AH exam 3

The injury that is least likely to result in a full thickness burn is: a. sunburn b. scald injury c. chemical burn d. electrical injury

a.

A male pt suffered full thickness burns to the chest and back and the nurse notes the pressure alarm on his mechanical ventilator is sounding every 5 minutes. What is the most relevant assessment to prevent respiratory complications in this pt? a. pH b. PaCO2 c. Breath sounds d. chest expansion

d. assessing the pt's chest expansion is initially the most important because a sever burn that includes the anterior and posterior thorax can restrict chest expansion from eschar or scar tissue.

7. Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need which treatment modality? A. Surgery B. Chemotherapy C. Radiation therapy D. Biologic drug therapy

A. Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Do you take salicylates?" b. "Are you taking any oral contraceptives?" c. "Have you been prescribed antiseizure drugs?" d. "How long have you taken antihypertensive drugs?"

ANS: A Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting.

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.

ANS: A The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP. DIF: Cognitive Level: Application REF: 1436-1437

1. The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which complications (select all that apply)? A. Vision loss B. Cerebral edema C. Pituitary dysfunction D. Parathyroid dysfunction E. Focal neurologic deficits

A,B,C,E Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

6. What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

A. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? A. Elevated D-dimers B. Elevated fibrinogen C. Reduced prothrombin time (PT) D. Reduced fibrin degradation products (FDPs)

A. Elevated D-dimers The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe b. parietal lobe c. occipital lobe d. temporal lobe

A. Frontal lobe

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? A. Prevent patient infection. B. Avoid abnormal bleeding. C. Give pneumococcal vaccine. D. Provide companionship while isolated.

A. Prevent patient infection. After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft. Thus the patient is immunosuppressed and is at risk for a life-threatening infection. The priority is preventing infection. Bleeding is not usually a problem. Giving the pneumococcal vaccine at this time should not be done; it should have been done previously. Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.

The patient is admitted with hypercalcemia; polyuria; and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient? A.Multiple myeloma B. Thrombocytopenia C. Megaloblastic anemia D. Myelodysplastic syndrome

A.Multiple myeloma Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

ANS: D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

ANS: A Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome. DIF: Cognitive Level: Apply (application) REF: 1370 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot

ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim. DIF: Cognitive Level: Apply (application) REF: 1383 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/mL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.

ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/mL unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

ANS: A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation.

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

ANS: A The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy. DIF: Cognitive Level: Application REF: 1434-1435

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

Classic symptoms of bacterial meningitis include a. papilledema and psychomotor seizures b. high fever, nuchal rigidity, and severe headache c. behavioral changes with memory loss and lethargy d. positive Kernig's and Brudzinski's signs and hemiparesis

B. High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such classic symptoms of meningitis that they are usually considered diagnostic for meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as complications of increased ICP and cranial nerve dysfunction.

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

B. Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

On physical examination of a patient with headache and fever, the nurse would suspect a brain abscess when the patient has a. seizures b. nuchal rigidity c. focal symptoms d. signs of increased ICP

C. The symptoms of brain abscess closely resemble those of meningitis and encephalitis, including fever, headache, and increased ICP, except the patient also usually has some focal symptoms that reflect the local are of the abscess.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

3. The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? A. Tonic spasms of the legs B. Curling in a fetal position C. Arching of the neck and back D. Resistance to flexion of the neck

D. Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

D. An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops over weeks or months

A patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? A. Skin care that will be needed B. Method of obtaining the treatment C. Gastrointestinal tract effects of treatment D. Treatment type and expected side effects

D. Treatment type and expected side effects The patient should first be taught about the type of treatment and the expected and potential side effects. Nursing care is related to the area affected by the disease and treatment. Skin care will be affected if radiation is used. Not all patients will have gastrointestinal tract effects of NHL or treatment. The method of obtaining treatment will be included in the teaching about the type of treatment.

Identify two ways the following three-volume components of intracranial pressure (ICP) can be changed to adapt to small increases in intracranial pressure. a. Cerebrospinal fluid (CSF) b. Brain Tissue c. Blood tissue

a. Increased absorption, decreased production, displacement into spinal canal b. herniation, lesion, edema, collapse of veins and dural sinuses, increased venous outflow and decreased blood flow c. distention of dura, slight compression of tissue

The nurse plans care for a male pt who suffered thermal burns to the entire posterior aspect of his body when he fell on an outdoor grill. Which pt need is likely to be the primary problem of this pt in the emergent phase? a. maintain tissue oxygenation b. halt progression of the burn c. maintain intravascular volume d. prevent invasion of pathogens

b. the first priority is halting the severity of the burn, to limit the depth of the burn and quick action must be a priority.

Pain management for the burn patient is most effective when a. opioids are administered on a set schedule around the clock b. the patient has as much control over the management of the pain as possible. c. there is flexibility to administer opioids withing a dosage and frequency range d. painful dressing changes are delayed until the pt's pain is totally relieved.

b. the patient has as much control over the management of the pain as possible. The more control the patient has in managing the pain, the more successful the chosen strategies. Active patient participation has been found to be effective for some patients in anticipating and coping with treatment-induced pain.

A patient is to undergo skin grafting with the use of cultured epithelial autografts full-thickness burns. The nurse explains to the patient that this treatment involves a) Shaving a split-thickness layer of the patient's skin to cover the burn wound. b) Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage. c) Growing small specimens of the patient's skin into sheets to use as permanent skin coverage. d) Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.

c Rationale: Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient's own unburned skin.

When assessing a pt with a partial thickness burn, the nurse would expect to find (select all that apply) a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

a, d, e

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. Which of the following would the nurse anticipate to be prescribed for the client? a. out of bed b. brp c. Immobilization of the affected leg d. placing the affected leg in a dependent position

c. autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3-7 days. this period allows the autograft time to adhere to the wound bed.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? a. using sterile sheets and linens b. performing strict hand washing technique c. wearing gloves and gown only when giving direct care to the client d. wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

c. ppe should be worn whenever entering the client's room

A female pt in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose of 485 mg/dL. What is the nurse's priority for preventing a life threatening complication of hyperglycemia for the burn patient? a. replace the blood lost b. maintain a neutral pH c. Maintain fluid balance d. Replace serum potassium

c. this pt is most likely experiencing hyperglycemic hyperosmolar nonketotic syndrome (HHNKS) which dehydrates a patient rapidly. This increases the pt's risk for hypovolemia and hypotension.

