AH2 Exam 4

A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this assessment finding? 1. inability of the damaged capillaries to maintain fluids in the cell walls 2. reduced vascular permeability at the site of the burned area 3. decreased osmotic pressure in the burned tissue 4. increased fluids in the extracellular compartment 5. the IV fluid being administered too quickly

ANS: 1 Rationale: Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments. Manifestations of fluid volume overload would be systemic, not localized to the burn areas.

A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn? 1. increasing fluid intake 2. applying mild lotions 3. taking mild analgesics 4. maintaining warmth 5. using sunscreen

ANS: 1 Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment measure.

When the nurse is explaining respiratory failure to the patient's family, what is the most accurate description to use? a. The absence of effective ventilation b. Any problem in which part of the airway is obstructed c. An episode of acute hypoxemia caused by a lung problem d. Inadequate gas exchange arising from problems with oxygenation or ventilation

AND: D Acute respiratory failure (ARF) occurs when oxygenation, ventilation, or both are inadequate. It results when the transfer of oxygen or carbon dioxide function in the respiratory system is impaired. The major factor in respiratory failure is inadequate gas exchange. Absence of ventilation is respiratory arrest and partial airway obstruction may not necessarily cause respiratory failure. Acute hypoxemia may be caused by factors other than a lung problem.

What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (select all that apply)? a. Atelectasis b. SOB c. Interstitial and alveolar edema d. Hyaline membranes line the alveoli e. Influx of neutrophils, monocytes, and lymphocytes

ANS: A, C, D The injury or exudative phase is the early phase of ARDS when atelectasis and interstitial and alveolar edema occur. Hyaline membranes composed of necrotic cells, protein, and fibrin line the alveoli. Together, these decrease gas exchange capability and lung compliance. SOB occurs but it is not a physiologic change. The increased inflammation and prliferation of fibroblasts occurs in the reparative or proliferative phase of ARDS, which occurs 1 to 2 weeks after the initial lung injury.

The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when which of the following is assessed? a. Increasing PaO2 b. Decreasing blood pressure c. Decreasing heart rate (HR) d. Increasing central venous pressure (CVP)

ANS: B

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% O2using a nonrebreather mask.

ANS: D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting O2 at 100%. The other actions can be taken after the action to correct gas exchange

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has crackles bilaterally in the lung bases c. A patient with emphysema who has an oxygen saturation of 90% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

ANS: D This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

Which characteristics accurately describe chemical burns (select all that apply)? a. Metabolic asphyxiation may occur. b. Metabolic acidosis occurs immediately following the burn. c. The visible skin injury does not often represent the full extent of tissue damage. d. Lavaging with large amounts of water is important to stop the burning process with these injuries. e. Alkaline substances that cause these burns continue to cause tissue damage even after being neutralized.

ANS: D, E With chemical burns, removing the chemical from the skin is important. Lavaging the skin with water or saline solution for 20 minutes to 2 hours postexposure may be needed. Alkali tends to adhere to skin and causes prolonged damage with protein hydrolysis and liquefaction. Metabolic asphyxiation is from the inhalation of carbon monoxide or hydrogen cyanide. Metabolic acidosis is most common in electrical burns, as is the "iceberg effect" of tissue injury below the skin.

A client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk? A. Hypoventilation B. Hypercapnia C. Respiratory acidosis D. Barotrauma

ANS: D. Rationale: the volume-cycled ventilator has the potential to increase pressure in order to deliver the set volume. barotrauma is a risk associated with this form of mechanical ventilation.

The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A) Manually ventilate the client. B) Put air into the endotracheal tube cuff. C) Check ventilator connections. D) Call the physician.

Answer: C Rationale: Ventilator connections should be check initially and loose connections or disconnections should be fixed. If there is no immediate problem found, the client should be manually ventilated and another person should check the ventilator connections. Test Plan: Management of care

A client has just been intubated for placement of a mechanical ventilator. What is the first assessment of the tube placement? A) Chest X-Ray B) Auscultation of breath sounds C) Pulse oximetry reading of 95% D) End tidal CO2 monitoring

Answer: D- End tidal CO2 monitoring Rationale: End tidal CO2 monitoring is the first intervention to determine if the endotracheal tube is in place, but a chest x-ray is still needed to confirm proper placement.

When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated? 1. decreased hemoglobin and elevated hematocrit levels 2. elevated hemoglobin and elevated hematocrit levels 3. elevated hemoglobin and decreased hematocrit levels 4. decreased hemoglobin and decreased hematocrit levels 5. hemoglobin and hematocrit levels within normal ranges

Correct Answer: 1 Rationale: Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated secondary to hemoconcentration, and fluid shifts from the intravascular compartment.

When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings? 1. These values are normal for the patient's post-burn injury condition. 2. The patient is demonstrating manifestations consistent with the onset of an infection. 3. The patient is demonstrating manifestations consistent with an electrolyte imbalance. 4. The patient is demonstrating manifestations consistent with renal failure. 5. The patient is demonstrating manifestations of fluid volume overload.

Correct Answer: 1 Rationale: The burn-injured patient is not considered tachycardic until the heart rate reaches 120 beats per minute. In the absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a hypermetabolic response.

The client with ARDS is on a mechanical ventilator. Which intervention addressing endotracheal tube (ET) care should be included in the nursing care plan? 1. Alternate the ET from side to side in the mouth. 2. Replace the ET daily. 3. Ensure the ET is deflated. 4. Check the lip line of the ET daily.

ANS: 1 Alternating the ET tube will help prevent a pressure ulcer on the client's tongue and mouth. The ET tube is not replaced daily; the cuff should be inflated no more than 25 cm H2O to ensure there is no air leakage; and the lip line should be checked more often than daily improves compliance, and helps prevent atelectasis. Tridil is a coronary vasodilator. Diuretics and NSAIDs are not routine medications for ARDS

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure(s) would most likely be implemented to maintain cardiac output? 1) Administer crystalloid fluids or colloid solutions. 2) Position the patient in the Trendelenburg position. 3) Place the patient on fluid restriction and administer diuretics. 4) Perform chest physiotherapy and assist with staged coughing.

