous amiodarone d. Synchronized cardioversion e. Intravenous calcium channel blockers

a, b, d, e - Medications that may be used for paroxysmal supraventricular tachycardia include adenosine, beta blockers, amiodarone, and calcium channel blockers. If the client is symptomatic or hemodynamically unstable, synchronized cardioversion is considered.

How does the human body conserve heat? Select all that apply. a. By decreasing muscle activity in the body b. Through peripheral vasodilation in the body c. Through peripheral vasoconstriction in the body d. By shunting blood to superficial body tissues e. By shunting blood away from the skin surface

a, c, d - The human body conserves heat through peripheral vasoconstriction in the body. During peripheral vasoconstriction, the warm blood is shunted away from the skin surface to minimize heat loss from the body. Shunting blood to superficial body tissues would facilitate loss of heat. Increased muscle activity causes heat loss; the body conserves heat through decreased muscle activity. The body conserves heat through peripheral vasoconstriction; vasodilation would cause heat loss.

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. The nurse is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client? a. Weight every day b. Urinary output every hour c. Blood pressure every 15 minutes d. Extent of peripheral edema every 4 hours

b (UOP) - Urinary output reflects circulating blood volumes; it is the most reliable, immediate available information that is useful assessing fluid needs in a burn client. Daily weight reflects fluid retention or loss; however, other factors besides fluid affect weight in a burn client. Blood pressure results may indicate hypovolemia or hypervolemia; however, it is not as accurate an indicator of insufficient fluid replacement as is urinary output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

In addition to its benefit in reducing pain and anxiety in the patient with pulmonary edema, the nurse understands morphine produces which primary effect on the pathophysiology of pulmonary edema? a. Decreasing the conduction rate at the AV node b. Decreasing preload c. Increasing cerebral perfusion d. Increasing afterload

b - Morphine sulfate is also indicated for acute pulmonary edema because it produces venous vasodilation that decreases cardiac preload, the amount of blood returning to the right ventricle. The net effect is a decrease in pulmonary venous congestion.

What comprises the prehospital priority care delivered by a nurse for a heatstroke victim? a. The nurse should provide cold compresses. b. The nurse should not give food or liquid to the victim. c. The nurse should stabilize the spine of the victim with a board. d. The nurse should closely monitor the blood pressure and respiratory function.

b - The nurse should not give food or liquid to the victim as prehospital care for heatstroke victim because vomiting and aspirations are risks. The nurse should provide cold compresses over the bit site in case the client is bitten by the brown recluse spider. The nurse should stabilize the spine of the victim with a board as prehospital care for a drowning victim. The nurse should closely monitor the blood pressure and respiratory function as part of prehospital care for a victim of a snake of spider bite.

A client who survived a lightning strike is admitted to the emergency unit. Which interventions could be beneficial for this client's condition? Select all that apply. a. Administration of diphenhydramine b. Applying spinal immobilization technique c. Stabilization of airway, breathing, and circulation d. Applying ice packs in the axillae and groin and on the neck and head e. Rapid rewarming in a warm bath at a temperature range of 104 to 108F

b, c - Applying spinal immobilization would reduce spinal cord injury pain. Stabilization of airway, breathing, and circulation may be beneficial to prevent respiratory and cardiac arrest. Administration of diphenhydramine would be beneficial in case of bee or wasp stings, not after a lightning strike. Applying ice packs in the axillae and groin and on the neck and head is beneficial for heat stroke victims, not lightning strike victims. Rapid rewarming in a water bath at a temperate range of 104 to 108F would help clients with cold-related injuries such as hypothermia and frostbite.

A patient has been prescribed nitroprusside for treatment of a hypertensive emergency. Which interventions will the nurse include when administering nitroprusside? Select all that apply. a. Vigorously shake the mixture before administration. b. Place the bottle in an opaque bag. c. Closely monitor the patient's blood pressure. d. Monitor the patient's thiocyanate levels. e. Administer the solution slow IV push. f. Do not mix nitroprusside with other drugs.

b, c, d, f - Nitroprusside will lower the patient's blood pressure owing to vasodilation. Thiocyanate toxicity is an adverse reaction, and levels should be monitored. To prevent drug interactions, nitroprusside should not be mixed with other drugs. The mixture should not be vigorously shaken. Nitroprusside sodium is rapidly inactivated by light; the IV bottle or bag must be wrapped with aluminum foil or another opaque material to protect the solution from degradation. The medication should not be administered IV push.