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a) Serum K+ of 4.5 mEq/L b) Urine output of 35 mL/hr c) Decreased bowel sounds d) Blood pressure of 86/72 mm Hg

d Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr. Mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg.

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a) "Blood loss from burned tissue is the most likely cause of hypovolemia." b) "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c) "The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces." d) "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of a. Blood loss from injured tissue. b. Third spacing of fluid into fluid-filled vesicles. c. Evaporation of fluid from denuded body surfaces. d. Capillary permeability with fluid shift to the interstitium.

d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

The client arrives at the emergency department following a burn injury that occurred in the basement at home and an inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client? a. 100% oxygen via an aerosol mask b. Oxygen via nasal cannula at 15L/min c. Oxygen via nasal cannula at 10L/min d. 100% oxygen via a tight fitting, non rebreather face mask

d.

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.

ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.

A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly."

ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family

ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory result would the nurse expect to find? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count

ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. Encourage adolescents and young adults to avoid crowds in the winter. b. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Emphasize the importance of hand washing to prevent the spread of infection.

ANS: C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic. DIF: Cognitive Level: Apply (application) REF: 1381 | 1383 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 128 beats/minute

ANS: C The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2. DIF: Cognitive Level: Apply (application) REF: 1363 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage. DIF: Cognitive Level: Apply (application) REF: 1369 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a. Pulse 102 beats/min b. Temperature 101.6° F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

ANS: B Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit

ANS: C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration. DIF: Cognitive Level: Apply (application) REF: 1364 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time.

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease

Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? a. Avoid any injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a. expressive aphasia. b. impaired judgment. c. right-sided weakness. d. difficulty swallowing.

ANS: B The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem. DIF: Cognitive Level: Apply (application) REF: 1376 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meats and protein?"

ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease (COPD). The other questions would be appropriate for patients who are anemic.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid venipunctures. b. Notify the patient's physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.

ANS: B The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.

ANS: B The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary. DIF: Cognitive Level: Apply (application) REF: 1371 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.

ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patient's room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patient's room without a mask.

ANS: D Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis. DIF: Cognitive Level: Apply (application) REF: 1383 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. White blood cell count d. Hemoglobin (Hgb) level

ANS: D Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Verify Glasgow Coma Scale (GCS) score. d. Palpate the head for hematoma or bony irregularities.

ANS: A Airway patency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that. DIF: Cognitive Level: Apply (application) REF: 1372 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

ANS: A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED. DIF: Cognitive Level: Application REF: 1437-1438

After receiving change-of-shift report for several patients *with neutropenia,* which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8° F (38.2° C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatigue

ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems

Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.

ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level

ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of *defe*roxamine (de-Fe - decrease iron)

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/mL. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal

A nursing measure that is indicated to reduce the potential for seizures and increased ICP in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain b. controlling fever with prescribed drugs and cooling techniques c. keeping the room darkened and quiet to minimize environmental stimulation d. maintaining the patient on strict bed rest with the HOB slightly elevated

B. Controlling fever with prescribed drugs and cooling techniques

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in the left knee joint. What should be the emergency nurse's immediate action? A. Immediate transfusion of platelets B. Resting the patient's knee to prevent hemarthroses C. Assistance with intracapsular injection of corticosteroids D. Range-of-motion exercises to prevent thrombus formation

B. Resting the patient's knee to prevent hemarthroses In patients with hemophilia, joint bleeding requires resting of the joint to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.

11. A male patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). He has been maintained on IV fluids for 2 days. The nurse seeks enteral feeding for this patient based on what rationale? A. Free water should be avoided. B. Sodium restrictions can be managed. C. Dehydration can be better avoided with feedings. D. Malnutrition promotes continued cerebral edema.

D. A patient with diffuse axonal injury is unconscious and, with increased ICP, is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings.

When assessing the body function of a patient with increased ICP, the nurse should initially assess a. corneal reflex testing b. extremity strength testing c. pupillary reaction to light d. circulatory and respiratory status

D. Circulatory and respiratory status- Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the *ABCs* (airway, breathing, and circulation)

Fluid and electrolyte shifts that occur during the early emergent phase include a. adherence of albumin to vascular walls b. movement of potassium into the vascular space c. sequestering of sodium and water in the interstitial fluid. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

c. sequestering of sodium and water in the interstitial fluid.

Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

a. A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that the anticipated therapeutic outcome of the escharotomy is: a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue

a. Escharotomies arepreformed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third degree burn.

A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment by the nurse requires immediate action? a. coughing and wheezing b. bright red skin with small blister on the burn sites c. thirst d. singed hair

a. coughing and wheezing may indicate that the child has inhaled smoke or toxic fumes. Maintaining airway patency is the highest nursing priority in this situation.

A pt in the emergent phase of burn care for thermal burns on 20% of the total body surface area is unconscious. Which assessment data is the most important for the nurse's evaluation of the pt's injuries? a. condition of the oropharynx b. percentage of TBSA affected c. location of the pt in the fire d. comorbidities of the pt

a. the pt is likely to have suffered a smoke inhalation injury because thermal burns are caused by flames that emit smoke and because the pt is unconscious.