ANS: 1 Low cardiac output may necessitate crystalloid fluids or colloid solutions in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the intensive care unit nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that ventilator alarms are functioning 3. Assess the client's upper extremity restraints. 4. Monitor the client's ABG results.

ANS: 1 Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is the nurse's first intervention; this machine is now functioning as the client's lungs. Verifying alarms, assessing the client's hands, and monitoring ABGs are appropriate but not before confirming the ventilator settings

A patient receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter. When evaluating the patient's intake and output, which of the following should be taken into consideration? 1. The amount of urine will be reduced in the first 24-48 hours, and will then increase. 2. The amount of urine output will be greatest in the first 24 hours after the burn injury. 3. The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins. 4. The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. 5. The amount of urine is expected to be decreased for three to five days.

ANS: 1 Rationale: The patient will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the patient will enter a period of diuresis. The diuresis begins between 24 and 36 hours after the burn injury.

A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient? 1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal. 2. The wound is a partial-thickness burn, and could take up to two weeks to heal. 3. The wound is a superficial burn, and will take up to three weeks to heal. 4. The wound is a full-thickness burn and will take one to two weeks to heal. 5. Wound healing is individualized.

ANS: 1 Rationale: The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than three weeks to heal. A superficial burn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not answer the patient's question about the severity of the burn.

A 72-year-old woman with aspiration pneumonia develops severe respiratory distress. Which diagnostic finding would indicate to the nurse that the patient has developed acute respiratory distress syndrome (ARDS)? 1) PaO2 of 42 mm Hg on 80% FIO2 2) PaO2 of 64 mm Hg on 24% FIO2 3) PaCO2 of 31 mm Hg and pH 7.51 4) PaCO2 of 70 mm Hg and pH 7.29

ANS: 1 Refractory hypoxemia indicates ARDS. If the PaO2 is 42 mm Hg on 80% FIO2, then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio<200). PaCO2 of 31 mm Hg and pH 7.51 indicates respiratory alkalosis. If PaO2 of 64 mm Hg on 24% FIO2, the PaO2/FIO2 ratio is 267, which indicates an acute lung injury (PaO2/FIO2 ratio between 200 to 300). PaCO2 of 70 mm Hg and pH 7.29 indicates respiratory acidosis. (FIO2, Fraction of inspired oxygen,)

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS. 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95% 4. The client has jugular vein distention and frothy sputum.

ANS: 1 The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.

The health-care provider ordered STAT ABGs for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92%, paCO2 38, HCO3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

ANS: 1 These ABGs are within normal limits, and therefore, the nurse should not take any action except to continue to monitor the client.

The HCP ordered stat ABGs for the client suspected of having ARDS. The ABG results are pH 7.42, PaO2 84, PaCO2 41, HCO3 23. Which action should the nurse implement? 1. Administer oxygen via nasal cannula to the client. 2. Encourage the client to take deep breaths and cough. 3. Administer 1 amp of intravenous sodium bicarbonate. 4. Notify the respiratory therapist of the ABG results.

ANS: 1 These ABGs are within normal limits, but the oxygen level is low, possibly secondary to ARDS. Because the client is suspected of having ARDS, administering oxygen will either increase the oxygen level or help confirm ARDS. If the oxygen level continues to decrease even with supplemental oxygen, the client is developing ARDS.

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

ANS: 1 When peak airway pressure is increased, teh nurse should implement the intervention least invasive for the client. This alarm goes off with a plugged airway, "bucking" in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.

A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury? 1. major 2. moderate 3. minor 4. superficial 5. intermediate

ANS: 1 Rationale 1: Partial-thickness injuries of greater than 25% of total body surface area in adults and full-thickness injuries 10% or greater of TBSA are considered major burns.

A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following? Select all that apply. 1. a superficial partial-thickness burn 2. a thermal burn 3. a superficial burn 4. a deep partial-thickness burn 5. a full-thickness burn

ANS: 1 and 2 Rationale: Superficial partial-thickness burn if often bright red, has a moist, glistening appearance and blister formation. Thermal burns result from exposure to dry or moist heat. A superficial burn is reddened with possible slight edema over the area. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or non-blanching red with a dry, leathery, firm wound surface.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

ANS: 3 Assessment is the first part of the nursing process and is the first intervention the nurse should implement when care for a client on a ventilator.

A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions? (Select all that apply) 1. Report any fever to your healthcare provider. 2. Report development of purulent drainage to your healthcare provider. 3. Use only sterile dressings on the fingers. 4. Cleanse the areas every hour with alcohol to prevent infection. 5. Apply the topical antimicrobial agent as instructed.

ANS: 1, 2, and 3 Rationale: Fever or purulent drainage are indicative of development of infection and should be reported to the healthcare provider. Sterile dressings only should be used on the areas of the superficial partial-thickness burns where the skin is not intact. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection of the areas.

A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask in determining the possible severity of the burn injury? Select all that apply. 1. What type of current was involved? 2. How long was the patient in contact with the current? 3. How much voltage was involved? 4. Where was the patient when the burn occurred? 5. What was the point of contact with the current?

ANS: 1,2,3 Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity.

The nurse is caring for the client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor the client's urine output. 3. Perform passive range-of-motion (ROM) exercises. 4. Maintain intravenous fluids as ordered. 5. Place the client with the HOB flat.

ANS: 1,2,3,4 Altered level of conscious- ness is the earliest sign of hypoxemia; urine output less than 30 mL/hr indicates decreased cardiac output; the client is at risk for complications of immobility and fluid volume overload. The semi-Fowler position, not the supine position, facilitates lung expansion and reduces the workload of breathing

The client diagnosed with respiratory distress has arterial blood gases of pH 7.45; PaCO2 54; HCO3 25; PaO2 52. Which should the nurse implement? Select all that apply. 1. Apply oxygen via nonrebreather mask. 2. Call the rapid response team (RRT). 3. Elevate HOB 4. Stay with the client. 5. Notify the HCP.

