CC exam 3 blueprint questions (29,32,34,35)

A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis?

Cardiac output (CO) of 8 L/min Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.

Decreased urine osmolality is a sign of which disorder?

Diabetes insipidus Decreased urine osmolality is a sign of diabetes insipidus.

The nurse is caring for a patient with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Which findings would confirm this diagnosis?

Increased ADH level and low serum osmolality Secretion of antidiuretic hormone (SIADH) occurs when there are increased levels of ADH in the blood compared with a low serum osmolality.

A patient with diabetic ketoacidosis (DKA) has an insulin drip infusing, and the nurse has just administered subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include what findings?

Irritability and paresthesia Irritability and paresthesia are seen in hypoglycemia.

A patient has been admitted with diabetic ketoacidosis, and treatment has been initiated. Which findings would lead the nurse to suspect the patient is dehydrated?

Poor skin turgor and flat neck veins Poor skin turgor and flat neck veins are indicative of dehydration. Dyspnea, crackles, extra heart sounds, and 3+ edema are signs of fluid overload. Chvostek and Trousseau signs are indicative of hypocalcemia.

When a patient with diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects a drop in the serum levels of which electrolytes?

Potassium and phosphate Frequent verification of the serum potassium concentration is required for patients with DKA receiving fluid resuscitation and insulin therapy. The serum phosphate level is sometimes low (hypophosphatemia) in DKA. Insulin treatment may make this more obvious as phosphate is returned to the interior of the cell. If the serum phosphate level is less than 1 mg/dL, phosphate replacement is recommended.

Patients discharged with antithyroid medications should be alerted to which potential side effect?

Agranulocytosis Patients discharged with antithyroid medications are alerted to the potential side effect of agranulocytosis. Symptoms of agranulocytosis include sudden cough, fever, rash, and inflammation.

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan?

Alcohol cessation As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program.

Which finding is expected in the patient with hypothyroidism?

Anemia Anemia is a common problem that is present in 25% to 50% of patients with hypothyroidism. Symptoms of fatigue and depression are associated. Erythropoiesis (red blood cell production) is impaired and inadequate. Coagulation abnormalities may coexist.

The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis (DKA), the intravenous (IV) line should be changed to a solution containing glucose when what happens?

Blood glucose drops to 200 mg/dL. When the serum glucose level decreases to 200 mg/dL, the infusing solution is changed to a 50/50 mix of hypotonic saline and 5% dextrose. Dextrose is added to replenish depleted cellular glucose as the circulating serum glucose level falls.

The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention is the highest priority?

Managing pain It is imperative to appropriately manage the patient's pain after gastrointestinal (GI) surgery. Adequate analgesia is necessary to promote the mobility of the patient and decrease pulmonary complications. Initial pain management may be accomplished by intravenous opioid (morphine, hydromorphone) administration by means of a patient-controlled analgesia (PCA) pump or through continuous epidural infusion of an opioid and local anesthetic (bupivacaine).

An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem?

Sepsis Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection.

The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient?

Severe hyperglycemia with minimal or absent ketosis The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type 2 diabetes.

A patient with bronchogenic oat cell carcinoma has a drop in urine output. The laboratory reports a serum sodium level of 120 mEq/L, a serum osmolality level of 220 mOsm/kg, and urine-specific gravity of 1.035. The nurse suspects the patient may be developing what problem?

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) A decreased urine output, hyponatremia, hypoosmolality, and high urine-specific gravity are classic signs of syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Oat cell carcinoma is a precipitating factor for SIADH.

The nurse is caring for a patient with a head injury who has developed diabetes insipidus (DI). What medication would the nurse expect to be prescribed for the patient?

Vasopressin Patients with central diabetes insipidus (DI) who are unable to synthesize antidiuretic hormone (ADH) require replacement ADH (vasopressin) or an ADH analog.

The nurse and a new graduate nurse are caring for a patient with extensive burns and are discussing skin grafts. Which statement indicates the new graduate understood the information?