When caring for a client with extensive burns, the nurse anticipates that pain medication will be administered via which route? a. oral b. IV c. IM d. Subq

b.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client? a. coma b. flushing c. dizziness d. tachycardia

b. 11-20% - signs include flushing, headache, decreased visual acuity, decreased cerebral functioning, and slight breathlessness. 21-40% - signs include nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; levels of 41-60% result in seizure and come and levels higher than 60% result in death

A pt who has an inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? a. GI distress b. tachycardia c. restlessness d. hypokalemia

b. albuterol stimulates beta adrenergic receptors in the lungs to cause bronchodilation and is nonselective and also causes receptors in the heart to increase heart rate.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which of the following would provide the most reliable indicator for determining the adequacy? a. vital signs b. urine output c. mental status d. peripheral pulses

b. successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses and clear sensorium.

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell (WBC) count of 2800/µL

ANS: D Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

The health care provider orders a liver/spleen scan for a patient who has been in a motor vehicle accident. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Place the patient on NPO status. d. Assist the patient to a flat position.

ANS: D During a liver/spleen scan, a radioactive isotope is injected IV and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter is not needed. The patient is placed in a flat position before the scan.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim

A nurse who provides care on a burn unit is preparing to apply a patient's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A) Apply the new ointment without disturbing the existing layer of ointment. B) Apply the ointment using a sterile tongue depressor. C) Apply a layer of ointment approximately 1/16 inch thick. D) Gently irrigate the wound bed after applying the antibiotic ointment.

Ans: C Feedback: After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16-inch thick using clean gloves. The wound would not be irrigated after application of new ointment.

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) During waking hours for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

Ans: C Feedback: Elastic pressure garments are worn continuously (i.e., 23 hours a day).

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening

A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18%

Ans: D Feedback: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor? a. "Do you have difficulty in hearing?" b. "Are you experiencing visual problems?" c. "Are you having any trouble with your balance?" d. "Have you developed any weakness on one side?"

ANS: B Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe. DIF: Cognitive Level: Apply (application) REF: 1376 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

ANS: B Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members' anxiety. DIF: Cognitive Level: Apply (application) REF: 1361 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Give the PRN diphenhydramine (Benadryl).

ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching

A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A) Education about home safety B) Education about safe storage of chemicals C) Education about workplace health threats D) Education about safe driving

Ans: A Feedback: A large majority of burns occur in the home setting; educational interventions should address this epidemiologic trend.

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain

Ans: D Feedback: Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the patient's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.

A patient has been diagnosed with acute myelogenous leukemia (AML). What should the nurse educate the patient that care will focus on? A. Leukopheresis B. Attaining remission C. One chemotherapy agent D. Waiting with active supportive care

B. Attaining remission Attaining remission is the initial goal of care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukopheresis or hydroxyurea to reduce the white blood cell count and risk of leukemia-cell-induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia, waiting may be done to attain remission, but not with AML.

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing? A. Thirst B. Fatigue C. Headache D. Abdominal pain

B. Fatigue The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? A. Start IV fluids. B. Maintain oxygenation. C. Maintain distal warmth. D. Check peripheral pulses.

B. Maintain oxygenation. Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority.

The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient on the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position

B. elevate the head of the bed to 30 degrees

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? A. Unit secretary B. A physician's assistant C. Another registered nurse D. An unlicensed assistive personnel

C. Another registered nurse Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.

The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a *decreasing LOC.* A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas measurement results reveal a a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 50 mm Hg d. PaCO2 of 30 mm Hg

C. PaO2 of 50 mm Hg- A PaO2 of 50 mm Hg reflects a hypoxemia that may lead to further decreased cerebral perfusion and hypoxia and must be corrected. The pH of SaO2 are within normal range, and a PaCO2 of 30 mm Hg reflects acceptable value for the patient with increased ICP

The nurse is caring for a patient with a diagnosis of disseminated intravascular coagulation (DIC). What is the first priority of care? A. Administer heparin. B. Administer whole blood. C. Treat the causative problem. D. Administer fresh frozen plasma.

C. Treat the causative problem. Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of CSF c. the loss of autoregulatory control of ICP d. a normal balance between brain tissue, blood, and CSF

D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg

A triage nurse in the ED admits a 50 year old male client with second degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of his body is burned? Record your answer using a whole number.

36 The anterior and posterior portions of one leg are 18%, if both legs are burned, the total is 36%.

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

ANS: 27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and each arm is 9%.

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

ANS: 600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 × 80 × 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

ANS: A An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

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

ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

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

ANS: A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management. (Also, don't use latex on someone with large wounds.)

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

ANS: A The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.

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

ANS: A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended. *(Watch appears to = wristwatch, not the verb "to watch")*

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

ANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

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

ANS: B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses."

ANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing.

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.

ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

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

ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

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

ANS: C A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are a good source of potassium, but are not high in protein and calories.

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

ANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal.

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

ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour

ANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL

ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

ANS: C The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.

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

ANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.

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

ANS: D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury.

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)

ANS: D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

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

ANS: D The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

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

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week

Ans: A Feedback: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)

Ans: A Feedback: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, ìI can't wait to have surgery to reconstruct my face so I look normal again.î What would be the nurse's best response? A) That's something that you and your doctor will likely talk about after your scars mature. B) That is something for you to talk to your doctor about because it's not a nursing responsibility. C) I know this is really important to you, but you have to realize that no one can make you look like you used to. D) Unfortunately, it's likely that you will have most of these scars for the rest of your life.

Ans: A Feedback: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the patient's query. It is true that the patient will not realistically look like he or she used to, but this does not instill hope.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping

Ans: A Feedback: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

Ans: A Feedback: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

Ans: A Feedback: If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells

Ans: A Feedback: Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally administered. Potassium chloride would exacerbate the patient's hyperkalemia.

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A) The causative agent B) The patient's preinjury health status C) The patient's prognosis for recovery D) The circumstances of the accident

Ans: A Feedback: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The patient's preinjury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patient's needs? A) A patient-controlled analgesia (PCA) system B) Oral opioids supplemented by NSAIDs C) Distraction and relaxation techniques supplemented by NSAIDs D) A combination of benzodiazepines and topical anesthetics

Ans: A Feedback: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the patient. The use of patient-controlled analgesia (PCA) gives control to the patient and achieves this goal. Patients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.