ANS: 1,2,3,4,5 The PaO2 level is very low; this client should be placed on a ventilator. The nurse should provide as much oxygen as possible until this can be done. The RRT is called when an individual identifies as situation that requires immediate intervention to prevent the client from going into an arrest situation. Elevating the HOB allows for better lung expanision. The nurse should not leave the client but should direct care from the bedside. The HCP should be notified of the client's status.

Which medication should the nurse anticipate the HCP prescribing for the client diagnosed with ARDS? 1. An intravenous Tridil (nitroglycerin) drip. 2. A synthetic surfactant. 3. An intravenous loop-diuretic. 4. A nonsteroidal anti-inflammatory drug (NSAID).

ANS: 2 Surfactant therapy may be pre- scribed to reduce the surface tension of the alveoli. This medication helps maintain open alveoli, decreases the work of breathing,

When caring for the patient with ARDS, the critical care nurse knows that therapy is appropriate for the patient when which goal is being met? 1) pH is 7.32. 2) PaO2 is greater than or equal to 60 mm Hg. 3) PEEP increased to 20 cm H2O caused BP to fall to 80/40. 4) No change in PaO2 when patient is turned from supine to prone position

ANS: 2 The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.

ANS: 2 Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids 2. Assess for airway patency 3. Administer oxygen as prescribed 4. Place a cooling blanket on the client 5. Elevate extremities if no fractures are present 6. Prepare to give oral pain medication as prescribed

ANS: 2,3,5 The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO status because of the altered gastrointestinal function that occurs as a result of a burn injury.

A patient has the following mixed deep partial-thickness and full-thickness burn injuries: face, anterior neck,right anterior trunk, and anterior surfaces of the right arm and lower leg. According to the rule of nines chart, what is the extent of the patient's burns?

ANS: 22.5%

Which assessment data would indicate the client diagnosed with ARDS is experiencing a complication secondary to the ventilator? 1. The client's urine output is 210 mL in 8 hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

ANS: 3 Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of ventilation. A urine output less than 30 mL/hr indicates renal failure, but it is not secondary to the ventilator. Sinus tachycardia is not secondary to the ventilator.

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100mL in four hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

ANS: 3 Asymmetrical chest expansion indicates the client has had a pneumothorax, whichis a complication of mechanical ventilation.

The client diagnosed with ARDS is on a ventilator, and the high alarm is going off. The client is having respiratory difficulty, and the nurse cannot determine the cause of the problem. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Auscultate the client's lung sounds. 3. Ventilate with a manual resuscitation bag. 4. Check the client's pulse oximeter reading.

ANS: 3 If the ventilator system malfunc- tions, the nurse must ventilate the client with a manual resuscitation bag (Ambu) until the problem is resolved. Remember "when in distress, do not assess." Assessing the lungs and pulse oximeter reading will not help the client's respiratory distress.

Arterial blood gas results are reported to the nurse for a 68-year-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order from a physician should the nurse prioritize? 1) Increase fluid intake to 2500 mL per 24 hours. 2) Instruct the patient to breathe into a paper bag. 3) Initiate oxygen at 2 L/min by nasal cannula. 4) Perform chest physical therapy four times per day.

ANS: 3 The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Breathing into a paper bag is indicated for hyperventilation to correct respiratory alkalosis. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.

The client who smokes two packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. :Smoking has caused your lungs to become weakened, so you got ARDS."

ANS: 3 The average lay person will not know what "alveoli" are. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble breathing.

The client whose husband has ARDS asks the nurse, "What is happening to my husband? Why did he get this?" Which statement by the nurse is most appropriate? 1. "No one really knows why your husband developed ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your husband's lungs are filling up with fluid, causing breathing problems." 4. "You are concerned about what is happening to your husband."

ANS: 3 This is a very basic explanation of ARDS and explains why the client is having trouble breathing. It is the nurse's best response. The nurse should provide information in simple terms. The layperson may not know terms such as platelets, alveoli, and permeability. The cause of ARDS is unknown, but the wife does not need to know this. The spouse is asking for information, so a therapeutic response (option 4) is not appropriate.

The nurse is admitting a 45-year-old asthmatic patient in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding most likely suggest to the nurse? 1) Spontaneous resolution of the acute asthma attack 2) An acute development of bilateral pleural effusions 3) Airway constriction requiring intensive interventions 4) Overworked intercostal muscles resulting in poor air exchange

ANS: 3 When the patient in respiratory distress has inspiratory wheezing, and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore the airway. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress.

The nurse is caring for a 37-year-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? 1) Observe stools for frank bleeding and occult blood. 2) Maintain head of the bed elevation at 30 to 45 degrees. 3) Begin enteral feedings as soon as bowel sounds are present. 4) Administer prescribed lorazepam (Ativan) to reduce anxiety.

ANS: 3 Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

When the nurse is explaining treatment to the families, for which patient would NIPPV be an appropriate intervention to promote oxygenation? 1) A patient whose cardiac output and blood pressure are unstable 2) A patient whose respiratory failure is due to a head injury with loss of consciousness 3) A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions 4) A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis

ANS: 4 NIPPV is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.

A 56-year-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/minute and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse to question? 1) Initiate a dobutamine (Dobutrex) infusion at 3 mcg/kg/minute 2) Administer one unit of packed red blood cells over the next 2 hours. 3) Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr. 4) Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.

ANS: 4 Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, administering crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the ET care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.

ANS: 4 The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one inch over the bifurcation of the bronchi. Alternating ET position will help prevent a pressure ulcer on the pt's tongue and mouth. A CXR is done immediately after insertion, but not daily. The cuff should be checked q 4 to 8 hrs, not daily.

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? properly. 1. The client has dyspnea and tachycardia and is feeling anxious. 2. The client respiratory rate is 26, and he has cyanotic buccal mucosa. 3. The client's arterial blood gases are pH 7.38,PaO2 90, PaCO2 44, HCO3 24 4. The client's pulse oximeter is 90% after 15 minutes of 10 L of oxygen.