A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check? a. Blood urea nitrogen (BUN) b. Sedimentation rate c. Hematocrit (hct) d. Blood pH

c (hct) - An increased Hct level indicates hemocentration secondary to fluid loss. The BUN level may be used to indicate dehydration from burns, but interpretation can be complicated by other conditions accompanying burns that also cause an increase in the BUN. An increase in the sedimentation rate indicates the presence of an inflammatory process not fluid loss. The pH level reflects acid-base balance.

The nurse is caring for a client with trauma in the emergency unit. Which action should the nurse perform as the highest priority? a. Applying dry dressing b. Evaluating chest expansion c. Providing adequate oxygen supply e. Applying direct pressure on a bleeding site

c (oxygen) - The nurse should prioritize care while caring for a client with trauma in the emergency department. Evaluation of chest expansion, respiratory effort, and evidence of chest wall trauma helps to assess breathing, a primary survey. The highest priority intervention is to establish a patient airway by providing adequate oxygen supply, thereby reducing the brain injury and progression to anoxic brain death. Direct application of pressure on the bleeding site with thick, dry dressing material helps to reduce external hemorrhage. Oxygen is the priority

A nurse must establish and maintain an airway in a client who has experience a near-drowning in the ocean. For which potential danger should the nurse assess the client? a. Alkalosis c. Renal failure d. Hypervolemia e. Pulmonary edema

c (pulmonary edema) - Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequel of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

The nurse is administering nitroglycerin at 10 mcg/min. The patient continues to complain of chest pain. What is the nurse's priority action? a. Perform an electrocardiogram (ECG). b. Stop the infusion. c. Increase the infusion by 5 mcg/min. d. Call the health care provider

c - A continuous infusion is started for the patient with chest pain at a rate of 10-20 mcg/min and increased by 5-10 mcg/min based on the patient's symptoms. The patient would have had an ECG at the beginning of the episode. Another ECG is not needed. The infusion should not be stopped. The health care provider does not need to be called because there are interventions that the nurse can do.

The nurse is assessing the victims of a disaster brought in to the emergency department for signs of hypothermia. Which statements made by the nurse indicate accurate awareness about the conditions associated with hypothermia? Select all that apply. a. "Shivering is the body's first attempt to conserve heat." b. "Wet clothing increases evaporative heat loss twice as much as normal." c. "Hypothermia can often be misdiagnosed as it mimics other disorders." d. "Near drowning increases evaporative heat loss to 25 times greater than normal." e. "Older adults are less prone to hypothermia due to medications that alter body defenses."

c, d - Hypothermia mimics cerebral or metabolic disturbances causing ataxia, confusion, and withdrawal, so the client may be misdiagnosed. Immersion in cold water, such as near drowning, increases evaporative health loss to 25 times greater than normal. Peripheral vasoconstriction is body's first attempt to conserve heat. As cold temperatures persist, shivering and moment are the body's only mechanisms for producing heat. Wet clothing increases evaporative heat loss to five times greater than normal. Older adults are more prone to hypothermia because of decreased body fat, diminished energy reserves, decreased basal metabolic rate, decreased shivering response, decreased sensory perception, chronic medical conditions, and medications that alter body defenses.

A patient is receiving mannitol for treatment of cerebral edema. The nurse assesses a heart rate of 110 beats/min and rhonchi throughout the lung fields and the patient complains of blurred vision. What will the nurse do? a. Continue to assess the patient. b. Encourage the patient to cough and deep breathe. c. Tell the patient to close her eyes and relax. d. Stop the infusion and call the health care provider.

d - Pulmonary congestion, tachycardia, and blurred vision are symptoms of adverse effects of mannitol. The nurse should stop the infusion. Coughing and deep breathing will not assist the patient.