A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hypermotility C) Respiratory arrest D) Hypokalemia

Ans: A Feedback: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

Ans: A Feedback: Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. A) Promote truthful communication. B) Avoid asking the patient to make decisions. C) Teach the patient coping strategies. D) Administer benzodiazepines as ordered. E) Provide positive reinforcement.

Ans: A, C, E Feedback: The nurse can assist the patient to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the patient practice appropriate strategies, and giving positive reinforcement when appropriate. The patient may benefit from being able to make decisions regarding his or her care. Benzodiazepines may be needed for short-term management of anxiety, but they are not used to enhance coping.

A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A) Perform mechanical dÈbridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.

Ans: B Feedback: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem and the nurse would not independently perform dÈbridement.

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat

Ans: B Feedback: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. *Silver products do not penetrate eschar;* Acticoat is a type of silver dressing.

The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from the viable tissue B) Removal of eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

Ans: B Feedback: Mechanical dÈbridementcan be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical dÈbridement can also be accomplished through the use of topical enzymatic dÈbridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural dÈbridement. Shaving the burned skin layers and early wound closure are examples of surgical dÈbridement.

A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A) Monitoring fluid and electrolyte imbalances B) Providing education to the patient and family C) Treating infection D) Promoting thermoregulation

Ans: B Feedback: Patient and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the patient is still in the acute phase of burn recovery.

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A) He's on a calorie-restricted diet in order to divert energy to wound healing. B) His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. C) He actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat. D) He lost many fluids while he was being treated in the emergency phase of burn care.

Ans: B Feedback: Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Patients are not placed on a calorie restriction during recovery and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication? A) Psychosis B) Post-traumatic stress disorder C) Delirium D) Vascular dementia

Ans: B Feedback: Post-traumatic stress disorder (PTSD) is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns.

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area under any circumstances.

Ans: C Feedback: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the patient's IV fluid infusion. B) Report the patient's early signs of acute kidney injury (AKI). C) Recognize that the patient is experiencing an expected onset of diuresis. D) Administer sodium chloride as ordered to compensate for this fluid loss.

Ans: C Feedback: As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Decreased blood pressure D) Sudden agitation

Ans: C Feedback: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurse's most appropriate intervention? A) Reinforce the Biobrane dressing with another piece of Biobrane. B) Remove the Biobrane dressing and apply a new dressing. C) Trim away the separated Biobrane. D) Notify the physician for further emergency-related orders.

Ans: C Feedback: As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. There is no need to reinforce the Biobrane nor to remove it and apply a new dressing. There is not likely any need to notify the physician for further orders.

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position. B) Administer PRN analgesia as ordered. C) Assess the patient's peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to set the new dressing.

Ans: C Feedback: Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be administered prior to the dressing change. ROM exercises do not normally follow a dressing change.

The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

Ans: C Feedback: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound dÈbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

Ans: C Feedback: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

Ans: D Feedback: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patient's risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? A) Apply skin emollients as ordered after granulation has occurred. B) Keep injured areas immobilized whenever possible to promote healing. C) Administer oral or IV corticosteroids as ordered. D) Encourage physical activity and range of motion exercises.

Ans: D Feedback: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.

A patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A) 0.45% NaCl with 20 mEq/L KCl B) 0.45% NaCl with 40 mEq/L KCl C) Normal saline D) Lactated Ringer's

Ans: D Feedback: Fluid resuscitation with lactated Ringers (LR) should be initiated using the American Burn Association's (ABA) fluid resuscitation formulas. LR is the crystalloid of choice because its composition and osmolality most closely resemble plasma and because use of normal saline is associated with hyperchloremic acidosis. Potassium chloride solutions would exacerbate the hyperkalemia that occurs following burn injuries.

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

Ans: D Feedback: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Butter is contraindicated.

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A) Maintenance of bed rest to aid healing B) Choosing appropriate splints and functional devices C) Administration of beta adrenergic blockers D) Prevention of venous thromboembolism

Ans: D Feedback: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A) Assess the patient for signs of electrolyte imbalances. B) Administer fluids as ordered. C) Assess the risk for injury recurrence. D) Assess the patient's psychosocial state.

Ans: D Feedback: Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn

Ans: D Feedback: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

Ans: D Feedback: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

While performing a patient's ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patient's behavior? A) The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior. B) The patient may be experiencing neurologic or psychiatric complications of his injuries. C) The patient may be experiencing inconsistencies in the care that he is being provided. D) The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.

Ans: D Feedback: The patient may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers.

The patient sustained a full-thickness burn encompassing the entire right arm. What is the best indicator an escharotomy achieved its desired effect? A. Patient rates the pain at less than 4. B. Blood pressure remains above 120/80 mm Hg. C. Right fingers blanch with a 2-second refill. D. Patient maintains full range of motion for the right arm.

C. Circulation to the extremities can be severely impaired by deep circumferential burns and subsequent edema that impairs the blood supply. An escharotomy (electrocautery incision through the full-thickness eschar) is performed to restore circulation. Normal refill is less than 2 seconds.

Multiple patients arrive in the emergency department from a house fire. Which patient is a priority? A. Patient with erythremic, dry burns over the arms and a history of taking prednisone B. Patient with moist blisters over the chest and who reports pain as 10 C. Patient with dry, black skin on one hand and a history of diabetes mellitus D. Patient with multiple reddened skin areas on the chest and with high-pitched respiratory sounds

D. Airway injury is a priority, and stridor results from a narrowing of the airway caused by edema. A history of prednisone use or diabetes is a concern for long-term infection risk, but the airway is always first.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which of the following interventions would the nurse expect to include in this patient's care (select all that apply)? A.Escharotomy B.Administration of diuretics C.IV and oral pain medications D.Daily cleansing and debridement E.Application of topical antimicrobial agent

a, c, d, e. An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. Pain control is essential in the care of a patient with a burn injury