"Autografts provide permanent coverage and are the least expensive." An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least expensive.

A patient with a history of type 2 diabetes was admitted after aneurysm repair. The patient's serum glucose levels have been elevated for the past 2 days, and the patient is concerned about becoming dependent on insulin. Which statement is the nurse's best response to the patient's concerns?

"The stress on your body has temporarily increased your blood sugar levels." Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.

A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What is the best response by the nurse?

"This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.

A patient is admitted with diabetic ketoacidosis (DKA). The patient presents with dry, cracked lips and is begging for something to drink. What reply would be the nurse's best response?

"We can't give you anything to drink until we get your blood sugar under control." Patients with diabetic ketoacidosis (DKA) are kept on NPO status (nothing by mouth) until the hyperglycemia is under control.

A patient is admitted with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes that has been well controlled with an insulin pump. The patient states, "I know it could not be my diabetes because my pump gives me 24-hour control." Which reply would be the nurse's best response?

"We'll check your serum blood glucose and ketones." Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to evaluate for diabetic ketoacidosis.

The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply, one, some, or all.)

-Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. -Start enteral nutrition within the first 48 hours after diagnosis of septic shock. -Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L.

A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply, one, some, or all.)

-Blood cultures -Wound cultures -Urine cultures -Sputum cultures

A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply, one, some, or all.)

-Heart rate greater than 100 beats/min -Weak, thready pulse -Increased right atrial pressure

A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply, one, some, or all.)

-Pulse oximetry and serial arterial blood gas measurements -Monitoring electrolyte blood levels -Assessing for signs of cerebral edema

A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse is administering hypertonic saline. The nurse knows that the serum sodium should not be raised more than how many milliequivalents per day?

10 mEq/day Serum sodium levels must be evaluated at least every 4 hours during the acute phase of sodium replacement. The serum sodium should not be raised more than 10 mEq/L in 24 hours.

Identify in the correct order the five layers of the skin from the surface inward. 1. Stratum granulosum 2. Stratum corneum 3. Stratum germinativum 4. Stratum lucidum 5. Stratum spinosum

2, 4, 1, 5, 3 From the surface inward, its five layers are the (2) stratum corneum, (4) stratum lucidum, (1) stratum granulosum, (5) stratum spinosum, and (3) stratum germinativum.

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum.

23.5% The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg.

5550 mL In a 75-kg person with a 37% burn injury (based on a rule of nines calculation: 18%—chest, 1%—perineum, 18%—right leg = 37% total body surface area [TBSA] burn), the Parkland formula estimates fluid resuscitation needs at 4 mL × 37 × 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement?

5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of LR over the next 16 hours Per the Parkland formula, you would administer 5950 mL of Lactated Ringer (LR) solution for the first 8 hours and 5950 mL of LR over the next 16 hours (4 mL × 85 kg × 45% = 15,300 mL in first 24 hours).

A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next?

Administer 100% high-flow oxygen via a nonrebreathing mask. The treatment of choice for carbon monoxide (CO) poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen.

A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control?

Administer analgesics around the clock. Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is essential.

The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient?

Administer sodium bicarbonate to keep arterial pH greater than 7.20. Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.

A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication?

Adult respiratory distress syndrome (ARDS) Inhalation injury predisposes the patient to the development of pneumonia and acute respiratory distress syndrome (ARDS). Management of ARDS necessitates mechanical ventilatory support and, in extreme cases, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority?

Assess the airway and provide 100% oxygen The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock?

Bacterial toxins lead to vasodilation. The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.

The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient?

Changing gloves and handwashing should be done when moving from area to area on the same patient. Cross-contamination by direct contact is a significant source of infection and a subsequent cause of sepsis. Effective handwashing technique cannot be overemphasized. Nurses must wash their hands and change gloves when moving from area to area on the same patient. For example, after changing the chest dressing, which may be contaminated with sputum from the tracheostomy, hands must be washed and gloves changed before the nurse moves to the legs. Gowns, gloves, and masks should be worn whenever contact with body fluids occurs. These garments also must be changed and hands washed before caring for a different patient. Maintaining patient-specific dressings and topical agents is recommended. Equipment such as thermometers, intravenous pumps, and stethoscopes should be designated for each patient or, when shared, should be cleaned with appropriate bactericidal cleansers between patients.

Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action?

Daily assessment for proper fit and effectiveness Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times, except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises.

The nursing management plan for a patient with full-thickness burns includes which intervention?

Daily wound care with premedication Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection. Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients should receive adequate premedication with analgesics and sedatives.

The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis?

Decreased cardiac index Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.

A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis?

Decreased platelet counts Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels.

Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem?

Decreased pulmonary compliance Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.

A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record?

Deep dermal partial-thickness burn Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. A deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.

A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next?

Escharotomy An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel.

The nurse is caring for a patient with acute liver failure. The provider asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom?

Have the patient extend the arms and dorsiflex the wrists. The patient should be evaluated for the presence of asterixis, or "liver flap," best described as the inability to voluntarily sustain a fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan?

IV rate should be increased and fluid status closely watched. Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/h; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus

Which pathophysiologic mechanism occurs in the patient with type 2 diabetes?

Imbalance between insulin production and use Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin resistance.

What is a leading cause of death in the hospitalized burn patient?

Infection Preventing infection in burn patients is a true challenge and involves complex decision making. Considerable debate has been going on about the infection control precautions to use with burn patients. The burn wound is the most common source of infection in burn patients.

A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase?

Intravenous opiates and assessment of pulses in both arms Pain management in burn injuries must be addressed early and frequently reassessed to determine the adequacy of interventions. Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation.

A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason?

Lack of blood supply After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary coverage of full- and partial-thickness wounds, burn wounds, and donor sites.

A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process?

Loss of sympathetic nervous system innervation Neurogenic shock can be caused by anything that disrupts the sympathetic nervous system (SNS). The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most common cause is spinal cord injury (SCI).

The nursing management plan for a patient with thyrotoxicosis would include which intervention?

Maintaining a quiet, restful environment Patients in thyroid storm are agitated, anxious, and unable to rest, and they benefit from an environment that is calm. Gradually, the effects of the antithyroid medications, iodides, and ß-adrenergic blocking drugs will decrease the neurologic symptoms related to the catecholamine sensitivity.

A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record?

Partial-thickness, second-degree burn A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn?

Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.

A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury?

Pneumothorax The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing, which is characterized by rapid synthesis of collagen. What phase is the patient in?

Proliferative phase The proliferative phase of healing occurs approximately 4 to 20 days after injury. The key cell in this phase of healing, the fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound.

What are the goals of the rehabilitation phase of burn management?

Recuperation and healing physically and emotionally The rehabilitation phase is one of recuperation and healing physically and emotionally.

The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called?

Sepsis When systemic inflammatory response syndrome (SIRS) is the result of infection, it is referred to as sepsis.

Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria?

Silver sulfadiazine Silver sulfadiazine (SSD; Silvadene cream) is a broad-spectrum antimicrobial agent with bactericidal action against many gram-negative and -positive bacteria associated with burn wound infection.

A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery?

Small doses of intravenous opioids titrated to effect Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous injections must not be administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury.

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center?

The medical history of the patient and the size and depth of the burn injury Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center.

Roughly 80% of burns in children are classified as what type of burn?

Thermal The most common type of burn is a thermal burn caused by steam, scalds, contact with heat, and fire injuries. About 80% of burns in children are caused by scalds (i.e., contact with hot objects or liquids).

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable to what cause?

Underresuscitation because of probable wound conversion The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated. Underresuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury.

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage?

Zone of coagulation The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery an RYGBP is. What is the best response by the nurse?

"It is a combination of restrictive and malabsorption types of bariatric surgery." Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure.

A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information?