ANS: 4 The classic sign of ARDS is decreased arterial oxygen level (PaO2) while high levels of oxygen are being administered; the oxygen is unable to cross the alveolar membrane. Dyspnea, tachycardia, anxiety, tachypnea, and cyanosis are also signs of ARDS. The ABGs are within normal limits.

The client with full-thickness burns to 40% of this body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Ensure adequate peripheral circulation to both feet.

ANS: 4 The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes.

The nurse is assessing a client with multiple trauma who is at risk for developing ARDS. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

ANS: 4 The earliest detectable sign of ARDS is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

The UAP is bathing the client diagnosed with adult respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the up position. Which action should the nurse implement? 1. Demonstrate the correct technique when giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

ANS: 4 The opposite side rail should be elevated so the client will not fall out of the bed. Because the UAP is ensuring the client's safety, the nurse should acknowledge the UAP's performance with praise.

When mechanical ventilation is used for the patient with ARDS, what is the rationale for applying positive end-expiratory pressure (PEEP)? a. Prevent alveolar collapse and open up collapsed alveoli b. Permit smaller tidal volumes with permissive hypercapnia c. Promote complete emptying of the lungs during exhalation d. Permit extracorporeal oxygenation and carbon dioxide removal outside the body

ANS: A

The patient progressed from acute lung injury to acute respiratory distress syndrome (ARDS). He is on the ventilator and receiving propofol for sedation and fentanyl to decrease anxiety, agitation, and pain to decrease his work of breathing, O2 consumption, carbon dioxide production, and risk of injury. What intervention may be recommended in caring for this patient? a. A sedation holiday b. Monitoring for hypermetabolism c. Keeping his legs still to avoid dislodging the airway d. Repositioning him every 4 hours to decrease agitaiton

ANS: A A sedation holiday is needed to assess the patient's condition and readiness to extubate. A hypermetabolic state occurs with critical illness. Enteral or parenteral nutrition is started within 24 to 48 hours. With these medications, the patient will be assessed for cardiopulmonary depression. Venous thromboembolism prophylaxis will be used, but there is no reason to keep the legs still. Repositioning the patient every 2 hours may help decrease discomfort and agitation.

During the rehabilitation phase of a burn injury, what can control the contour of the scarring? a. Pressure garments b. Avoidance of sunlight c. Splinting joints in extension d. Application of emollient lotions

ANS: A After wound healing, pressure garments help to keep scars flat and prevent elevation and enlargement above the original burn injury area. Avoidance of sunlight is necessary for at least 3 months to prevent hyperpigmentation and sunburn injury to healed burn areas. Water-based lotions and splinting are used to prevent contractures.

What is the initial cause of hypovolemia during the emergent phase of burn injury? a. Increased capillary permeability b. Loss of sodium to the interstitium c. Decreased vascular oncotic pressure d. Fluid loss from denuded skin surfaces

ANS: A Although all of the selections add to the hypovolemia that occurs in the emergent burn phase, the initial and most pronounced effect is caused by fluid shifts out of the blood vessels as a result of increased capillary permeability.

The best patient response to treatment of ARDS occurs when initial management includes what? a. Treatment of the underlying condition b. Administration of prophylactic antibiotics c. Treatment with diuretics and mild fluid restriction d. Endotracheal intubation and mechanical ventilation

ANS: A Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction, and mechanical ventilation are used as ARDS progresses.

When assessing a patient's full-thickness burn injury during the emergent phase, what would the nurse expect to find? a. Leathery, dry, hard skin b. Red, fluid-filled vesicles c. Massive edema at the injury site d. Serous exudate on a shiny, dark brown wound

ANS: A Dry, waxy, white leathery, or hard skin is characteristic of full-thickness burns in the emergent phase, and it may turn brown and dry in the acute phase. Deep partial-thickness burns in the emergent phase are red and shiny and have blisters. Edema may not be as extensive in full-thickness burns because of thrombosed vessels.

The nurse initially suspects the possibility of sepsis in the burn patient based on which change? a. Vital signs b. Urinary output c. Gastrointestinal function d. Burn wound appearance

ANS: A Early signs of sepsis include an elevated temperature and increased pulse and respiratory rate accompanied by decreased blood pressure and, later, decreased urine output and perhaps paralytic ileus. A burn wound may become locally infected without causing sepsis.

After endotracheal intubation and mechanical ventilation have been started, a patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is most important for the nurse to do first? a. Evaluate the patient's pain level, ABGs, and electrolyte values. b. Sedate the patient to unconsciousness to eliminate patient awareness. c. Give as-needed vecuronium to promote synchoronous ventilations. d. Slow the ventilator's rate of ventilations to allow for the patient to spontaneously breathe.

ANS: A It is most important to assess the patient for the cause of the restlessness and agitation (e.g. pain, hypoxemia, electrolyte imbalances) and treat the underlying cause before sedating the patient. Although sedation, analgesia, and neuromuscular blockade are often used to control agitation and pain, these treatments may contribute to prolonged ventilator support and hospital stays.

The burn patient has developed an increasing dread of painful dressing changes. What would be the most appropriate treatment to ask the health care provider to prescribe? a. Midazolam to be used with morphine before dressing changes b. Morphine in a dosage range so that more may be given before dressing changes c. Buprenorphine (Buprenex) to be administered with morphine before dressing changes d. Patient-controlled analgesia so that the patient may have control of analgesic administration

ANS: A Midazolam is useful when patients' anticipation of the pain experience increases their pain because it causes a short-term memory loss and, if given before a dressing change, the patient will not recall the event. A dosage range of morphine is useful, as is patient-controlled analgesia, but seldom will these doses effectively relieve the discomfort of dressing changes. Buprenorphine is an opioid agonist/antagonist and cannot be used with other opioids.

A patient with deep partial-thickness burns over 45% of his trunk and legs is going for debridement in the cart shower 48 hours post- burn. What is the drug of choice to control the patient's pain during this activity? a. IV morphine b. Midazolam c. IM meperidine (Demerol) d. Long-acting oral morphine

ANS: A Morphine is the drug of choice for pain control, and during the emergent phase it should be administered IV because GI function is impaired and IM injections will not be absorbed adequately. Amnesia from midazolam is not needed for pain control.