A client's burn is infected and mafenide (Sulfamylon) is prescribed. The nurse's knowledge about this medication would indicate that which organism is involved? a. pseudomonas aeruginosa b. tubercle bacillus c. Methicillin resistant staphylococcus aureus (MRSA) d. Candida albicans

a. Mafenide is useful in treatment of partial and full thickness burns to prevent septicemia caused by organisms such as Pseudomonas aeruginosa.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which of the following recommendations? A. The total 24-hour fluid requirement should be administered in the first 8 hours. B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

b. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment, the nurse would expect to find which of the following symptoms? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

b. The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours. *like a sunburn or a scald*

To maintain a positive nitrogen balance in a major burn, the patient must a. increase normal caloric intake by about 3 times b. eat a high-protein, low-fat, high-carbohydrate diet. c. eat at least 1500 calories per day in small, frequent meals. d. eat rice and whole wheat for the chemical effect on nitrogen balance

b. eat a high-protein, low-fat, high-carbohydrate diet. The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. Your priority intervention for wound care is to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times each day.

b. observe the wound for signs of infection during dressing changes Infection is the most serious threat for further tissue injury and possible sepsis

When caring for a patient with an electrical burn injury, the nurse should question a health care provider's order for A. Mannitol 75 gm IV. B. Urine for myoglobulin. C. Lactated Ringer's at 25 ml/hr. D. Sodium bicarbonate 24 mEq every 4 hours.

c. Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at a rate sufficient to maintain urinary output at 75 to 100 ml/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 ml/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

A child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the most appropriate nursing action? a. give a small glass of clear liquid b. give a small glass of a full liquid c. keep the child NPO d. order a pediatric meal tray with extra liquids

c. Until a complete assessment and treatment plan are initiated, the child should be kept NPO. A complication of major burns is paralytic ileus, so until that has been ruled out, oral fluids should not be provided.

A patient is admitted with first- and second-degree burns covering the face, neck, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, the nurse would calculate the extent of these burns as being A. 9%. B. 18%. C. 22.5%. D. 36%.

c. Using the rule of nines, the face and neck together encompass 4.5% of the body area; the right upper arm encompasses 9% of the body area; and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together, the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A nurse is caring for a client with a new donor site that was harvested to treat a burn. The nurse should position the client to: a. allow ventilation of the site b. make the site dependent c. avoid pressure on the site d. keep the site fully covered

c. a universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure.

What is the best method for preventing hypovolemic shock in a client admitted with severe burns? a. administering dopamine b. applying medical antishock trousers c. infusing i.v. fluids d. infusing fresh frozen plasma

c. during the early postburn period, large amounts of plasma fluid extravasates into interstitial spaces. Restoring the fluid loss is necessary to prevent hypovolemic shock; this is best accomplished with crystalloid and colloid solutions.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, the nurse should implement which of the following dietary choices? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

d. A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increases gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

2. A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? A. A halo sign on the nasal drip pad B. Decreased blood pressure and urinary output C. A positive reading for glucose on a Test-tape strip D. Clear nasal drainage along with the bloody discharge

A. When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased blood pressure and urinary output would not be indicative of a CSF leak.

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

A. Avoiding positioning the patient with neck and hip flexion- Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to avoid an error during this procedure? A. Check the identifying information on the unit of blood against the patient's ID bracelet. B. Select new primary IV tubing primed with lactated Ringer's solution to use for the transfusion. C. Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction. D. Add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow.

A. Check the identifying information on the unit of blood against the patient's ID bracelet. The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's solution because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.

For the patient undergoing a craniotomy, the nurse provides information about the use of wigs and hairpieces or other methods to disguise hair loss a. during pre operative teaching b. in the patient asks about their use c. in the immediate postoperative period d. when the patient expresses negative feelings about his or her appearance

A. During pre operative teaching- The prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed pre operatively that the head is usually shaved in surgery while the patient is anesthetized and that methods can be used after the dressings are removed postoperatively to disguise the hair loss. In the immediate postoperative period, the patient is very ill, and the focus is on maintaining neurologic function, bur preoperatively the nurse should anticipate the patient's postoperative need for self-esteem and maintenance of appearance.

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

The nurse receives a physician's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.

A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for a. patency of of airway b. presence of a neck injury c. neurologic status with Glascow Coma Scale d. CSF leakage from ears and nose

A. Patency of airway is the #1 priority with all head injuries

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about (select all that apply.)? A. Strict hand washing B. Daily nasal swabs for culture C. Monitor temperature every hour. D. Daily skin care and oral hygiene E. Encourage eating all foods to increase nutrients. F. Private room with a high-efficiency particulate air (HEPA) filter

A. Strict hand washing D. Daily skin care and oral hygiene F. Private room with a high-efficiency particulate air (HEPA) filter Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora; other people; and uncooked meats, seafood, and eggs; unwashed fruits and vegetables; and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4°F or more, but temperature is not monitored every hour.

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

ANS: 21 To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/minute or 21 drops/minute

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

ANS: 72 mm Hg The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure 2)/3] = intracranial pressure. DIF: Cognitive Level: Application REF: 1452-1453

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg, and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

ANS: 74 Calculate the CPP: (CPP = mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] - diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit B) Decreased prothrombin time (PT) C) Potassium deficit D) Decreased hematocrit

ANS: A Feedback: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, base-bicarbonate deficit, and elevated hematocrit. PT does not typically decrease.

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

ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-year-old receiving IV antibiotics for meningococcal meningitis b. A 25-year-old admitted with a skull fracture and craniotomy the previous day c. A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy d. A 35-year-old with ICP monitoring after a head injury last week

ANS: A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Encourage the use of effective insect repellents during mosquito season. b. Remind patients that most cases of viral encephalitis can be cared for at home. c. Teach about the importance of prophylactic antibiotics after exposure to encephalitis. d. Arrange for screening of school-age children for West Nile virus during the school year.

ANS: A Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall. DIF: Cognitive Level: Apply (application) REF: 1384 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.