"Shock is an acute, widespread process of inadequate tissue perfusion." Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

A patient has thyroid storm. The nurse is providing medication instruction for home. The patient asks, "If I have a fever, should I take Tylenol or aspirin?" Which response would be the most appropriate?

"Take Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation." For management or elevated temperature, patients are instructed to use acetaminophen rather than salicylates because salicylates increase the amount of free thyroid hormone in circulation.

The neuroendocrine stress response produces which findings? (Select all that apply, one, some, or all.)

-Elevated blood pressure -Decreased gastric motility -Tachycardia -Increased glucose

A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply, one, some, or all.)

-Epigastric and abdominal pain -Nausea and vomiting -Jaundice -Fever

Which disorders or conditions are potential causes of acute liver failure? (Select all that apply, one, some, or all.)

-Ischemia -Hepatitis A, B, C, D, E, non-A, non-B, non-C -Acetaminophen toxicity -Wilson disease -Reye syndrome

A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K+ is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply, one, some, or all.)

-NS 1.5 L IV fluid bolus -Insulin infusion at 5 units/h -Potassium 20 mEq/L of IV fluid

A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all that apply, one, some, or all.)

-Serum amylase -Serum glucose -White blood cells -Serum triglycerides

A patient has been admitted with hyperosmolar hyperglycemic state (HHS). The nurse knows that intravenous insulin is usually administered at what dosage?

0.1 U/kg/h Regular insulin infusing at an initial rate calculated as 0.1 unit per kg hourly (7 U/h for a person weighing 70 kg) should lower the plasma glucose by 50 to 70 mg/dL in the first hour of treatment. If the measured glucose does not decrease by this amount, the insulin infusion rate may be doubled until the blood glucose is declining at a rate of 50 to 70 mg/dL/h.

The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called?

Absolute hypovolemia Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure.

Which medication can place a patient at risk for developing syndrome of inappropriate secretion of antidiuretic hormone (SIADH)?

Acetaminophen Acetaminophen increases the release of antidiuretic hormone.

A patient presents with ketoacidosis and a blood glucose level of 125 mg/dL. Diabetic ketoacidosis has been ruled out. The nurse knows that ketoacidosis can occur in which condition?

Acute pancreatitis Ketoacidosis also occurs with acute pancreatitis, starvation, and alcoholic ketoacidosis.

A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds, abdominal guarding, distention, and a discoloration around the umbilicus. The nurse suspects the patient may have which condition?

Acute pancreatitis The results of physical assessment of a patient with pancreatitis usually reveal hypoactive bowel sounds and abdominal tenderness, guarding, distention, and tympany. Findings that may indicate pancreatic hemorrhage include Grey Turner sign (gray-blue discoloration of the flanks) and Cullen sign (discoloration of the umbilical region); however, they are rare and usually seen several days into the illness.

A patient is admitted with diabetic ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis?

Administer insulin and fluids intravenously. Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.

A patient has been admitted with diabetic ketoacidosis (DKA). The nurse knows that the top priority in the initial treatment of DKA is which intervention?

Administering intravenous fluids A patient with diabetic ketoacidosis (DKA) is dehydrated and may have lost 5% to 10% of his or her body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.

In caring for a patient with a thyrotoxicosis, the nurse would expect to observe which neurologic symptom?

Agitation Agitation and the inability to rest are often found in a patient with thyrotoxic crisis.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. Which side effect is the nurse monitoring for?

Chest pain A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension, acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident

An older patient reports taking cimetidine for several years. The nurse knows that this medication can cause central nervous system side effects. Which side effect would the nurse monitor the patient for?

Confusion Side effects of histamine antagonists include central nervous system (CNS) toxicity (confusion or delirium) and thrombocytopenia.

A patient with hyperglycemic hyperosmolar state (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138 mEq/L. What is the intravenous fluid of choice?

D5W The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose more than 7 to 10 L of fluid. Physiologic saline solution (0.9%) is infused at 1 L/h, especially for patients in hypovolemic shock if there is no cardiovascular contraindication. Several liters of volume replacement may be required to achieve a blood pressure and central venous pressure within normal range. Infusion volumes are adjusted according to the patient's hydration state and sodium level.