To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

ANS: A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both. Cognitive Level: Comprehension Text Reference: p. 1805Nursing Process: Assessment NCLEX: Physiological Integrity

Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia, rate 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

ANS: A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP.

2. The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has a. chest trauma and multiple rib fractures. b. carbon monoxide poisoning after a house fire. c. left-sided ventricular failure and acute pulmonary edema. d. tachypnea and acute respiratory distress syndrome (ARDS).

ANS: A Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning, acute pulmonary edema, and ARDS are more commonly associated with hypoxemia. Cognitive Level: Application Text Reference: p. 1800Nursing Process: Assessment NCLEX: Physiological Integrity

In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit? a. Refractory hypoxemia b. Bronchial breath sounds c. Progressive hypercapnia d. Increased pulmonary artery wedge pressure (PAWP)

ANS: A Refractory hypoxemia is a hallmark of ARDS and is always present. Bronchial breath sounds may be associated with the progression of ARDS. PaCO2 levels may be normal until the patient is no longer able to compensate in response to the hypoxemia. Pulmonary artery wedge pressure (PAWP) that is normally increased in cardiogenic pulmonary edema is normal in the pulmonary edema of ARDS.

During the early emergent phase of burn injury, the patient's laboratory results would most likely include a. ↑ Hct, ↓ serum albumin, ↓ serum Na, ↑ serum K. b. ↓ Hct, ↓ serum albumin, ↓ serum Na, ↓ serum K. c.↓ Hct, ↑ serum albumin, ↑ serum Na, ↑ serum K. d.↑ Hct, ↑ serum albumin, ↓ serum Na, ↓ serum K.

ANS: A With increased capillary permeability, water, sodium, and plasma proteins leave the plasma and move into the interstitial spaces, decreasing serum sodium and albumin. Serum potassium is elevated because injured cells and hemolyzed red blood cells release potassium from cells. An elevated hematocrit is caused by water loss into the interstitium, creating a hemoconcentration.

A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patient's chance for survival is poor. b. inform the family that home health nurses will be able to help them maintain the mechanical ventilation at home after patient discharge. c. refer the family to social support services and case management to plan for transfer of the patient to a long-term care facility.. d. provide hope and encouragement to the family because the patient's disease process has started to resolve.

ANS: A Rationale: The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process.

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. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

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.

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

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 the face was exposed). Flush the chemical from the 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.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degrees. b. Give enteral feedings at no more than 10 mL/hr. c. Suction the endotracheal tube every 2 to 4 hours. d. Limit the use of positive end-expiratory pressure.

ANS: A Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving? a. gentamicin 60 mg IV b. pantoprazole (Protonix) 40 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 60 mg IV

ANS: A Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other drugs are appropriate for the patient with ARDS.

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

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. O2 saturation of 99% b. Heart rate 106 beats/minute c. Crackles audible at lung bases d. Respiratory rate 22 breaths/minute

ANS: A The FIO2 of 80% increases the risk for O2 toxicity. Because the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not be the most important data to report to the health care provider.

A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The stroke volume is increased. c. The heart rate is 58 beats/minute. d. The stroke volume variation is 12%.

ANS: A The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation.

A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion.

ANS: A The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient's anxiety.

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Red-brown drainage from nasogastric tube b. Blood urea nitrogen (BUN) level 32 mg/dL c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

ANS: A The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.

When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.

ANS: A The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

Patients with acute respiratory failure will have drug therapy to meet their individual needs. Which drugs meet the goal of reducing pulmonary congestion (select all that apply)? a. Morphine b. Ceftriaxone c. Nitroglycerin d. Furosemide e. Albuterol f. Methylprednisolone

ANS: A, C, D Morphine and nitroglycerin will decrease pulmonary congestion caused by heart failure; IV diuretics are also used. Ceftriaxone and azithromycin are used to treat pulmonary infections. Inhaled albuterol or metaproterenol sulfate will relieve bronchospasms. Methylprednisolone will reduce airway inflammation. Morphine is also used to decrease anxiety, agitation, and pain.

What are strategies to prevent Ventilator-associated Pneumonia? (select all that apply) A. Oral care every 4 hours B. HOB elevated 30-45 degrees unless contraindicated by the patient's condition C. HOB elevated 10-15 degrees, unless contraindicated by the patient's condition D. Allow family to suction patient as needed to remove secretions

ANS: A,B A. Oral care Q4h B. HOB elevated 30-45 degrees unless contraindicated by patients condition.

A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation? A. Delivers a set volume, which will help overcome the client's airway resistance changes. B. The mechanism by which the phase of the breath switches from inspiration to expiration. C. Provides a consistent tidal volume. D. Delivers a preset volume of gas to the lungs to generate high pressures.

ANS: A. Rationale: Volume- cycled ventilation delivers a preset volume of gas to the lungs, making volume constant therefore, overcoming the changes in lung compliance and airway resistance.

The nurse assesses that bowel sounds are absent and abdominal distention is present in a patient 12 hours post-burn. The nurse notifies the health care provider and anticipates doing what action next? a. Withhold all oral intake except water. b. Insert a nasogastric tube for decompression. c. Administer a H2 -histamine blocker such as ranitidine (Zantac). d. Administer nutritional supplements through a feeding tube placed in the duodenum.

ANS: B The patient with large burns often develops paralytic ileus within a few hours, and a nasogastric tube is inserted and connected to low, intermittent suction. After GI function returns, feeding tubes may be used for nutritional supplementation, and H2 histamine blockers may be used to prevent Curling's ulcers. Free water is not given to drink because of the potential for water intoxication.

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

ANS: B 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. WBCs may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning.