ANS: A Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains

ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

ANS: A Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate. DIF: Cognitive Level: Application REF: 1430-1431

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 154/68, pulse 56, respirations 12 b. Blood pressure 134/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. DIF: Cognitive Level: Apply (application) REF: 1360 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual. DIF: Cognitive Level: Application REF: 1431-1433

The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

ANS: A The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally.

ANS: A The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. DIF: Cognitive Level: Apply (application) REF: 1359-1361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

ANS: A This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. ABO blood typing b. Bone marrow biopsy c. Abdominal ultrasound d. Complete blood count (CBC)

ANS: B A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or guardian.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient

A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain. d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.

ANS: B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion. DIF: Cognitive Level: Application REF: 1440

The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin

ANS: B Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

ANS: B Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure. DIF: Cognitive Level: Apply (application) REF: 1367 | 1361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

ANS: B Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] - diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take

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

ANS: B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage. DIF: Cognitive Level: Application REF: 1438-1439

Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

ANS: B Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur. DIF: Cognitive Level: Application REF: 1444

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. b. bilirubin level. c. stool occult blood test. d. gastric analysis testing.

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss

It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours d. Apply cold packs intermittently to face.

ANS: B Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders. DIF: Cognitive Level: Apply (application) REF: 1369 | 1374 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.

ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Refer the family members to the hospital counseling service to deal with their anxiety. d. Call the family's pastor or spiritual advisor to take them to the chapel while care is given.

ANS: B The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety. DIF: Cognitive Level: Apply (application) REF: 1375 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

ANS: B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Apply (application) REF: 1365 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

ANS: B The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 44-year-old with sickle cell anemia who says "my eyes always look sort of yellow" b. 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.

ANS: C Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I a. need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.

ANS: C Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse (RN)-level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness

ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal. DIF: Cognitive Level: Understand (comprehension) REF: 1360 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.

ANS: C Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/mL

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis

Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.

ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP.

ANS: C The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take. DIF: Cognitive Level: Analysis REF: 1426

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation

ANS: C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities.

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.

ANS: D All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

ANS: D Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented. DIF: Cognitive Level: Apply (application) REF: 1382 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood

ANS: D H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)

ANS: D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture. DIF: Cognitive Level: Apply (application) REF: 1369 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours.

ANS: D ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness. DIF: Cognitive Level: Apply (application) REF: 1380 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 88/42 mm Hg.

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Apply (application) REF: 1382 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient who is being discharged after an emergency splenectomy following an automobile accident. Which instructions should the nurse include in the discharge teaching? a. Watch for excess bruising. b. Check for swollen lymph nodes. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.

ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.

Following successful treatment of Hodgkin's lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c. A 40-year-old patient who lost consciousness for a few seconds after a fall d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

ANS: D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation. DIF: Cognitive Level: Analyze (analysis) REF: 1366 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cells (WBCs) 15,500/µL

ANS: D The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

ANS: D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Apply a sterile 2-inch gauze dressing to the site. c. Use a half-inch sterile gauze to pack the wound. d. Have the patient lie on the left side for 1 hour.

ANS: D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head.

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? Administration of packed red blood cells Administration of oral or IV corticosteroids Administration of clotting factors VIII and IX Maintenance of reverse isolation and application of standard precautions

Administration of oral or IV corticosteroids Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

5. The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)? A. Judgment B. Eye opening C. Abstract reasoning D. Best verbal response E. Best motor response F. Cranial nerve function

B,D,E The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

4. The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B. Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

9. Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated ICP causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like which posture represented below? A. A (hands together on chest) B. B (hands turned out at sides) C. C (one hand on chest one turned out at sides) D. D (hands at side with back arched)

B. Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury.

The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? A. 11:45 AM B. 12:00 noon C. 12:30 PM D. 3:30 PM

B. 12:00 noon The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.

Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? A. 5 B. 15 C. 30 D. 60

B. 15 As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11

B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4 Total = 7

Which patient is most likely to experience anemia related to an increased destruction of red blood cells? A. A 59-yr-old man whose alcoholism has precipitated folic acid deficiency B. A 23-yr-old African American man who has a diagnosis of sickle cell disease C. A 30-yr-old woman with a history of "heavy periods" accompanied by anemia D. A 3-yr-old child whose impaired growth and development is attributable to thalassemia

B. A 23-yr-old African American man who has a diagnosis of sickle cell disease A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

Vasogenic cerebral edema increases ICP by a. shifting fluid in gray matter b. altering the endothelial lining of cerebral capillaries c. leaking molecules from the intracellular fluid to the capillaries d. altering the osmotic gradient flow into the intravascular component

B. Altering the endothelial lining of cerebral capillaries

The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate? A. Encourage deep breathing and coughing. B. Assist with or perform phlebotomy at the bedside. C. Teach the patient how to maintain a low-activity lifestyle. D. Perform thorough and regularly scheduled neurologic assessments.

B. Assist with or perform phlebotomy at the bedside. Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.

A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient? A. Plan for 30 minutes of rest before and after every meal. B. Encourage foods high in protein, iron, vitamin C, and folate. C. Instruct the patient to select soft, bland, and nonacidic foods. D. Give the patient a list of medications that inhibit iron absorption.

B. Encourage foods high in protein, iron, vitamin C, and folate. Increased intake of protein, iron, folate, and vitamin C provides nutrients needed for maximum iron absorption and hemoglobin production. The other interventions do not address the patient's identified problem of inadequate intake of essential nutrients. Selection of foods that are soft, bland, and nonacidic is appropriate if the patient has oral mucosal irritation. Scheduled rest is an appropriate intervention if the patient has fatigue related to anemia. Providing information about medications that may inhibit iron absorption (e.g., antacids, tetracycline, soft drinks, tea, coffee, calcium, phosphorus, and magnesium salts) is important but does not address the patient's problem of inadequate intake of essential nutrients.

Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor of the a. ventricles b. frontal lobe c. parietal lobe d. occipital lobe

B. Frontal lobe- frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, and personality changes that are very disturbing and frightening to the family. Physical symptoms, such as blindness, disturbances in sensation and perception, and even seizures, that occur with other tumors are more likely to be understood and accepted by the family

The blood bank notifies the nurse that the two units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? A. Immediately pick up both units of blood from the blood bank. B. Infuse the blood slowly for the first 15 minutes of the transfusion. C. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. D. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

B. Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging 1 unit of blood. Only 1 unit of blood can be picked up at a time, it must be infused within 4 hours, and it cannot be hung with dextrose.

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? A. Confirm the IV solution is 0.9% saline. B. Obtain the vital signs before the transfusion is initiated. C. Monitor the patient for shortness of breath and back pain. D. Double check the patient identity and verify the blood product.

B. Obtain the vital signs before the transfusion is initiated. The RN may delegate tasks such as taking vital signs to UAP. Assessments (e.g., monitoring for signs of a blood transfusion reaction [shortness of breath and back pain]) are within the scope of practice of the RN and may not be delegated to UAP. The RN must also assume responsibility for ensuring the correct IV fluid is used with blood products. A licensed nurse must complete verification of the patient's identity and the blood product data.

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control appropriate behavior b. using diversion techniques to keep the patient stimulated and motivated c. assisting and supporting the family in understanding any changes in behavior d. limiting self care activities until the patient has regained maximal physical functioning e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs.

C, E

12. In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver? A. Seizure disorders may occur in weeks or months. B. The family will be unable to cope with role reversals. C. There are often residual changes in personality and cognition. D. Referrals will be made to eliminate residual deficits from the damage.

C. In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

8. A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. High blood flow to the brain B. Normal intracranial pressure C. Impaired blood flow to the brain D. Adequate autoregulation of blood flow

C. Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.

10. The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient? A. Administer IV mannitol (Osmitrol). B. Ventilator use to hyperoxygenate the patient C. Use strict aseptic technique with dressing changes. D. Be aware of changes in ICP related to leaking CSF.

C. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol (Osmitrol) or hypertonic saline will be administered as ordered. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

The nurse instructs an African American man who has sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement? A. "When I take a vacation, I should not go to the mountains." B. "I should avoid contact with anyone who has a respiratory infection." C. "When my vision is blurred, I will close my eyes and rest for an hour." D. "I may experience severe pain during a crisis and need narcotic analgesics."

C. "When my vision is blurred, I will close my eyes and rest for an hour." Blurred vision should be reported immediately and may indicate a detached retina or retinopathy. Hypoxia (at high altitudes) and infection are common causes of a sickle cell crisis. Severe pain may occur during a sickle cell crisis, and narcotic analgesics are indicated for pain management.

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? A. Lactated Ringer's B. 5% dextrose in water C. 0.9% sodium chloride D. 0.45% sodium chloride

C. 0.9% sodium chloride The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood because they will cause RBC hemolysis.

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse check on first? A. A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL B. A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer C. A 40-yr-old patient with a temperature of 100.8oF (38.2oC) and a neutrophil count of 256/μL D. A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/μL

C. A 40-yr-old patient with a temperature of 100.8oF (38.2oC) and a neutrophil count of 256/μL A low-grade fever greater than 100.4°F (38°C) in a patient with a neutrophil count below 500/μL is a medical emergency and may indicate an infection. An infection in a neutropenic patient could lead to septic shock and possible death if not treated immediately.

Increased ICP in the left cerebral cortex, caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as a. uncal herniation b. tentorial herniation c. cingulate herniation d. temporal lobe herniation

C. Cingulate herniation- the dural structures that separate the two hemispheres and the cerebral hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulated herniation occurs where there is lateral displacement of brain tissue beneath the falx cerebri.

The nurse knows that hemolytic anemia can be caused by which extrinsic factors? A. Trauma or splenic sequestration crisis B. Abnormal hemoglobin or enzyme deficiency C. Macroangiopathic or microangiopathic factors D. Chronic diseases or medications and chemicals

C. Macroangiopathic or microangiopathic factors Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias. Trauma or splenic sequestration crisis can lead to anemia from acute blood loss. Abnormal hemoglobin or enzyme deficiency are intrinsic factors that lead to hereditary hemolytic anemias. Chronic diseases or medications and chemicals can decrease the number of red blood cell (RBC) precursors which reduce RBC production.

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

C. Perform the exercises less frequently because posturing can increase ICP- If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor CNS depressants would be indicated.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

C. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required. There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide that would be beneficial to the patient? A. Take enteric-coated iron with each meal. B. Take cobalamin with green leafy vegetables. C. Take the iron with orange juice one hour before meals. D. Decrease the intake of the antiseizure medications to improve.

C. Take the iron with orange juice one hour before meals. With microcytic, hypochromic anemia may be caused by iron, vitamin B6, or copper deficiency; thalassemia; or lead poisoning. The iron prescribed should be taken with orange juice one hour before meals as it is best absorbed in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help red blood cell (RBC) maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. The health care provider will prescribe changes in medications.

CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by a. assessing for nystagmus b. testing the corneal reflex c. testing pupillary reaction to light d. testing for oculocephalic (doll's eye) reflex

C. Testing pupillary reaction to light- One of the functions of CN III, the oculomotor nerve, is *pupillary constriction*, and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII, and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associatted with specific lesions or chemical toxicities and is not a definitive sign of ICP

The nurse is alerted to possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery b. has focal symptoms of brain damage with no recollection of a head injury c. develops decreased LOC and a headache within 48 hours of head injury d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC

C. develops decreased LOC and a headache within 48 hours of head injury

Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP

D. Absence of signs and symptoms of increased ICP- The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of a. mosquito or tick bites b. chickenpox or measles c. cold sores or fever blisters d. an upper respiratory infection

D. An upper respiratory infection- Meningitis is often a result of an upper respiratory infection or middle ear infection, where organisms gain entry to the CNS. Epidemic encephalitis is transmitted by ticks and mosquitoes, and nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps. Encephalitis caused by the herpes simplex virus carries a high fatality rate

Metabolic and nutritional needs of the patient with increased ICP are best met with a. enteral feedings that are low in sodium b. the simple glucose available in D5W IV solutions c. a fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate

D. Balanced, essential nutrition in a form that the patient can tolerate= A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea has a platelet count of 43,000/µL. It is most important for the nurse to take which action? A. Insert two 18-gauge IV catheters. B. Administer prescribed enoxaparin. C. Monitor the patient's temperature every 2 hours. D. Check stools for presence of frank or occult blood.