A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis?

Decreased level of consciousness Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.

A patient is admitted with diabetic ketoacidosis (DKA) and is experiencing polyuria. Which electrolyte disturbances would the nurse expect to see at this phase of DKA?

Decreased potassium and sodium levels Polyuria results in large volumes of water, along with sodium, potassium, and phosphorus, being excreted in the urine, causing a fluid volume deficit.

Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an increased risk of developing which disorder?

Diabetes insipidus Any patient who has head trauma or resection of a pituitary tumor has an increased risk of developing diabetes insipidus.

Which pathophysiologic mechanism occurs in the syndrome of inappropriate antidiuretic hormone (SIADH)?

Dilutional hyponatremia, reducing sodium concentration to critically low levels Patients with the syndrome of inappropriate antidiuretic hormone (SIADH) have an excess of antidiuretic hormone secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia.

A patient is admitted with a long history of mental illness. The patient's spouse states the patient has been drinking up to 10 gallons of water each day for the past 2 days and refuses to eat. The patient is severely dehydrated and soaked with urine. The nurse suspects the patient has which problem?

Dipsogenic DI Psychogenic diabetes insipidus (DI) is a rare form of the disease that occurs with compulsive drinking of more than 5 L of water a day. Long-standing psychogenic DI closely mimics nephrogenic DI because the kidney tubules become less responsive to antidiuretic hormone as a result of prolonged conditioning to hypotonic urine.

How would the nurse administer sucralfate through a gastric tube?

Dissolved in 10 mL of water to form a slurry Sucralfate should not be crushed but may be dissolved in 10 mL of water to form a slurry. It is also available as a suspension.

Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage?

Ensuring the patient has a patent airway Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of comorbid conditions (e.g., coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding.

A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first?

Epinephrine Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.

A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient?

Epinephrine Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock.

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA?

Excessive thirst Diabetic ketoacidosis (DKA) has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.

A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC?

Excessive thrombosis and fibrinolysis Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.

A patient is admitted with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse understands that the hyponatremia associated with this disorder is the result of which mechanism?Q

Excessive water reabsorption The patient with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) has an excess of ADH secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia.

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for this patient?

Extensive hydration Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with diabetic ketoacidosis (DKA) are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.

A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention?

Finding and eradicating the cause of infection Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.

An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention must be given to which intervention?

Fluid administration The physical examination may reveal a profound fluid deficit. Signs of severe dehydration include longitudinal wrinkles in the tongue, decreased salivation, and decreased central venous pressure, with increases in heart rate and rapid respirations (Kussmaul air hunger does not occur). In older patients, assessment of clinical signs of dehydration is challenging.

A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse would expect the first line treatment to include which intervention?

Fluid restriction Reduction in fluid intake is one component of the treatment plan for syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms?

Hematemesis and melena The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is that of a patient in hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.

A patient is presenting with signs of diabetes insipidus (DI). Which findings would confirm this diagnosis?

Hyperosmolality and hypernatremia In central diabetes insipidus (DI), there is an inability to secrete an adequate amount of antidiuretic hormone (arginine vasopressin) in response to osmotic or nonosmotic stimuli, resulting in inappropriately dilute urine. Hypernatremia is usually associated with serum hyperosmolality.

A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock?

Hypoperfusion results in loss of gut barrier function With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS).

The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem?

Inability of the heart to pump blood forward Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the lack of insulin results in which process?

Increased gluconeogenesis The release of glucagon from the liver is stimulated when insulin is ineffective in providing the cells with glucose for energy. Glucagon increases the amount of glucose in the bloodstream by breaking down stored glucose (glycogenolysis). In insulin deficiency states, fat is rapidly converted into glucose (gluconeogenesis)

A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is given. Which findings support this diagnosis?