Which type of burn injury would cause myoglobinuria, long bone fractures, dysrhythmias, and/or cardiac arrest? a. Thermal b. Electrical c. Chemical d. Smoke and inhalation

ANS: B An electrical injury causes tissue damage from intense heat generated by the electrical current passing through tissue, including muscle contractions that can fracture long bones and vertebrae. Myoglobin is released into the circulation when massive muscle damage occurs. The electric shock can even cause cardiac standstill or dysrhythmias as well as delayed dysrhythmias during the first 24 hours after injury.

Which findings would lead the nurse to suspect the early stage of ARDS in a seriously ill patient? a. Develops respiratory acidosis b. Exhibits dyspnea and restlessness c. Has diffuse crackles and wheezing d. Has a decresed PaO2 and increased PaCO2

ANS: B Early signs of ARDS are insidious and difficult to detect, but the nurse should be alert for any early signs of hypoxemia, such as dyspnea, tachypnea, cough, and restlessness in patients at risk for ARDS. Later, tachycardia, diaphoresis, mental status changes, cyanoisis, and pallor may be present. Abnormal findings on physical examination or diagnostic studies, such as worsened lung sounds and respiratory distress, respiratory alkalosis, or decreasing PaO2, are usually indications that ARDS has progressed beyond the initial stages.

A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min.

ANS: B Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain. Cognitive Level: Application Text Reference: p. 1806Nursing Process: Assessment NCLEX: Physiological Integrity

What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body? a. Fever b. Shivering c. Severe pain d. Unconsciousness

ANS: B Shivering often occurs in a patient with a burn as a result of chilling that is caused by heat loss, anxiety, or pain. Fever is a sign of infection in later burn phases. Severe pain is not common in full-thickness burns, nor is unconsciousness unless other factors are present.

The patient was admitted to the burn center with a full-thickness burn 42 hours after the thermal burn occurred. The nurse will apply actions related to which phase of burn management for this patient's care? a. Acute b. Emergent c. Postacute d. Rehabilitative

ANS: B The emergent phase usually lasts up to 72 hours after the time the burn occurred and focuses on fluid resuscitation. The acute phase is after the emergent phase and may last weeks to months after the burn occurred but begins when the extracellular fluid is mobilized and diuresis occurs. There is no postacute phase. The rehabilitative phase begins weeks to months after the injury, when the wounds have healed and the patient participates in self-care.

A burn patient has a nursing diagnosis of impaired physical mobility related to a limited range of motion (ROM) resulting from pain. What is the best nursing intervention for this patient? a. Have the patient perform ROM exercises when pain is not present. b. Provide analgesic medications before physical activity and exercise. c. Teach the patient the importance of exercise to prevent contractures. d. Arrange for the physical therapist to encourage exercise during hydrotherapy.

ANS: B The limited ROM in this situation is related to the patient's inability or reluctance to exercise the joints because of pain and the appropriate intervention is to help control the pain so that exercises can be performed. The patient is probably never without some pain. Teaching about prevention of contractures with exercise and enlisting the help of the physical therapist are important, but neither of these interventions addresses the cause.

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.

Which patient manifestations confirm the development of MODS? a. Upper GI bleeding, GCS score of 7, and Hct of 25% b. Elevated serum bilrubin, serum creatinine of 3.8 mg/dL, and platelet count of 15,000/uL c. Urine output of 30 mL/hr, BUN of 45 mg/dL, and WBC of 1120/uL d. Respiratory rate of 45 breaths/min, PaCO2 of 60 mm Hg, and chest x-ray with bilateral diffuse patch infiltrates.

ANS: B The presense of MODS is confirmed when there is defined clinical evidence of failure of 2 or more organs. Elevated serum bilirubin indicates liver dysfunction, a serum creatinine of 3.8 mg indicates kidney injury, and a platelet count of 15,000 indicates hematologic failure. Other criteria include urine output <0.5 mL/kg/hr, BUN > 100 mg/dL, upper or lower GI bleeding, GCS < 6, and Hct <20%. A respiratory rate of 45 bpm, PaCO2 of 60 mm Hg, and CXR with bilateral diffuse patchy infiltrates indicate respiratory failure, but no other organ damage.

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.

ANS: B The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced.

A patient with ARDS has a nursing diagnosis of risk for infection. To detect the presence of infections commonly associated with ARDS, what should the nurse monitor? a. Gastric aspirate for pH and blood b. Quality, quantity, and consistency of sputum c. Subcutaneous emphysema of the face, neck, and chest d. Mucous membranes of the oral cavity for open lesions

ANS: B Ventilator-associated pneumonia (VAP) is one of the most common complications of ARDS. Early detection requires frequent monitoring of sputum smears and cultures and assessment of the quality, quantity, and consistency of sputum. Prevention of VAP is done with strict infection control measures and ventilator bundle protocol. Blood in gastric aspirate may show a stress ulcer and subcutaneous emphysema of the face, neck, and chest occurs with barotrauma during mechanical ventilation. Oral infections may result from prophylactic antibiotics and impaired host defenses but are not common.

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. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

ANS: B Enteral feedings can usually be started 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 unless the gastrointestinal tract is not available for use.

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 first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

ANS: B The decrease in pulse and numbness 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.

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 or rolled towel because the head should be maintained in an extended position in order to avoid contractures.

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

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 dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

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

ANS: B After an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor. Assessing the oral temperature and pain is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important, but it will take time before the laboratory results are back. The first intervention is to place the patient on a heart monitor and assess for dysrhythmias so that they can be monitored and treated if necessary.

A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O2 saturation above 93%.

ANS: B Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? a. "PEEP will push more air into the lungs during inhalation." b. "PEEP prevents the lung air sacs from collapsing during exhalation." c. "PEEP will prevent lung damage while the patient is on the ventilator." d. "PEEP allows the breathing machine to deliver 100% O2 to the lungs."

ANS: B By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes the connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours.

ANS: B The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia and are not indicated routinely.

How is the immune system altered in a burn injury? a. Bone marrow stimulation b. Increase in immunoglobulin levels c. Impaired function of white blood cells (WBCs) d. Overwhelmed by microorganisms entering denuded tissue

ANS: C Burn injury causes widespread impairment of the immune system, with impaired white blood cell functioning, bone marrow depression, and a decrease in circulating immunoglobulins, which allows microorganisms to grow.