D. Check stools for presence of frank or occult blood. A platelet count below 150,000/µL indicates thrombocytopenia. Prolonged bleeding from trauma or injury does not usually occur until the platelet counts are below 50,000/µL. Bleeding precautions (e.g., check all secretions for frank and occult blood) are indicated for patients with thrombocytopenia. Injections (including IVs) should be avoided; however, when needed for critical fluids and medications, IV access should be provided through the smallest bore devices that are feasible. Enoxaparin, an anticoagulant administered subcutaneously, is contraindicated in patients with thrombocytopenia. Monitoring temperature would be indicated in a patient with leukopenia.

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

A patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? A. Brentuximab vedotin (Adcetris) B. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine C. Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine D. BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone

Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine The patient with a favorable prognosis early-stage Hodgkin's lymphoma (stage 1A) will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.Note: Some of acronyms for drug protocols use the brand/trade name of drugs (Adriamycin, Oncovin). These brand/trade names have been discontinued but the drugs are still available as generic drugs.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which of the following assessment findings would alert you to the presence of an inhalation injury (select all that apply)? A.Singed nasal hair B.Generalized pallor C.Painful swallowing D.Burns on the upper extremities E.History of being involved in a large fire

a, c. Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and cherry red skin color

A male burn pt who was struck by lightning arrives at the emergency department with full thickness burns to the arms and chest and with a cervical collar in place. Which assessment finding is the nurse's priority? a. serum K+ of 5.6 mEq/L b. Arterial blood ph of 7.35 c. Cervical spine fracture d. hemoglobin 18g/dL

a. The pt's potassium level puts them at risk for life threatening cardiac dysrhythmias.

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitative phase of burn recovery is: a. applying pressure garments. b. repositioning the pt every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water based moisturizers

a. applying pressure garments. Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

A client is admitted to a burn intensive care unit with extensive full thickness burns. What should be the nurse's initial concern? a. fluid status b. risk for infection c. body image d. level of pain

a. in early burn care, the client's greatest need has to do with fluid resuscitation because of large volume fluid loss through the damaged skin.

The nurse should expect to apply which type of ordered antiseptic to a client with a burn wound, once the area has been cleansed with sterile saline? a. copper containing b. silver containing c. biguanide d. acetic acid

b. silver sulfadiazine is a metallic type of antiseptic that is widely used on burns. The silver in the solution is toxic to bacteria, and prevents them from reproducing.

Knowing the most common causes of household fires, which of the following prevention strategies would the nurse focus on when teaching about fire safety? a. set hot water temp at 140 F b. use only hardwired smoke detectors c. encourage regular home fire exit drills d. never permit older adults to cook unattended.

c.

A client with burn injury asks the nurse what the term full thickness means. The nurse should respond that burns classified as full thickness involve tissue destruction down to which level? a. epidermis b. dermis c. subcutaneous tissue d. internal organs

c. A full thickness burn involves all skin layers, including the epidermis and dermis, and may extend into the subcutaneous tissue and fat.

The adult client was burned as a result of an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? a. 18% b. 24% c. 36% d. 48%

c. anterior head = 4.5%, upper half of anterior torso = 9%, lower half of both arms is 9%, posterior head 4.5%, upper half of posterior torso 9%, total 36%

The condition of a client with extensive third degree burns begins to deteriorate. The nurse is aware that which type of shock may occur as a result of inadequate circulating blood volume that occurs with a burn injury? a. cardiogenic b. distributive c. hypovolemic d. septic

c. burns and the resulting low circulating fluid volume can cause hypovolemic shock.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50, a pulse of 110, and urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following prescriptions? a. transfusing 1 unit of packed red blood cells b. administering a diuretic to increase urine output c. increasing the amount of IV lactated Ringers solution administered per hour d. changing the IV lactated Ringer's solution to one that contains dextrose in water.

c. fluid management during the first 24 hours following a burn injury generally includes the infusion of LR solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30mL/hr. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, should expect ↑ of LR's.

The nurse plans emergent care for four male pt's who have burns covering between 40-50% of the total body surface area. Rank these patients according to their risk for an inhalation injury beginning with the pt who has the highest risk. a. has posterior chemical burns from an exhibit at a parking lot b. has osteoporosis and electrical burns of the lower extremities c. has thermal burns of the right side and is a volunteer fireman d. has chronic bronchitis and thermal burns around the abdomen

d, c, a, b.

A patient has been treated for second- and third-degree burns over 30% of his body and is now ready for discharge. You provide discharge instructions related to wound care. Which statement indicates that the patient understands the instructions? a. "I can expect occasional periods of low grade fever and can take Tylenol every 4 hours" b. "I must wear my jobst elastic garment all day and can only remove it when I'm going to bed." c. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water." d. "If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

d. If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

A victim of an industrial accident has chemical spilled on his face and body. The chemical, which has a pH of 7.51, is flushed with water by paramedics. What is the most important information for the receiving nurse to obtain about the pt from the paramedics? a. containment of chemical b. duration of water flushing c. other injuries of the victim d. specific location of accident

d. The nurse must know where the accident occurred to determine if the pt was rescued from an enclosed space. If so, the pt is at high risk for an inhalation injury because the enclosure concentrates the noxious fumes making an inhalation injury more likely.

The nurse is caring for a client who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury? a. decreased heart rate b. increased urinary output c. increased blood pressure d. elevated hematocrit levels

d. during the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shift.