Increased serum osmolality and increased serum glucose Laboratory findings are used to establish the definitive diagnosis of hyperglycemic hyperosmolar syndrome (HHS). Plasma glucose levels are strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.

A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the dehydration associated with DKA results from which pathophysiologic mechanism?

Increased serum osmolality and urea Hyperglycemia increases the plasma osmolality, and the blood becomes hyperosmolar. Cellular dehydration occurs as the hyperosmolar extracellular fluid draws the more dilute intracellular and interstitial fluid into the vascular space in an attempt to return the plasma osmolality to normal.

A patient in diabetic ketoacidosis (DKA) is comatose with a temperature of 102.2° F. The nurse suspects the patient may have which secondary disorder?

Infection A patient in diabetic ketoacidosis can experience a variety of complications, including fluid volume overload, hypoglycemia, hypokalemia or hyperkalemia, hyponatremia, cerebral edema, and infection.

Which nursing intervention should be initiated on all patients with the syndrome of inappropriate antidiuretic hormone (SIADH)?

Initiating seizure precautions The patient with the syndrome of inappropriate antidiuretic hormone (SIADH) has an excess of ADH secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia. Symptoms of severe hyponatremia include an inability to concentrate, mental confusion, apprehension, seizures, a decreased level of consciousness, coma, and death.

A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid?

Inserting a large-diameter peripheral intravenous catheter Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit?

Insertion of an intraaortic balloon pump (IABP) Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intraaortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation.

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating potassium supplements with the patient's insulin therapy?

Insulin drives the potassium back into the cells Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for patients with diabetic ketoacidosis (DKA) who are receiving fluid resuscitation and insulin therapy.

A patient has been admitted after surgery for removal of a brain tumor. The nurse suspects the patient may be developing diabetes insipidus (DI). Which findings would confirm the nurse's suspicion?

Intense thirst and passage of excessively large quantities of dilute urine The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of diuretics, a fluid challenge, or hyperglycemia. Characteristics of DI are intense thirst and the passage of excessively large quantities of very dilute urine.

A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to note to support this diagnosis?

Jaundice Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism.

The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the provider to order for this patient?

Lactulose Lactulose, a synthetic ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a nasogastric tube or as a retention enema. The result is the creation of an acidic environment that results in ammonia being drawn out of the portal circulation. Lactulose has a laxative effect that promotes expulsion.

The nurse is developing a discharge education plan for a patient with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Which topic should be included in the plan?

Measuring intake and output Patient and family education about syndrome of inappropriate secretion of antidiuretic hormone (SIADH), its effect on water balance, and the reasons for fluid restrictions using the teach back method should include how to measure intake and output.

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care?

Monitor the patient for hypovolemic shock from plasma volume depletion. Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous insulin may be required.

The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order?

Obtain a serum lactate level According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation. 1. Measure lactate level.2 Obtain blood cultures prior to administration of antibiotics. Administer broad spectrum antibiotics. Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.

A patient was admitted with diabetic ketoacidosis (DKA) an hour ago and is on an insulin drip. Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The nurse notifies the practitioner. The nurse would anticipate an order for which intervention?

Obtaining serum electrolytes Hypokalemia can occur within the first hours of rehydration and insulin treatment. Continuous cardiac monitoring is required, because low serum potassium (hypokalemia) can cause ventricular dysrhythmias.

A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage?

Peptic ulcers Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastro mucosal lining, is the leading cause of upper gastrointestinal (GI) hemorrhage, accounting for approximately 21% of cases.

A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism?

Peripheral vasodilation Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output.

The nurse is caring for a critically ill patient with type 1 diabetes. The nurse understands that the patient is at risk for developing diabetic ketoacidosis (DKA) secondary to what etiology?

Physiologic and psychologic stress Major neurologic and endocrine changes occur when an individual is confronted with physiologic stress caused by any critical illness, sepsis, trauma, major surgery, or underlying cardiovascular disease.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism?

Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop because of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids. Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood f rom areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach.

As a patient with diabetic ketoacidosis (DKA) receives insulin and fluids, the nurse knows careful assessment must be given to which electrolyte?

Potassium Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for the patient with diabetic ketoacidosis receiving fluid resuscitation and insulin therapy.

A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs because of what pathophysiologic mechanism?

Premature activation of inactive digestive enzymes, resulting in autodigestion In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.

A patient is admitted with severe hyperglycemia. The patient is very lethargic and has a "fruity" odor to his breath. The nurse knows the odor on the patient's breath is indicative of which situation?

Presence of acetone Acid ketones dissociate and yield hydrogen ions (H+) that accumulate and precipitate a decrease in serum pH. The level of serum bicarbonate also decreases, consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic "fruity" odor.

A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen?

Prevents the tube from adhering to the gastric wall The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa.

The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which medical intervention would the nurse expect to see ordered for this patient?

Rapid rehydration with intravenous fluids The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of the hyperglycemic hyperosmolar state (HHS) must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.

A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism?

Repeat exposure to an antigen in the presence of preformed IgE antibodies Immunoglobulin E (IgE) is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs.

The nurse understands that the onset of seizures in the patient with diabetes insipidus (DI) is indicative of which situation?

Severe dehydration This excessive intake of water reduces the serum osmolality to a more normal level and prevents dehydration. In the person with a decreased level of consciousness, the polyuria leads to severe hypernatremia, dehydration, decreased cerebral perfusion, seizures, loss of consciousness, and death.

A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock?

Spinal cord injury The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

A patient was admitted with acute liver failure. The patient is lethargic, confused, and has marked asterixis. What stage of hepatic encephalopathy is the patient exhibiting?

Stage 2 The patient is in Stage 2 hepatic encephalopathy as evidenced by lethargy, moderate confusion, marked asterixis, and abnormal electroencephalography (EEG).

The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence?

Subcutaneous emphysema The clinical signs and symptoms include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck.

A patient is admitted after surgery with a history of hyperthyroidism. The nurse suspects the patient may be developing thyroid storm. Which finding would confirm this suspicion?

Tachycardia Thyroid storm, also called thyroid crisis, is a rare and life-threatening exacerbation of hyperthyroidism. The pathophysiology underlying the transition from hyperthyroidism to thyroid storm is not fully understood because thyroid hormone levels are not necessarily different from patients with hyperthyroidism. Atrial fibrillation is the most common dysrhythmia in patients with hyperthyroidism, and tachydysrhythmias should be anticipated in thyroid storm, especially in patients with underlying heart disease.

The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury?

Tumor necrosis factor Tumor necrosis factor-á (TNF-á, also known as cachectin) is a polypeptide that is released from macrophages and lymphocytes in response to endotoxin, tissue injury, viral agents, and interleukins. When present in excessive amounts, TNF-á causes widespread destruction in most organ systems and is responsible for the pathophysiologic changes in systemic inflammatory response syndrome (SIRS) and septic shock, including fever, hypotension, decreased organ perfusion, and increased capillary permeability.

The nurse is caring for a patient with myxedema coma. The patient's temperature is 93° F. Which intervention would the nurse include in the plan of care for this patient?

Use warming blankets to slowly warm the patient. Hypothermia will gradually improve as the patient is treated with thyroid hormone. Several warm blankets comfortably wrapped around the patient (with mild hypothermia) may be sufficient to help raise the body temperature to normal. Active warming devices are also used. Continuous assessments are important to avoid too-rapid heating and vasodilation.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the provider to order for this patient?

Vasopressin In acute variceal hemorrhage, control of bleeding can be accomplished by using pharmacologic agents. Intravenous vasopressin, somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed.

A patient weighs 140 kg and is 60 inches tall. The patient's blood sugar is being controlled by glipizide. Which topic would be important for the nurse to include in the patient's discharge education plan?

Weight loss This patient weighs 308 lb and is 5 feet tall. Diet management and exercise are interventions to facilitate weight loss in patients with type 2 diabetes.