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

ANS: B 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 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase.

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

ANS: B This patient has evidence of lower airway injury and hypoxemia, and should be assessed immediately to determine the need for O2 or intubation (or both). The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

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. "Why do you feel that way? It will get better as your recovery progresses." d. "It is really too early to know how much your life will be changed by the burn."

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.

Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.

ANS: B, C, D, E All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)? a. Referred to as ventilatory failure b. Main problem is inadequate O2 transfer c. Risk of inadequate O2 saturation of hemoglobin exists d. Body is unable to compensate for acidemia of increased partial pressure of carbon dioxide in arterial blood (PaCO2) e. Most often caused by ventilation-perfusion (V/Q) mismatch and shunt f. Exists when partial pressure of oxygen in arterial blood (PaO2) is less than 60 mm Hg, even when O2 is given at 60% or more

ANS: B, C, E, F The main problem in hypoxemic respiratory failure is inadequate oxygen transfer. There is a risk of inadequate oxygen saturation of hemoglobin. It is often caused by ventilation-perfusion (V/Q) mismatch and shunt. It exists when the partial pressure of oxygen in arterial blood in 60 mm Hg or less, even though oxygen is given at 60% or more. Ventilatory failure is hypercapnic respiratory results from an imbalance between ventilatory supply and ventilatory demand and the body is unable to compensate for the acidemia of increased partial pressure of carbon dioxide in arterial blood.

Identify the factors that increase nutritional needs of the patient during the emergent and acute phases of burn injury (select all that apply). a. Electrolyte imbalance b. Core temperature elevation c. Calories and protein used for tissue repair d. Hypometabolic state secondary to decreased gastrointestinal function e. Massive catabolism characterized by protein breakdown and increased gluconeogenesis

ANS: B,C,E There is a hypermetabolic state proportional to the size of the burn, which increases the core temperature. Massive catabolism can occur and leads to malnutrition and delayed healing without adequate calorie and protein supplementation. The electrolyte imbalance has more effect on the fluid resuscitation than the nutritional needs.

A patient's deep partial-thickness facial burns are treated with the open method. What should the nurse do when caring for the patient? a. Ensure that sterile water is used in the debridement tank. b. Wear a cap, mask, gown, and gloves during patient contact. c. Use sterile gloves to remove the dressings and wash the wounds. d. Apply topical antimicrobial ointment with clean gloves to prevent wound trauma.

ANS: B. When the patient's wounds are exposed with the open method, the staff must wear caps, masks, gowns, and gloves. Sterile water is not necessary in the debridement tank. If dressings are used with the open method, they are removed and wounds are washed with clean gloves. Topical antiinfective agents should be applied with sterile gloves to prevent infection.

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 drug? a. Bowel sounds b. Stool frequency c. Stool occult blood d. Abdominal distention

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

At the end of the emergent phase and the initial acute phase of burn injury, a patient has a serum sodium level of 152 mEq/L (152 mmol/L) and a serum potassium level of 2.8 mEq/L (2.8 mmol/L). What could have caused these imbalances? a. Free oral water intake b. Prolonged hydrotherapy c. Mobilization of fluid and electrolytes in the acute phase d. Excessive fluid replacement with dextrose in water without potassium supplementation

ANS: C At the end of the emergent phase, fluid mobilization moves potassium back into the cells and sodium returns to the vascular space, causing hypokalemia and hypernatremia. As diuresis in the acute phase continues, sodium will be lost in the urine and potassium will continue to be low unless it is replaced. Free oral water intake and prolonged hydrotherapy can cause a decrease in both sodium and potassium. Excessive fluid replacement with 5% dextrose in water without potassium supplementation can cause hyponatremia with hypokalemia.

In patients with ARDS who survive the acute phase of lung injury, what manifestations are seen when they progress to the fibrotic phase? a. Chronic pulmonary edema and atelectasis b. Resolution of edema and healing of lung tissue c. Continued hypoxemia because of diffusion limitation d. Increased lung complince caused by the breakdown of fibrotic tissue

ANS: C In the fibrotic phase of ARDS, diffuse scarring and fibrosis of the lungs occur, resulting in decreased surface area for gas exchange and continued hypoxemia caused by diffusion limitation. Although edema is resolved, lung compliance is decreased because of interstitial fibrosis. Long-term mechanical ventilation is needed. The patient has a poor prognosis for survival.

How should the nurse position the patient with ear, face, and neck burns? a. Prone b. On the side c. Without pillows d. With extra padding around the head

ANS: C Patients with ear burns are not allowed to use pillows because of the danger of the burned ear sticking to the pillowcase, and patients with neck burns are not allowed to use pillows because contractures of the neck can occur.

Which burn patient should have orotracheal or endotracheal intubation? a. Carbon monoxide poisoning b. Electrical burns causing cardiac dysrhythmias c. Thermal burn injuries to the face, neck, or airway d. Respiratory distress from eschar formation around the chest

ANS: C Patients with major injuries involving burns to the face and neck require intubation within 1 to 2 hours after burn injury to prevent the need for emergency tracheostomy, which is done if symptoms of upper respiratory obstruction occur. Carbon monoxide poisoning is treated with 100% oxygen and eschar constriction of the chest is treated with an escharotomy.

When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. "The infection spread through the circulation from the urinary tract to the lungs." b. "The urinary tract infection produced toxins that damaged the lungs." c. "The infection caused generalized inflammation that damaged the lungs." d. "The fever associated with the infection led to scar tissue formation in the lungs."

ANS: C Rationale: The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever. Cognitive Level: Application Text Reference: p. 1813 Nursing Process: Implementation NCLEX: Physiological Integrity

A 24-yr-old female patient does not want the wound cleansing and dressing change to take place. She asks, "What difference will it make anyway?" What will the nurse encourage the patient to do? a. Have the wound cleaned and the dressing changed. b. Have a snack before having the treatments completed. c. Talk about what is troubling her with the nurse and/or her family. d. Call the chaplain to come and talk to her and convince her to have the care.

ANS: C There is a tremendous psychologic impact with a burn injury. Open communication with caregivers, close friends, and the burn team about fears regarding loss of life as she once knew it, loss of function, temporary or permanent deformity and disfigurement, return to routine life, financial burdens, rehabilitation, and her future are all essential. Simply convincing her to have the wound cared for ignores her psychologic, emotional, and perhaps spiritual needs.

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? A.) The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air B.) The nurse places soiled bed linens and hospital gowns on the floor when making the bed C.) The nurse moves the patient table away from the nurse's body when wiping it off after a meal D.) The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

ANS: C The nurse moves the patient table away from the nurse's body when wiping it off after a meal. According to the principles of medical asepsis, the nurse should move equipment away from the body when brushing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas.

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 high-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 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 assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

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 of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching for a blood transfusion.

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

ANS: C 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.

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. 219 mL/hr b. 625 mL/hr c. 938 mL/hr d. 1875 mL/hr

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.

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 patient who has twice-daily burn debridements to partial-thickness facial burns b. A patient who has just returned from having a cultured epithelial autograft to the chest c. A patient who has a weight loss of 15% from admission and will have enteral feedings started d. A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

ANS: C 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.

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding? a. Reposition the patient every 1 to 2 hours. b. Increase suctioning frequency to every hour. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.

ANS: C Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

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

ANS: C 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.

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 of 53% b. Serum sodium of 147 mEq/L c. Serum potassium of 6.1 mEq/L d. Blood urea nitrogen of 37 mg/dL

ANS: C Hyperkalemia can lead to life-threatening 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.

A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patient's heart rate is 97 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 450 mL.

ANS: C Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range.

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient was last suctioned 6 hours ago. b. The patient's oxygen saturation drops to 93%. c. The patient's respiratory rate is 32 breaths/min. d. The patient has occasional audible expiratory wheezes.

ANS: C The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? a. Give the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol). c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.

ANS: C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Persistent cough of blood-tinged sputum. b. Scattered crackles in the posterior lung bases. c. Oxygen saturation 90% on 100% O2 by nonrebreather mask. d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

ANS: C The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased. B. Weaning will continue. C. The client will be placed back on full ventilatory support. D. The client will be extubated.

ANS: C. The client will be placed back on full ventilatory support.Rationale: Weaning should be discontinued, as the client is showing signs of intolerance.

Which statement describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate? a. MODS may occur independently from SIRS. b. All patients with septic shock develop MODS. c. The GI system is often the first to show evidence of dysfunction in SIRS and MODS. d. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin.

ANS: D A common initial mediator that causes endothelial damage leading to SIRS and/or MODS is endotoxin. MODS results from SIRS. NOt all patients with septic shock develop MODS, although they do have SIRS. The respiratory system is often the firs to show evidence of SIRS and MODS.

A patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm. What is most important for a nurse to assess in this patient? a. Presence of pain b. Swelling of the arm c. Formation of eschar d. Presence of pulses in the arms

ANS: D In circumferential burns, circulation to the extremities can be severely impaired, and pulses should be monitored closely for signs of obstruction by edema. Swelling of the arms would be expected, but it becomes dangerous when it occludes blood vessels. Pain and eschar are also expected.

The nurse caring for a patient diagnosed with ARDS understands that low tidal volume ventilation will be prescribed while the patient is on mechanical ventilation. Using the knowledge, what is the most appropriate tidal volume if this patient weights 175 lbs.? a. 700 mL b. 800 mL c. 525 mL d. 477 mL

ANS: D Low tidal volume ventilation is calculated using 4 to 8 mL/kg. The patient weights 79.5 kg. Using 4mL/kg the tidal volume would equal 318 mL; 5mL/kg equals 298 mL; 6mL/kg equals 477mL; 7mL/kg equals 557mL and 8mL/kg equals 636mL.

The nurse understands that patients diagnosed with ARDS may be allowed to have permissive hypercapnia. Which patient should the nurse recognize as being contraindicated for this practice? a. A patient with a C5 spinal cord injury b. A patient with opacities on chest x-ray and a P/F ratio of 225 c. A patient who has metabolic acidosis from acute kidney injury d. A patient with increased intracranial pressure after blunt trauma to the skull.

ANS: D Permissive hypercapnia is contraindicated in patients with increased ICP as increased CO2 levels will cause an increase in cerebral flow worsening the patient's intracranial pressure.

The nurse determines that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior? a. Cannot breathe unless he is sitting upright b. Uses the abdominal muscles during expiration c. Has an increased inspiratory-expiratory (I/E) ratio d. Has a change in respiratory rate from rapid to slow

ANS: D The increase in respiratory rate needed to blow off accumulated CO2 predisposes to respiratory muscle fatigue. The slowing of a rapid rate in a patient in acute distress shows tiring and the possibility of respiratory arrest unless ventilatory assistance is provided. Orthopnea, accessory muscle use, and decreased inspiratory-expiratory distress but do not necessarily signal respiratory fatigue or arrest. Abdominal muscle use is normal.

Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. To benefit the PaO2 the nurse knows that this strategy will a. increase the mobilization of pulmonary secretions. b. decrease the workload of the diaphragm and intercostal muscles. c. promote opening of atelectatic alveoli in the upper portion of the lung. d. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.

ANS: D When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent and fluid-filled and the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. if the patient is turned prone, air-filled nonatelectatic alveioli in the anterior part of the lung receive more blood and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions.

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

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

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/hr. 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.

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.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

ANS: D Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax.

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a. obtaining a ventilation-perfusion scan. b. drawing blood for arterial blood gases. c. positioning the patient for a chest x-ray. d. insertion of a pulmonary artery catheter

ANS: D Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to resecure the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.

ANS: D The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate.

To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation.

ANS: D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3 - of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. increase the tidal volume. c. increase the respiratory rate. d. decrease the respiratory rate.

ANS: D The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.

A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.

Correct Answer: 22.5 Rationale : The anterior trunk has superficial partial-thickness burns and is calculated in TBSA as 18%. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA.